“Consent rituals”, meaningful decision making, and ethics

Gerd Gigerenzer and Muir Gray’s new book is out: Better Doctors, Better Patients, Better Decisions. The message is that patients have to be involved in making decisions about their health, and I couldn’t disagree. As Gigerenzer (one of my heroes) has pointed out in Reckoning with Risk, the numbers we base our decisions on, however, can be misleading and often counterintuative.

My issues are twofold. The biggest determinant of health  is still poverty, not the decisions we can later make about our health – there is only so much we can truly ‘decide’ for ourselves. And second, there is a danger that patients who are less well informed, less capable, or less inclined, could be overtaken by people who are more able, for whatever reason, to research and demand the care they want. My job as a doctor, at it’s heart, is to stop that imbalance from occuring through acting as advocate or advisor.

This recent editorial in the Lancet, coauthored by another of my heroes, highlights the problems of ‘the wrong sort’ of ethics. A lack of consideration that harm was done by routine steriods in head injury caused deaths until a trial was done showing our routine practice was in fact harmful and/or lethal. This delay was caused in part with gaining ethical approval for the study.  The editorial shows that the more time to delay giving a useful treatment, tranexamic acid, for haemorrhage, means more deaths occur. This even occurs at a delay of just one hour. The question is if the time to gain informed consent could contribute to this: while patients have a right to autonomy and their own choices, there has to be a sensible appreciation that sometimes things are truly urgent.

There should be a roundtable discussion online soon about the issues raised in Muir and Gerd’s book: I’ll post when I have a link.

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