Medical Consent

What Is Medical Consent?

Medical consent is when a patient gives permission before receiving any form of medical treatment, examination or test.

Adults are generally able to give consent, but there are times when this isn’t true. A patient may lack capacity, and therefore be deemed unable to give consent, if their ability to make decisions is impaired in some way.

In the case of young children, their guardians are able to give consent on their behalf. Consent is trickier when it comes to young adults – but you need to understand the issues, so you can treat them appropriately and safely.

Why Is Consent Important?

Consent is an important issue to consider when dealing with medical ethics scenarios because it means that the patient has agreed to what is about to happen to them. It also enables patients and healthcare professionals to work together to make important decisions.

How Do We Define Consent In Healthcare?

Consent in healthcare is defined as when all three of these criteria are met:

• It is voluntary. The decision to consent or not consent is made by a patient and is not influenced by pressures of relatives, friends or healthcare professionals.
• It is informed. A patient is given all the information about what the treatment in question involves. This will include the benefits, the potential risks and what would happen if the treatment didn’t go ahead.
• The patient has capacity. This means that the patient is capable of giving consent.

How Is Consent To Treatment Given?

Medical consent is given in two main ways:

• Verbally. For example, “I am happy to have a blood test.”
• Written. For example, a patient signs a surgery consent form.

A patient could also give non-verbal consent, as long as they understand what is about to take place. For example, presenting their arm for a blood test.

Consent should be given to the medical professional who is responsible for the patient’s treatment. When a major procedure or operation is taking place, consent should be obtained well in advance. If the patient gives consent and then changes their mind before the procedure, they are entitled to withdraw their consent.

When Is Consent Not Needed?

In some instances, treatment may proceed without a patient’s consent.

Examples of such instances can include:

• Emergency life-saving treatment in which a patient is unable to give consent because they are incapacitated (such as being unconscious).
• Additional emergency procedures during an operation.
• The patient has a severe mental health condition such as schizophrenia, bipolar disorder or dementia which renders them incapable of giving consent.
• Under the Mental Health Act 1983, if there is a need for hospitalisation for a severe mental health condition but a competent patient has self-harmed, attempted suicide and refuses treatment, their relatives or social workers must make an application to forcibly keep the patient in a hospital. Two Doctors will assess the patient’s condition.
• If there is a wider risk to public health if the patient goes untreated, such as rabies or tuberculosis.
• When someone is extremely ill, unhygienic and living in poor conditions, they can be taken in for treatment. This is in line with the National Assistance Act 1948.

Consent In Mental Health Patients

For someone to consent for mental health treatment, they must:

• Have capacity to make this decision.
• Be over 16 years old, as a general rule.
• Have enough information to make the decision.
• Be giving consent voluntarily, without pressure from others.

If there is a lack of capacity to consent for treatment, the medical professional must make a decision in the person’s best interests and take a variety of factors into account. This could involve talking to the person’s family or close friends.

In addition to instances of lacking capacity, mental health patients may also receive treatment without consent if it’s an emergency life-saving treatment, or if they are detained/sectioned under certain sections of the Mental Health Act.

Children And Consent

The Children Act 2004 (a reinforcement of TCA, 1989) states that adulthood is reached after the 18th birthday. This means that 18-year olds are to be treated like all other adults who are able to consent for themselves, unless there are exceptional circumstances.

16- and 17-year-olds are presumed to be able to make decisions about their health independently from their parents and are usually able to consent for themselves.

It is typically under 16s who must be assessed for competency to consent before being able to agree to an intervention. This is known as Gillick competence.

If a child is unable to demonstrate this competence, then the following people can consent on their behalf:

• The child’s mother or father
• A legally appointed guardian
• Local authority designated to care for the child
• A person with a residence order concerning the child
• A local authority/person with an emergency protection order for the child

The Four Pillars of Ethics And Consent

Consent is a difficult concept, particularly when it comes to children and young people. You should apply the four pillars of ethics to any dilemmas about consent.

When it comes to autonomy, you should think about:

• If a child can make a decision about their health, their decision should be respected.
• Only those able to make informed decisions that promote health and avoid harm should have the privilege of autonomy.

This means that a child should not be able to consent to a test or treatment if they cannot understand the intervention and its accompanying risks and benefits.

For beneficence, think about:

• If a child is able to understand the treatment and decide that it is in their best interests, they should be deemed competent to consent.
• Children under 16 may lack the cognition to understand the implications of certain tests or treatments, so their decision may not be rational and in their true best interests.

This is particularly important when children refuse treatment. If refusing treatment may result in serious mental or physical harm, the decision may be overruled by a parent or a court of law, to ensure the best interests of the child are prioritised over autonomy.

When it comes to non-maleficence, consider:

• If preventing a child from receiving a treatment that they are willing to consent for causes them harm, accepting their consent and giving them treatment will avoid this harm.
• If a child is engaging in potentially dangerous or illegal behaviour, it could be argued that their parents should be informed.

It is important to consider whether the child is put at risk from treatment or a lack of treatment.

For justice, be sure to think about:

• The Gillick test was created to ascertain if a child under 16 was capable of making their own decisions.
• With legal guidelines promoting the autonomy of children if they are deemed competent, there are no specific legal arguments against the autonomy of children – it is down to clinical judgements and avoidance of harm.

The Gillick test states that if a child can understand and comprehend a treatment, its implications (including the risks and benefits) and alternative options, they have the ability to consent.

To get a better understanding of applying the key pillars of ethics to consent and young children, it is worth looking into the Keira Bell case.

Medical Consent Scenario

A 15-year-old girl comes in alone and tells her GP that she is sexually active. She also states that she would like to start taking contraception.

When it comes to capacity and consent, you should consider:

• If you refuse to supply contraception without parental consent, the child may suffer emotional harm from revealing her sexual activity to her parents.
• On the other hand, she may decide not to tell her parents and continue the sexual activity without contraception. This would put her at risk of unwanted pregnancy and sexually transmitted infections.

However, if the girl was engaging in sexual activity with an inappropriate adult, the situation would change. By providing treatment, you may be allowing the behaviour to continue and remain a secret from the parents, both of which would put the child at risk of harm. In this instance, Gillick competence is very important and will help the GP to understand whether sexual abuse is taking place, whether the child’s safety is at risk and whether the child is able to consent to sexual activity.

For the specific case of contraception in under 16s, it may be valuable to familiarise yourself with the Fraser guidelines.

Medical Consent Questions

It is possible that you will encounter questions about medical consent in your interview. Some topics that could arise are:

• Are there any scenarios in which consent is not required? If so, can you give an example?
• A patient admits they are using illegal substances. Can you disclose this to the local authorities without patient consent?

To find out the answer to these questions, check out our ethics questions guide.