Consent In Medicine Is More Than Risk and Benefit

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Dr. Wells, my friend, and a colleague wrote about the recent decision by the Pennsylvania Supreme Court on the role of a physician in obtaining consent. I agree with her, securing consent cannot be delegated to other members of the “care team.” But my objections are more about ritual and less about legal niceties. 

A ritual "is a sequence of activities involving gestures, words, and objects, performed in a sequestered place, and performed according to set sequence." 

Surgery is unique among the medical specialties because the time from intervention to a result can be very swift. And every surgeon, whether in training or practice has “lost” a patient, a euphemistic way of saying that after we laid hands upon them, they died or were injured. It is hard in those circumstances to not see a connection between your actions and those results. So it is my belief, that the ritual of consent is not so much about the content of your words, the area the law is most concerned with in the creation of a “contract,” but in the act itself. This is a moment when an emotional bond, however transient, is formed.

Ritual provides so many functions. For patients, anxious in confronting surgery and who isn’t, it is a moment of control and a step towards the operation ahead. For the surgeon, it is a reminder of the life being entrusted to you and at the same time it connects you with all of your previous surgeries and those of your teachers or mentors. When we are attentive, when physician and patient pause to make it a moment, “obtaining” consent is extremely effective in creating the emotional component of those legal niceties. 

But as with many of our rituals, we go through the motions without opening ourselves up to meaning. The change, from observance to routine, attentive to removed is to my mind the substance of the Pennsylvania case, consent has become a routine, parceled out to other providers and in the process, all the emotional components stripped away. 

I do not doubt that other members of the care team, especially those involved in the day-to-day care of patients can communicate to patients their view of a given treatment or procedures risks and benefits; often in terms more familiar and resonant for the patient. That is good and important, perhaps necessary, but it is not sufficient. Consent acknowledges a shared experience, binding of the actions of one upon another. When we strip consent of its ritual, we impoverish the patient-physician relationship, and it robs us of the opportunity for the magic of healing.