A patient sometimes consents to a particular line of treatment because of the apparent advantages or benefits as described by the dentist. Care should be taken to ensure that the information given is balanced and accurate, and that any claims (as to likely success) can be substantiated. Statements such as “your crown will last for life”, or “your molar root treatment will be 100% successful” or “I guarantee you will have no problem” may dramatically weaken the value and validity of the consent contained.
Where treatment is unusual or experimental, it is important that the patient should fully understand the situation and it is worthwhile to get the patient to sign a statement to the effect that they recognise the controversial or relatively untried nature of the treatment, and accept that the risks are greater and perhaps even unknown.
For a clinician to say “I obtained informed consent from the patient”, or (worse still, as often heard in a hospital setting) “I consented the patient” rather implies that this clinician is in a position to determine the point at which the patient has been given sufficient information in order to make a rational choice. This is almost as paternalistic as giving the patient no information at all, on the time-honoured “doctor knows best” principle. But a patient who is given only some of the relevant facts and considerations regarding a specific procedure, may well be very happy to proceed, while the same patient, if given some additional information, may not. “Informed consent” will always be a misnomer if the patient remains unaware of a further relevant fact that could have influenced their decision.
Similarly, consent cannot be said to be “informed” if the patient misunderstands the information, perhaps because of the words used, or the way in which the information is imparted. At the beginning of the consent process the clinician has the advantage of knowing much more than the patient, about what the procedure involves, about its risks, benefits, limitations, about alternatives and how they compare in each of these respects and also in terms of relative costs. On the other hand, the clinician may also be at a similar disadvantage in knowing relatively little about the patient, and his/her life and personal circumstances.
The clinician must therefore ask the patient the right questions in the right way, at the right time, and needs to listen carefully to the patient’s responses, in order to gain an insight into any additional information that this particular, individual patient might require in order to decide whether or not to proceed. Any failure to elicit this information, if it might be material to the patient’s decision, is more likely to be used to criticise the clinician, than to criticise the patient for not having volunteered the information without prompting. Patients, after all, may not understand why the information is even relevant, let alone important.
Choosing to withhold certain information – for example, the risks or limitations of procedure A – or declining to mention the option of procedure B at all, is always fraught with dento-legal risks. It will be argued that the resulting ‘consent’ cannot be valid because it was based on only a selected sample of the information that could and should have been provided to the patient.
Taken to an extreme, one might reach a position where the clinician is placed in a situation where every detail of every procedure, and every possible adverse outcome (however minor or rare) would need to be explained to the patient before starting any treatment. Clearly this would place an impossible burden on the clinician.
- The purpose
- The nature of the treatment (what it involves)
- The likely effects and consequences
- Risks, limitations and possible side effects
- Alternatives and how they compare
When patients believe that they have been denied sufficient information they often feel angry, misled or indeed violated or assaulted. These are powerful, destructive feelings that are likely to destroy any relationship of trust upon which consent is founded.
There is in reality the inter-dependence between the patient and dentist that requires both parties to communicate effectively so that a decision can be made that respects patient autonomy. It is obviously important that the dentist also feels comfortable with proceeding. Effective two-way communication is therefore a corner stone of the consent process.
Consent is all about communication and a relationship of trust between a patient and a healthcare professional. It relies on a total respect for patient autonomy as far as the patient’s capacity will allow. The “best interest” principle, whilst having a valuable role in special needs and emergency situations, needs to be cautiously applied because of the risk of paternalism. These dilemmas are not unusual in dentistry and helpful advice is always at hand from Dental Protection.