Capacity and consent
In the realm of medical practice, the principles of consent and capacity are foundational to ethical and legal patient care. Aspiring medical students must grasp these concepts to prepare for their future roles and to excel in medical school interviews.
What is Consent?
Definition
Consent in medicine refers to the agreement by a patient to undergo a specific medical intervention. This agreement must be informed, voluntary, and made by a person with the capacity to do so.
Types of Consent
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Informed Consent: Patients must be given all necessary information regarding the proposed treatment, including risks, benefits, and alternatives, to make an educated decision.
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Implied Consent: Assumed consent when a patient's actions suggest they agree to treatment, such as rolling up a sleeve for a blood test.
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Explicit Consent: Clearly articulated agreement, either verbally or in writing, often required for more significant procedures.
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Proxy Consent: Obtained from a legally authorized representative when a patient cannot provide consent due to lack of capacity.
Elements of Informed Consent
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Disclosure: Providing all relevant information about the treatment or procedure.
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Comprehension: Ensuring the patient understands the information.
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Voluntariness: The decision must be made freely without coercion.
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Competence: The patient must have the capacity to make the decision.
Importance in Medical Ethics
Informed consent is central to respecting patient autonomy—a core principle in medical ethics. It ensures patients make decisions aligned with their values and preferences, fostering trust and promoting shared decision-making.
What is Capacity?
Definition
Capacity is the ability of a patient to understand information relevant to a treatment decision and to appreciate the potential consequences of their choices.
It is a fundamental concept in medical ethics. It's important to have a grasp of the concepts of time, decision and the basics of assessing capacity when referring to these types of questions.
Assessing Capacity
Assessment of capacity involves evaluating whether a patient can:
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Understand: Grasp the information presented about the treatment.
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Retain: Keep the information long enough to make a decision.
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Weigh up: Use the information to compare risks and benefits and make a reasoned decision.
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Communicate: Convey their decision clearly.
Capacity is Decision-Specific
Capacity is not a blanket status; it can vary with different decisions and can change over time. A patient may have the capacity to make some decisions but not others, depending on the complexity and context.
Making a choice on a medication for a skin condition with little side effects versus medication that could cause lung damage would be a very different consideration and require a deeper understanding and ability to analyse the pros and cons. A patient with schizophrenia can decide on taking over-the-counter pain relief for a headache but might not be able to comprehend and weigh the risks and benefits of a proposed surgical intervention.
For example:
The capacity to understand the implications of an amputation and the effect it will have on their rehabilitation and quality of life, versus the risks of not having the amputation, is a complex and difficult decision to make. A person with dementia might not be able to understand this, however they might be able to understand whether they want to be in a care home or at their own home.
Capacity is Time-Specific and a dynamic process
Capacity isn't static, in that it can fluctuate based on many factors. A person making a decision at one time in their assessment might have capacity, but later on in the day may lack capacity. Temporary changes in the person's cognitive state, due to illness, mental health conditions or a condition like dementia, may alter their ability to understand, retain, weigh up or communicate.
This means that capacity might need to be reassessed at different times of the day, or more likely when the person begins to make a recovery to the reversible or predictable change that has happened to them, for example confusion due to infection.
For example:
Doris is a 85 year old woman who is admitted for a urine infection. She normally looks after herself independently, however she is more confused during the hospital stay for several days. She becomes more aggressive and starts seeing objects that aren't there. This is unusual for her as her memory and cognition are normally very good. Currently she cannot understand or retain the information that is given to her by the medical team to decide whether she has an antibiotic with a certain side effect. She doesn't have capacity to make this medical decision at this time.
Several days later, she makes a good recovery and becomes 'herself' again. She's able to understand the risks of the antibiotic, and keep it in her head long enough to weigh up the pros and the cons. She communicates this thought process to the medical team, and it is clear she has capacity.
The time that the capacity was assessed made all the difference in this case, and it was important to reassess this at a time a change had occurred.
The Interplay Between Consent and Capacity
Effective consent relies on the patient having the capacity to provide it. If a patient lacks capacity, consent must be obtained from a proxy, or the medical team may need to act in the patient's best interest, especially in emergencies.
If the person can't understand, weigh up, retain and communicate the information they won't have the capacity to make the decision on whether they can consent to a procedure. Even though the information given to them is insightful, showing them the pros and cons (fully informing them of the risks, benefits and alternatives) they cannot comprehend it fully to make the decision.
Interview question example
"Can you describe a situation where a patient's capacity to consent might be questioned and how you would handle it?"
When looking at this question, it is initially daunting, however you have a lot of tools to tackle it just by understanding the basics of consent and capacity.
Explain what each are, showing your insight into these complex issues, and build upon the answer as much as you can by demonstrating for example the specific components of capacity (understand, weigh up, retain, communicate) and how they relate to the patient.
For more marks look at the interplay between capacity and consent, and be clear you understand the difference between each, because it's easy to confuse the two in a stressful interview.
"In a situation where a patient's capacity is in question, such as in cases of acute confusion or mental illness, I would first ensure a thorough assessment is conducted. This involves evaluating their ability to understand, retain, and weigh information regarding their treatment options. If the patient is found to lack capacity, I would involve a legally authorized representative or consider the patient's best interests, adhering to ethical and legal guidelines. Throughout, maintaining clear communication and respect for the patient’s dignity is paramount."