Deformed Consent: It Was a Million to One Shot, Doc!

Informed consent in healthcare is the process by which the provider informs the patient about the options for the diagnosis and treatment of the patient’s condition. In addition, the risks and benefits are described to the patient so that the patient can make a rational decision regarding what he or she wants to be done.

Informed consent is a good aspect of healthcare. Giving patients the information to make decisions about their health preserves their right to autonomy. Many people mistakenly believe that informed consent is simply getting a patient to sign a written form. It is more than that. It is a process of communication between the patient and provider that results in the patient’s authorization or agreement to undergo a specific intervention. Patients should always have the opportunity to ask questions to elicit a better understanding of treatments or procedures. Patients should always be able to make an informed decision to proceed or to refuse a particular intervention. All medical encounters should conclude with the patient agreeing that all his questions have been exhausted. And patients should be adequately advised patients prior to any procedure in order to exercise the patient’s right to choose which side of the risk/benefit table he would like to place his chips.

So how do we fully inform a patient? In order to be as fully informed as his doctor, must the patient be sent to medical school? Actually, yes. By committing even minor omissions, doctors fail to deliver a fully informed consent. After all, patients who do not have the same medical knowledge as their provider can never truly comprehend all of the risks of a given intervention in the same way their doctor does. And what of minor, but likely possibilities? Should we be required to tell a patient that he may get a papercut by handling an informed consent form? What if the patient refuses treatment, and in his haste to exit, gets a static electricity shock from the doorknob. No big deal, right? Not worth metioning, right? What if that shock shorted out his pacemaker? Ahh…bigger deal. Should we have provided the warning to this possible, but foreseeable event? Can you picture the huge disclaimer poster required to be put in medical waiting rooms informing potential patients of all risks and benefits of opening the door to the office hallway? And another poster in the hallway denoting all of the risks of entering the treatment room. I don’t even want to imagine the one in the restroom.

We would most certainly have to stop offering coffee and tea in the waiting area. I mean, right now, the cups come pre-printed with: CAUTION – CONTENTS MAY BE HOT. I am not sure there would be room on the cup for: CAUTION – CONTENTS MAY BE HOT, WET, CAFFEINATED, DECAFFEINATED or SWEETENED. MAY STING EYES, CAUSE DIABETES, CANCER, ANXIETY, HYPERTENSION or DROWNING. DO NOT INVERT OVER EYES, EARS OR PRIVATE PARTS. DO NOT INSERT RECTALLY. WARNING IS CONTINUED ON NEXT CUP. NO, NOT THAT ONE, THE BROWN ONE. And of course all written warnings need to be in 6800 languages in case someone who understands only Luxembourgish wants a cup of joe.

Informed consent is an excellent idea and one that healthcare should embrace…within reason. Patients have a right to the explanation of procedural or invasive risks in advance. Exclusive of emergency procedures in life threatening situations, informed consent should be made available whenever possible for significant risks with a high estimated likelihood of occurrence and tempered with the potential benefits and alternatives. Minor risks would take too long to explain, and would cloud even the most simple of procedures: “I’m going to draw blood from you now, Mrs. Smith. By inserting this needle in your arm, I am exposing you to the following 40,000 infinitesimally small risks which I shall explain in detail one at a time….” The delivery of informed consent would take hundreds of times longer than any actual procedure!

As for chiropractic, there are, of course, some common risks. These risks are usually temporary and minor, involving things like post treatment soreness. There are also a few major risks which, in terms of likelihood of occurrence, are more akin to choking on an aspirin tablet. To date, there is no warning on bottles of Bayer aspirin telling the user he may choke and die on the tablet. It certainly is a real risk with such a low likelihood of occurrence, it hardly warrants mentioning. If a patient asks if there is a chance of dying by choking on an aspirin, his doctor should address the concerns honestly and directly. I am not implying that doctors should skirt around any patient questions but a proactive stance for remote risks does neither the patient, the doctor, nor the entire field of healthcare any good.

In communicating with our patients, we should make sure they understand that which is likely and that which is serious. The operative action here is to communicate. If we strive to improve the doctor/patient relationship, and provide honest, open communication, we would do much to reduce the reasons informed consent has exploded into ridiculousness in the first place.

Brett Kinsler is an informed and consenting chiropractor in Rochester. NY

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8 Comments

  1. January 11, 2010 at 8:27 am

    Dear Brett,
    from your mouth to the ears of CT Board of Chiropractic Examiners and the legislature of the state of CT.
    excellent commentary,
    John

  2. Richarde E Vincent said,

    January 11, 2010 at 12:41 pm

    Great blog……. sure is risk in everything we do……..gotta remember that without risk life would be one boring trip.
    Dick

  3. January 20, 2010 at 2:32 am

    I dig the sarcasm. 😉

    The informed consent situation is simply another attack on our great profession. The thing that bother’s me the most is that lack of backbone(pun fully intended) our profession continues to have.

    The moment we band together as a unified group, and stand up for out entire profession, the naysayers and attackers will back off. I am not talking about attacking back, simply catching up with the other professions that figured out there is power in numbers.

    That being said, I am not against there being informed consent for care or procedures that would put people at risk. What I am saying is the risk is so rarely, if ever, found at the hands of a chiropractor.

    Nice blog. Gonna subscribe.

  4. January 20, 2010 at 10:12 pm

    I agree that informed consent is a good idea for the chiropractic profession — it just shouldn’t be used as a wolf in sheep’s clothing like the current situation in Connecticut. Thank you for your thoughts, Dr. Gibson.

  5. January 20, 2010 at 10:20 pm

    Exactly! Thanks, John.

  6. January 20, 2010 at 10:21 pm

    Thanks for visiting, Dr. Vincent!

  7. February 14, 2010 at 10:22 pm

    This is a sticky topic, and should really be common knowlegde. We have a duty as human beings to know our bodies, and what can happen to them if a hot liquid is dumped into our laps. Some possibilities, ie the likelyhood of a stroke after getting your haircut, should not have to be written down on a consent form. Something like this could, and probably will, be opening a can of worms that we just don’t want to see.

    I find your commentary light-hearted and spirited. Thank you for your ideas.

  8. RokBromirem said,

    February 16, 2010 at 5:52 pm

    I really like when people are expressing their opinion and thought. So I like the way you are writing


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