INFORMED CONSENT

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INFORMED CONSENT

• How Do I Gain A Patients Valid Consent to
  Benefit Their Oral Health?

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• Curiosity is the most insatiable of lusts.
• Michel Foucault
• French Philosopher
• 1926-1984

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Two Moral Principles Provide the Ethical
Foundation for Informed Consent

• Principle of Beneficience
• Do Good for the Patient by Promoting Their
  Well-Being.
• Principle of Respect for Autonomy
• Each Person Should be Self-Determining, the
  Author of His/Her Own Life.

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Instrumental Value of Self-Determination

• In most cases, the individuals well-being is
  best served by his/her own subjective judgement.

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Intrinsic Value of Self-Determination

• ...Unless the patient has requested this course
  of conduct, the individual will not have been
  shown proper respect as a person nor provided
  with adequate protection against arbitrary,
  albeit well-meaning domination by others.
• Even if it could be shown that another could
  do a better job of determining what is in the
  individuals interest, there is still a reason
  for recognizing self-determination as an
  individuals right

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Quote from John Stuart Mill

• The human faculties of perception, judgement,
  discriminative feeling, mental activity, and even
  moral preference, are exercised only in making a
  choice. He who does anything because it is the
  custom makes no choice. He gains no practice
  either in discerning or desiring what is best.
  The mental and moral, like the muscular powers,
  are improved by being used...

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• He who lets the world, or his own portion of
  it, choose his plan of life for him, has no need
  of any other faculty than the ape-like one of
  imitation. He who chooses his plan for himself
  employs all his faculties. He must use
  observation to see, activity to gather materials
  for decision, discrimination to decide, and when
  he has decided, firmness and self-control to hold
  his deliberative decision...

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• Where, not the persons own character, but the
  traditions and customs of other people are the
  rules of conduct, there is wanting one of the
  principle ingredients of human happiness.
• John Stuart Mill
• English Philosopher
• Formulator of Utilitarianism

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BeneficenceAutonomy

• The definition of health is imprecise and
  indefinite. It depends to some extent upon the
  goals and values of the individual.
• Even when the definition is agreed upon there is
  often no definitive criterion to determine how to
  achieve it.
• In recommending therapy, health professionals
  tend to reflect their own values and preferences,
  which may differ from their patients.
• Determining what constitutes health and how it is
  best promoted requires knowledge of the patients
  goals, values, and preferences.

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• For the reasons just given, determining whether a
  treatment plan will, if successful, promote a
  patients well-being is a matter of individual
  judgement.
• In each case the goals and interests of
  particular patients incline them in different
  directions not only as to how, but even as to
  whether, treatment should be provided.

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• It is important to note that the ethical (and
  legal) imperative of informed consent does not
  give patient the right to insist upon anything
  they might want
• Health professionals are also bound by the
  concept of non-maleficence, not causing harm.
• The choices available to patients must be limited
  to medically accepted options, all of which
  scientific evidence indicates will have some
  possibility of promoting the patients welfare.

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Opinion inJohn Canterbury versus William Spence

• every human being of adult years and sound
  mind has a right to determine what shall be done
  with his body True consent to what happens to
  ones self is the informed exercise of a choice,
  and that entails an opportunity to evaluate
  knowledgeably the options available and the risks
  attendant upon each.

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Major Components of Informed Consent

• Disclosure of Adequate Information with
  Associated Patient Understanding
• Lack of Coercion
• Competence/Decisional Capacity

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Four Standards Considered For Adequate Information

• Full Disclosure
• Customary Disclosure
• Disclosure of all Risks
• Reasonable Person Standard

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Full Disclosure

• Disclose every benefit and risk, no matter
  how small or remote.
• Rejected
• Too prohibitive and unrealistic. If taken
  literally, full disclosure is impossible. If
  taken, as probably intended, to reveal adequate
  information, the standard provides no guidance.

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Customary Disclosure

• Disclose all information that other
  practitioners would be likely to disclose under
  similar circumstances. (Also called community or
  professional standard.)
• Rejected
• Customary practice does not necessarily ensure
  that the patients right to self-determination is
  respected does not ensure that adequate
  information will be provided.

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Disclose All Risks

• Disclose every risk that a patient would deem
  significant to his decision.
• Rejected
• Places an undue burden on the practitioner in
  that it requires the practitioner to second guess
  the patients subjective view of what would count
  as significant information.

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Reasonable Person Standard

• Disclose the benefits and risks that a
  reasonable person, in what the practitioner knows
  to be the patients position, would be likely to
  deem relevant in deciding whether to forego a
  proposed therapy.
• Accepted, on the grounds that the scope of
  the standard is not subjective as to the
  practitioner or the patient it remains objective
  with due regard for the patients informational
  needs and with suitable leeway for the
  practitioners situation.

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Two Exceptions to the Rule of Disclosure

• Emergency situations where the patient is
  incapable of giving consent, and harm from
  failure to treat is imminent and outweighs any
  harm threatened by the proposed treatment.
• When disclosure of risks itself poses a threat of
  harm to the patient. However, this privilege
  does not accept the paternalistic notion that the
  practitioner may remain silent simply because
  divulgence might prompt the patient to forego
  therapy the practitioner feels the patient really
  needs.

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Under the Reasonable Person Standard, Adequate
Information Generally Includes

• Benefits
• Risks
• Complications
• Alternatives
• Prognosis
• Non-Treatment
• Costs

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Lack of Coercion

• Coercion is defined as a threat, either
  psychological or physical, of sufficient force
  that no rational person would be able to resist
  it.
• Education and persuasion are not coercive.
• Manipulation/deception and psychological or
  physical inducements of benefit or threats of
  harm are coercive.
• Key idea is that the consent is fully voluntary.

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Decisional Capacity

• In much of the ethics literature, the term
  competency is used to designate decisional
  capacity. However, the term has taken on legal
  connotations with the decision regarding a
  persons competency determined by the courts.
  Thus, increasingly the term decisional capacity
  is employed to designate the third ingredient
  necessary for a consent to be informed/valid.

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Decisional Making Capacity Requires

• Possession of a set of values and goals.
• The ability to communicate and to understand
  information, and
• the ability to reason and deliberate about ones
  choices.
• From The Presidents Commission for the Study
  of Ethical Problems in Medicine and Biomedical
  and Behavioral Research

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Surrogate Decision Making

• Examples of individuals who cannot rationally
  deliberate in the process of informed consent
  are
• minors
• persons with dementia
• psychotics
• persons with extreme anxiety or fear
• the mentally retarded
• persons under the influences of abused substances
  

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Misconceptions About Informed Consent

• Informed consent is merely a legal doctrine and
  has little to do with a good and ethical
  practice.
• Informed consent is a single event.
• Informed consent merely involves the listing of
  risks and benefits the dentist believes would
  best serve the patients interests.

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• Because of their special education and training,
  practitioners are the best judges of what would
  serve their patients best interests.
• The primary obligation of the dentist is to act
  in the best interest of the patients health, as
  the dentist understands it.
• It is permissible to forego informed consent so
  long as you are acting in the patients best
  interest.

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• Patients do not want to be informed of bad news
  and are always better served by practitioners
  remaining positive, even if it involves
  deception.
• Any individual who would make a decision that is
  obvious to the practitioner as contrary to their
  health and well being is irrational.
• The practitioners obligations do not extend
  beyond the legal requirements concerning informed
  consent.