Aspects of consent
The General Dental Council is involved in various matters of consent, as ethical issues which reflect upon the professional conduct of a dentist. The General Dental Council identifies the main ethical principles of getting consent as:
- Informed consent
- Voluntary decision making
Is consent given voluntarily?
In order for consent to be valid, it must be given freely and voluntarily, without any pressure or influence being brought to bear on the patient. This pressure might be from a family member, parent or a health care professional. It is important when seeking to obtain consent that you satisfy yourself that consent has been freely given.
These types of situation will rarely arise in dental practice but when issues of authority and competence confuse the picture, for example in decisions concerning orthodontic treatment of teenagers, you should be considering who is driving the decision to accept treatment. Equally undue pressure should never be exerted on a patient who is unsure about whether to accept a complex, expensive treatment plan. They should be given all the alternatives, and plenty of time to think about their choice prior to starting treatment.
General anaesthesia and sedation
The General Dental Council (GDC) takes an active interest in matters relating to consent, as an ethical issue which reflects upon the professional conduct of a dentist.
When receiving treatment under general anaesthesia or sedation, the patient is temporarily deprived of their capacity to give a valid consent to treatment. This makes it all the more important that they understand what is proposed in advance of the treatment because it will not be possible to refer to them once treatment is under way. It is also undesirable for the consent process to be carried out immediately prior to the administration of the anaesthesia or sedation, because patients are likely to be preoccupied with or anxious about what lies ahead. Ideally, the consent process should take place at a prior visit, giving the patient time to reflect upon the information provided, and to raise any further questions when they arrive for the procedure to be carried out.
The General Dental Council requires that a valid consent to treatment under general anaesthetic or sedation must be obtained, and confirmed in writing(11) by the patient (or parent) prior to carrying out the treatment. The dentist must himself (or herself) have explained to the patient the treatment proposed, the risks involved in the treatment, and any alternative treatments. All the procedures involved in the anaesthesia/sedation, and in the dental treatment itself, must be explained to the patient. The Council makes it clear that the onus is on the dentist to ensure that all necessary information and explanations have been given to the patient or parent / guardian, either by the dentist or by the anaesthetist. It is not acceptable for these explanations to be given by a member of the practice staff.
But providing treatment for a sedated or anaesthetised patient can raise other complications where consent is concerned. In the middle of treatment you notice that there is a cavity on an adjacent tooth to the one that you are treating. Do you fill it to avoid the need for further sedation or leave it and run the risk of the patient being inconvenienced? Does it make a difference if the patient has travelled a great distance for treatment? These are questions that are difficult to answer other than by saying that it depends upon the patient. The “best interests” consideration needs to be weighed carefully against the question of patient autonomy and choice, bearing in mind the fact that some patients might be more than happy for a clinician to proceed whilst others would want the opportunity to influence and to take a specific decision in relation to a specific further item of treatment.
In some cases one could pre-empt this by discussing such possibilities with a patient in advance of treatment – but unforeseen circumstances can always arise. It is the classic dilemma of paternalism against autonomy and there is no “one size fits all” answer.
Private or NHS?
The General Dental Council considers that it is the responsibility of the dentist to explain the nature of the contract clearly to the patient, i.e. whether the patient is being accepted for treatment under the NHS, or under private contract.
Patients must never be misled into accepting private treatment. The dentist is encouraged to avoid misunderstandings by giving the patient a written treatment plan and estimate, and to obtain the patient’s agreement to these terms in writing. The Council states that written treatment plans and estimates should always be provided for “extensive or expensive” courses of treatment although the term is not defined. The Council makes it clear that any acts or
omissions by dentists, in connection with their practices which are liable to mislead the public, may be held to constitute serious professional misconduct.
In this context, NHS practitioners are reminded that they are obliged, under the NHS (General Dental Services Contracts) Regulations 2005, Part 2, to complete a form FP17DC for any private treatment carried out for a patient who has also been offered NHS treatment.
There can be no better defence against a subsequent allegation that the patient was not aware that the treatment was being provided on a private basis – an allegation which could well be the subject of a PCT/ LHB investigation and/or a complaint to the General Dental Council.