The consent process

How much to tell and how should it be told?

The provision of information to the patient is at the heart of informed consent (Meisel A et al 1981). How this “information” is communicated to the patient and their reaction to it is important. The responsibility for the transfer of information lies with the clinical practitioner whether this is the doctor or the photographer.

The information

This includes the elements already considered:

• What the procedure is
• Why it is necessary and
• Who will see the photographs afterwards

and two additional features:

• Offering to answer any of the patient’s questions and
• Statement that they can withdraw at any time (without prejudice or jeopardy)

The last in parenthesis may not be applicable in some circumstances where the consultant will not go ahead with surgery without a photographic record of the patient. Some authors also suggest information about methods used to ensure anonymity should be included (Tarcinale MA 1980).

See also aspects of maintaining [[confidentiality]].

The patient

There are a number of factors which affect how the patient receives or reacts to the information you provide in your explanation (Harris DL 1982, Rennie D 1980), for example if they have been given a premed like Valium before going to the operating theatre.

Guided reflection - List the factors which think may affect how patients understand or receive the consent procedure.

[[Factors that may affect patients' understanding]]

As Hawkins C 1985 suggests;

“We should not insist on getting fully informed consent from anxious patients nor should we deny detailed information to enquiring ones.”

If patients want to know more it is advisable to have a booklet or leaflet of information available, including copies in a range of different languages. This is especially important for patients whose first language is not English who may come without an interpreter or relative who can translate for you.

Rennie D 1980 regarding consent to a medical procedure showed that;

“ . .only about half the patients remember the salient points; most have forgotten factors that would have undermined their decision to go ahead with an operation once it is over, and some flatly deny having had any conversations at all.”

Beloff H 1984 describes the approach we should take very well:

“The patient should understand that they are a worthy person who has been acknowledged in a kindly manner, but that their symptoms illness is something separate. They will be treated with sympathy; and their disorder with scientific accuracy.”

The verbal explanation

The method used to convey the information, and how much, has to be carefully balanced with the state of the patient and how the information is received.

Consent must be fully and freely given when the patient is not under avoidable stress eg. when naked or undressed prior to photography. A quiet moment to sit down and explain what is going to be undertaken before starting the photography is necessary.

Where patients are told also has an effect. The studio setup itself can appear daunting from the patients eye view (Beloff H 1984). It can be useful to have relaxing chairs slightly to one side in the studio to discuss the consent and acclimatise the patient to the studio surroundings.

Legal principle “primum non nocere” - foremost not to harm (Hawkins C 1985). For example, when you believe that revealing all the risks or the extent to which photographs might be used would create harmful anxiety and might deter a patient from undergoing a procedure, ie. fluorescein angiography, it may be best not to go into too much detail. Where the procedure is needful, in their own interests, the consent explanation should not put the patient off.

A balance must be struck between too much or too little information against a little knowledge being more worrying than knowing the full facts. A patient is often more agreeable if they know the rarity of a complication or extent of use ie. very few photographs used for publication.

Legal duty is determined by the courts not by doctors or medical illustrators. Consideration is given to what is “usual practice” which becomes the accepted norm.

Some information is automatically given when you explain the procedure. What is included in the photograph is important. After all the patient cannot see through the viewfinder to know what you are or are not going to photograph. For example, records for breast reconstruction or augmentation should include the shoulders but there is no need to include the head so anonymity is maintained and a patients possible fears alleviated.

Resources

Weblinks

Ontario Consultants on religous tolerance website http://www.religioustolerance.org/

References

Beloff H. (1984) Social interactions in photographing -even in medical illustration . . . J Audiovis Media Med; 7: 44-7.

Harris DL. (1982) The symptomatology of abnormal appearance: an anecdotal survey. Br J Plast Surg; 35: 312-23.

Rennie D. (1980) Informed consent by “well-nigh abject” adults. N Eng J Med; 302 (16): 917-8.

Tarcinale MA. (1980) Medical photographer’s role in protecting a patient’s right to privacy. J Biol Photogr; 48(4): 183-5.