The Lancet – Nov 05, 2016

The Lancet
Nov 05, 2016 Volume 388 Number 10057 p2209-2322 e12

After Bolam: what’s the future for patient consent?
The Lancet
Published: 05 November 2016
“Patients are now widely regarded as persons holding rights, rather than as the passive recipients of the care of the medical profession”, declared the UK Supreme Court in the case of Montgomery vs Lanarkshire Health Board in 2015, affirming the patient as a subject and not simply the object of medical care. Before Montgomery, whether doctors reasonably communicated risks to patients about potential procedures was judged by reference to a responsible body of medical opinion (Bolam test), in line with the paternalistic model of medicine. Since Montgomery, what makes a risk material for a doctor to tell their patient about are the circumstances, views, and values of the individual patient, rather than the opinion of the medical profession.

In response to this renewed emphasis on patients’ rights to self-determination, the Royal College of Surgeons has released new guidance to help surgeons and other health-care professionals to obtain and document consent. Recognising that it is not enough to simply substitute expert opinion with an exhaustive list of potential risks and benefits, the guidance advocates for “supported decision-making”, with a focus on tailoring discussions to individual patients.

Considerable practical challenges loom large, not least of which is time. The guidance states that to determine the content of discussions around risk, doctors should take time to get to know their patients. These discussions need to take place long enough before planned interventions so patients have enough time to reflect, and in particularly complex or potentially life changing scenarios might need to take place over several sessions.

To deal with the new time pressures that this approach will involve, the guidance recommends surgeons raise the issue with their hospital management. But surely, to enable real patient-centred decision making to take root, we must do more than simply tell already time-pressed doctors to find yet more time. Such changes will require cultural and administrative reform at the institutional level. If we want to support patient choice and autonomy, then we must empower our medical professionals with the resources they need to make it happen.


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