Sunday, 22 June 2008

Consent

Just a quick one, since it's Sunday.

Dr. Crippen's theoretical post about 'medical rape' got me thinking.

Consent is a funny issue with lots of people in the sphere of healthcare. I try to see it as a bit of a black and white issue, as it's easier.

The situation is thus:

You are a hospital doctor, working in obstetrics. You are called to the Labour Ward by the midwifes. Ms Smith is a 29 year old barrister and is in labour. Her partner, aged 32, and also a barrister, is with her. It is her first baby and she is towards the end of the labour which has been uneventful but a little longer than expected. She declined an epidural. She has, at her own request, had only “gas and air” for analgesia. She has been fully dilated for nearly an hour. She was pushing well at first but, suddenly, she is very tired, and she can no longer push effectively. The foetal heart rate has dropped suddenly and precipitously. The baby’s head is on the perineum, but Ms Smith cannot push it out.

The baby must be delivered quickly. You tell Ms Smith that she needs to have some help, that you need to do a forceps delivery. She is close tears and exhausted. She agrees. “Yes, please, just deliver my baby as quickly as possible.” Ms Smith is put up in the stirrups. You infiltrate some local anaesthetic, put the forceps on the baby’s head without difficultly and are about to do what the obstetricians (not the patient) would call a “simple lift out”. You start to apply gentle traction on the forceps. The baby’s head begins to move easily. At this point, Ms Smith starts to scream, “No, no, no, stop, take those bloody things out of me now.” Ms Smith’s partner mops her brow. She continues to scream, “Take those bloody things out of me”. You ignore her request saying “it won’t take a minute” and continue to increase traction on the forceps. Ms Smith screams more and keeps saying “take them out, take them out.” Twenty seconds later, the baby’s head is born, and you remove the forceps. Ms Smith stops screaming. The rest of the birth continues without problems. The on-call paediatrician is present. The baby has a low Apgar at one minute but then pinks up very quickly and is handed to the mother alive and well.


In my comment on DC's site, I mention how I'm not sure what'd happen if the Doc would've removed the forceps at the moment the pregnant refused. For example, if this would've caused damage to baby and/or mother than the doctor is in an ethically screwed area. On one hand, s/he does something for the best: to sort out a problem and keep both parties as healthy as possible whilst running the risk of being called a rapist. On the other, s/he takes notice of the patient and lives with the consequences. This could, essentially, go against ethics or morals. To do no harm, and to do good, specifically.

Even so, I'd go with the latter option. There might not be a court in the land who could try and prosecute a doctor for doing what s/he thought was right, i.e. delivering the baby, however in this new consumer-obsessed world of 'choice' and the like, the latter choice would be the one for me. As long as you've explained what you want to do (before doing it) and then, once the patient has asked you to stop, explained what the consequences of not doing/completing the procedure, I don't see the problem in stopping. If the patient complains about it in the future, you could just play the old 'respecting your wishes card'.

Brilliant.

3 comments:

Zarathustra said...

To be honest, I just read this post as Dr C getting a bit hot and bothered because he's been slagged off by some crazy feminists.

There's absolutely no way that the doctor in such a situation could be prosecuted for rape, because there was no sexual intent to his actions. Possibly battery for giving treatment without consent, but not rape.

The Mental Capacity Act says that to have capacity to consent a person has to be able to understand the decision, weigh up the decision in their mind, retain the information for the decision in their head, and communicate their decision to you.

If I were a doctor in that situation I'd argue that because Mum was panicking at that particular moment, she was therefore unable to weigh up the decision in her head, and therefore did not have capacity to consent. I would also point out that when not panicking (and therefore had capacity) she had indicated that she wished me to use the forceps. I would also point out that this was a lifesaving proceduring requiring an instant decision.

Section 3.6 of the Mental Capacity Act Code of Practice may also be relevant here:

Clearly, in emergency medical situations (for example, where a person
collapses with a heart attack or for some unknown reason and is
brought unconscious into a hospital), urgent decisions will have to
be made and immediate action taken in the person’s best interests.
In these situations, it may not be practical or appropriate to delay the
treatment while trying to help the person make their own decisions,
or to consult with any known attorneys or deputies. However, even in
emergency situations, healthcare staff should try to communicate with
the person and keep them informed of what is happening.


So, basically the Code of Practice is saying, if you have to make a snap decision, do what you think is in the patient's best interests and just keep talking to them while you're doing it. That's a nice, common-sense answer.

OFMN said...

I agree with the general thrust of your argument, but in doing what we, as medical professionals, think is right we often run the risk of looking like control freaks. Which is sad, but possibly true.

GrumpyRN said...

"This could, essentially, go against ethics or morals. To do no harm, and to do good, specifically." Yes but against/for whom? The mother or the baby? "I don't see the problem in stopping." If you take out the forceps you have a live mother and a dead baby, if you carry on then you have a live mother and a live baby. To be legal, consent has 5 requirements. The patient must understand the information given, they must be aware of the procedure and any related risks, they must give permission and they must be competent. She had already given informed consent for the procedure, the real question is does she have the right to refuse treatment which will kill her baby? Answer is no, and usually these things are dealt with by the courts - hospital seeks permission to treat against patients wishes - in an emergency situation all bets are off and clinician does what is best using their knowledge and experience.