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HOSPITAL AUTHORITY CONVENTION 2016Masterclasses

Wednesday, 4 MayM15.3 What Matters? — Perspectives and Challenges for Better 14:30 Convention Hall C
Patient and Staff Experience

Patient Consent – Any Consensus Among Ourselves?
Chow KM
Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong
Not long ago, informed consent is considered a panacea for promoting patient autonomy. Medical staff should disclose
everything whenever possible, it has been posited. Is it true?
The famous UK story of Nadine Montgomery1 relates a diabetic lady of short stature expecting her first baby predicted by
ultrasound to weigh more than 4kg when labour was induced. She expressed anxieties about delivery to her obstetrician
on several occasions, but had not specifically inquired about caesarean section. After the vaginal delivery complication of
severe shoulder dystocia and then cerebral palsy, the Supreme Court opined that women have a right to information about “any
material risks” in order to make an autonomous decision about how to give birth, and that it was inappropriate that disclosure
of risk be based on (the doctor’s) clinical judgement.
At first glance, this implied the dogma to disclose everything. The key question is to hit a balance between information
overload and patient’s right to know.2 The former situation leads to unnecessary patient anxiety, whereas the latter raises
concerns about ethical and legal process. Another area of controversy is the question as to how much our patients want to
know.3
Stated another way, we want to give the information not too little, not too much, but just right. The corollary is that Goldilocks
wanted her porridge not too hot, not too cold, but just right. She wanted her bed not too hard, not too soft, but just right. This
has been termed the Goldilocks Effect, assuming that there is a “right” metric of patient autonomy and paternalism.3,4
At this moment, we are uncertain how to tackle the dilemma. One proposed strategy is to explore the patients’ value and
assess the nature of decision. As pointed out by a recent New England Journal of Medicine perspective article4, “Common
sense suggests that clinicians are more likely to leave decisions to patients when they don’t have strong feelings about the
best course of action. These, however, are the decisions for which patients may benefit most from a recommendation.”

References:
1. Heywood R. Patient-oriented disclosure – a standard worth waiting for? Montgomery v Lanarkshire Health Board [2015]

UKSC 11. Med Law Rev 2015; 23: 455-66
2. Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and simple consent.

Ann Intern Med 2003; 140: 54-59
3. Rosenbaum L. The paternalism preference – choosing unshared decision making. N Engl J Med 2015; 373: 589-92
4. Fried TR. Shared decision making – finding the sweet spot. N Engl J Med 2016; 374: 104-5

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