Changing lifestyles also contribute to breast cancer

Criteria to evaluate decision-making capacity for consent Dr KK Aggarwal Consent taking is an integral part of clinical practice. Doctors are required to obtain informed consent from their patients before initiating treatment or carrying out any procedure, therapeutic or diagnostic. The concept of consent is derived from the ethical principle of patient autonomy. Consent is therefore an ethical obligation and legal requirement. There are three components of a valid consent: • The patient gives it voluntarily without any coercion • The patient has the minimum of adequate level of information about the nature of the procedure to which he is consenting to. • The patient has the capacity and competence to give consent Criteria that have been deemed to be necessary to reach to a decision by the patient regarding his/her treatment have been defined: Understanding, expressing a choice, appreciation and reasoning. Assessment of these criteria for decision making capacity is an essential part of the process of informed consent. Understanding: Is the patient able to grasp or comprehend the meaning of the information provided to him/her by the doctor and retain that knowledge? This includes information about the disease condition, the proposed treatment or alternative treatments, the associated benefits and risk of proposed treatments, alternative treatments as well as no treatment. The ability to understand the relevant facts has a great role in the decision making ability of the patient. Because if the patient does not understand the information given, he/she cannot pick information that is relevant to their situation. The information must be simple and clear and imparted in language, which the patient can understand, avoiding too many medical terms. Memory problems, intelligence can affect understanding of the information. Expressing a choice: Is the patient able to clearly communicate to the doctor his/her choice of preferred treatment option from the multiple proposed treatment options and is the patient able to maintain a relatively stable decision regarding treatment choice for it to be implemented? Patients may often change their mind about their treatment choice and withdraw consent at any time. This does not mean that the patient lacks the capacity to make a decision if the patient is able to give a justifiable rationale for the change in decision. However, frequent changes in decision making may put a question mark on the capacity of the patient to come to a decision. Appreciation: This component goes beyond the mere understanding of the facts given to a patient. Is the patient able to relate the information about the proposed diagnostic and treatment intervention and the likely consequences to himself/herself directly? Whether the patient understands the consequence of refusal of treatment? Reasoning: Is the patient able to rationally use the relevant information and give reasons for selecting a particular treatment option keeping his best interests in mind? This component deals with the process by which the patient arrives at a decision and not the final decision as chosen by the patient. If a patient lacks reasoning, he/she will not be able to compare the benefits and risk of various treatment options in a rational or logical manner. Reasoning is affected in conditions like psychosis, depression, any phobia, dementia.

Who can give consent?

Who can give consent? Dr KK Aggarwal Informed consent is an integral and crucial part of medical treatment today. It is not only a procedural requirement, but also a legal requirement. Not taking consent is gross negligence. Consent has to be taken before starting a treatment or a procedure. For consent to be valid, it should be voluntary i.e. given without coercion, informed and the patient should be competent to understand the information given. Consent indicates a respect for patient autonomy, a very important principle of medical ethics. This means that patients have the decision making capacity and doctors need to respect their right to make decision regarding their care. And, no doctor treats a patient without informed consent. Who can give the consent? Informed consent must ideally be taken from the patient himself/herself. In a traditional Indian setting, if the husband is hospitalized, the wife, at times, may not be taken into confidence by the relatives about the gravity of the situation or otherwise. Most often, it is one of the family members who usually sign the consent in such cases. If the patient is unconscious, then the spouse should authorize one person as a legal heir to take legal decisions, in case the spouse does not want to take decisions or is not informed. In an emergency situation when the patient is not able to give consent, then treatment may be given without consent, if there is no other person available to give consent. But, the onus lies on the doctor to prove that the treatment given was lifesaving. The facts of the case must be documented. The Medical Council of India (regulation 7.16) states that “Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed”. The MCI should revisit the regulation 7.16 and come out with a clause of “next of kin” consent or “surrogacy” consent, which should also include “all legal heirs” and not just one as part of the consent. Disclaimer: The views expressed in this write up are entirely my own

Are you being blamed of commercialization?

Are you being blamed of commercialization?

Dr K K Aggarwal, National President IMA

Padma Shri, Dr KK Aggarwal. HCFI, MCI, IMA, National President, HSG, Health, 

Most doctors are honest. It’s only a minority who bring a bad name to the entire profession.

In Samira Kohli vs Dr. Prabha Manchanda and Anr, SCI Appeal (Civil) No. 1949 of 2004, 16.01.2008, the Supreme Court of India has observed:

“27. On the other hand, we have the Doctors, hospitals, nursing homes and clinics in the private commercial sector. There is a general perception among the middle class public that these private hospitals and doctors prescribe avoidable costly diagnostic procedures and medicines, and subject them to unwanted surgical procedures, for financial gain. The public feel that many doctors who have spent a crore or more for becoming a specialist, or nursing homes which have invested several crores on diagnostic and infrastructure facilities, would necessarily operate with a purely commercial and not service motive; that such doctors and hospitals would advise extensive costly treatment procedures and surgeries, where conservative or simple treatment may meet the need; and that what used to be a noble service oriented profession is slowly but steadily converting into a purely business.

28.    But unfortunately not all doctors in government hospitals are paragons of service, nor fortunately, all private hospitals/doctors are commercial minded. There are many a doctor in government hospitals who do not care about patients and unscrupulously insist upon ‘unofficial’ payment for free treatment or insist upon private consultations. On the other hand, many private hospitals and Doctors give the best of treatment without exploitation, at a reasonable cost, charging a fee, which is reasonable recompense for the service rendered. Of course, some doctors, both in private practice or in government service, look at patients not as persons who should be relieved from pain and suffering by prompt and proper treatment at an affordable cost, but as potential income-providers/customers who can be exploited by prolonged or radical diagnostic and treatment procedures. It is this minority who bring a bad name to the entire profession.”