Case report provided by Providence Health Care

Case Report: Jack arrives in emergency and presents with severe abdominal pain. The on-call surgeon decides that a laparoscopy is required in order to investigate and determine the source of the pain. When the surgeon tells Jack that he requires this procedure, Jack says that he knows he needs it but he doesn’t want to discuss it. He tells the surgeon “just do the procedure” and that he wants the surgeon to “do his best.”

• Should the surgeon proceed with the procedure?
• Is Jack’s consent sufficient, even if he doesn’t know all the facts related to procedure?
• Or does he need to make a decision after he is informed about the risks and benefits of the procedure?

Healthcare providers are morally obligated to respect a patient’s autonomy by seeking a patient’s informed consent about the medical procedures that may be performed on his body. A patient can also exercise his autonomy by refusing procedures or treatments, even if they are medically recommended. In Jack’s case, however, he is not refusing treatment. Rather, he simply doesn’t want to know about what the procedure involves or the risks associated with it.

Question: It seems that Jack is making an autonomous choice about the procedure. But, is this informed consent?
Answer: The answer is no. Even if Jack tells the surgeon to “do his best” and “to just do the procedure”, informed consent is more than simply granting permission.

Discussion: In order that a patient provides informed consent, he must have decisional capacity, or the cognitive ability to understand and evaluate the nature of, and reasons for a medical procedure, and the risks involved in undergoing it (or not), in light of the relevant and appropriate information about the procedure, which any reasonable person would want to know, provided by the healthcare professional.
(The Health Care Consent Act outlines the conditions for making an informed decision http://www.bclaws.ca/civix/document/id/complete/statreg/96181_01#part2)

With these thoughts in mind about informed consent, what should we think about Jack’s case?

1. We have no reason to think that Jack lacks capacity unless there is evidence that suggests otherwise. 
2. However, Jack has not been properly informed about the procedure by the physician and the physician has no way of determining whether Jack is capable of understanding the implications of the procedure. 
3. Therefore, the health care provider has a moral (and legal) obligation not to perform the procedure at this time.

However, the healthcare provider should continue to engage in dialogue with Jack, in order to determine why he doesn’t want to know about the procedure or its risks. Is Jack highly fearful? Is there a cultural reason why Jack doesn’t want to know?

Having a discussion with a patient about his reasons for not wanting to know about the procedure or risks is part of the process of informed consent between patient and health care provider, as well as crucial to establishing trust within the therapeutic relationship.

Bibliography
Johnston, Carolyn, and Penelope Bradbury. 100 Cases in Clinical Ethics and Law, Second Edition, CRC Press: Boca Raton, FL, 2015.


With grateful thanks to Providence Health Care for sharing a bioethics case report from their resources.  http://www.providencehealthcare.org/ethics_services/index.html

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