I RECENTLY attended a presentation by a research team about doctors and consent. It was fascinating and thought-provoking, particularly the findings about how doctors perceived, understood and conceptualised consent in practice. I was struck by the ways in which the respondents talked about consent.
Recurrent references to bureaucracy, paperwork, rules, forms, “being sued” and systems were made. Articulation of dignity, relational ethics, autonomy, self-determination and choice were scarcely mentioned by these respondents.
There may, of course, be many reasons for these findings: methodological approach, sampling and selection, the context within which the research took place and any number of other variables which informed the project. That I was sitting in the audience as a professor of ethics interpreting what I was hearing, or maybe that which I thought I was hearing, adds a further layer to the analytic mille-feuille that characterises the interpretation of any research.
Nonetheless, the presentation lingered. Did it matter what motivated those doctors in how they sought consent in their practice? Were the rationales that they described for obtaining consent important provided that valid consent was obtained politely and efficiently? What difference does it make if consent is sought as a defence or because it is “required” by an employer, rather than with any consideration of values, virtues or principles? Was anything more at stake than an ethicist’s professional pride as her hopes of hearing her own way of looking at the world reflected in the results diminished as the presentation progressed?
Several weeks of mulling have led me to conclude that motivation and explanation do matter when it comes to ethics. First, to focus on values, such as respect for equality and for others, or on virtues, such as trust, is to attend to the moral significance of the clinical encounter. It is to shift from the form or the paperwork to the interaction and the relationship. It acknowledges that there is something of value at stake that matters. It is not merely a transaction like any other: it is a complex meeting where need, vulnerability, expertise, power, emotion, information and choice collide.
Considering the moral dimension of seeking consent is to show regard for the patient, the exchange and, importantly too, oneself as a professional. It is to accept the discretion that characterises most professional roles and, therefore, to acknowledge the responsibilities and the challenges that inevitably accompany that discretion. To conceptualise the seeking of consent merely as a matter of routine or something that is imposed by a monolithic employer is to disregard the presence and potential influence of professional judgement, choice and individual approach.
To be actively engaged in the ethical considerations that underpin and inform consent as a concept is to allow for consideration of context. It is an approach that demands thought, reflection and discussion. There will be divergence. Doctors will disagree about the ethical value and purpose of consent. Patients will engage variably with the process. Choices and adjustments will be made in varying ways about how best to make information meaningful for an individual at a specific time or in relation to a particular decision.
That divergence and difference are necessary: the essence of an ethical rather than a bureaucratic approach which privileges the human and the personal over the generalised, unthinking routine. It is an approach that enables a professional to notice when the system within which he or she is working is compromising care and impeding ethical practice. It offers a language and framework for action to raise concerns and address systemic constraints with those who can effect change.
Motivation and explanation reflect engagement, awareness and commitment. The ‘why’ of our behaviour reminds us what matters in a profession and a clinical encounter, perhaps especially when we are under pressure. Attention to motivation alerts us when we are neglecting or privileging the wrong considerations or questions. Being able to articulate why we do what we do or act as we have done is to offer an explanation that prompts discussion and dialogue with others. It is the door to exchange and to rich learning. It demonstrates that we inevitably frame questions through our own lenses and it may give us pause.
So, as I sat in that audience and heard, with admittedly some disappointment, that consideration of and reference to the language of ethics were largely absent from the respondents’ accounts of seeking consent, there was one important question I had to ask about my own reaction. Why?
Deborah Bowman is Professor of Bioethics, Clinical Ethics and Medical Law at St George’s, University of London