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Report of the consent working party

March 2001

Executive summary and recommendations
In July 1998 the BMA’s annual representative meeting passed the following resolution:

“That this meeting believes that the current practice of obtaining informed consent is inadequate and fails to serve patients or doctors and recommends that the BMA establish a working party to produce guidelines to assist all doctors in obtaining proper informed consent.”

To this end a working party was established involving representatives from a range of BMA committees including the central consultants and specialists committee, the medical ethics committee, the junior doctors committee and the board of medical education. It was agreed that the working party should consult with other bodies and individuals, including the royal colleges, patient groups and lawyers, as appropriate.

After undertaking a wide consultation exercise and reviewing the literature on this subject the working party found that, despite the proliferation of guidance on this issue, current awareness of the relevant ethical and legal principles relating to consent among the medical profession is largely inadequate. In view of this, the working party saw its responsibility not simply as being to reiterate the ethical and legal principles, but rather to find ways of ensuring that existing guidelines on obtaining patient consent are implemented in practice.

Ultimately, the working party concluded that the whole way in which the process of seeking consent is viewed should be fundamentally reassessed. In particular, the working party considered that too much emphasis was placed on the final signature on a consent form rather than consent being seen as a continuing process. Consent should not be seen as the sole responsibility of the doctor who obtains the patient’s signature, but rather as a matter for the whole clinical team whose members all have a responsibility for ensuring that patients’ questions and concerns in relation to the intervention or treatment are adequately addressed. The working party considered that health authorities, trusts, employing authorities, medical schools and individual doctors all have an interest and responsibility in ensuring that the ethical and legal principles relating to consent are adhered to in practice.

The working party considered that, ultimately, the doctor who recommends the treatment or intervention should be responsible for providing an explanation to the patient about what the procedure will involve – including a discussion of the various treatment options, the alternatives available, the prognosis and the risks associated with the intervention – and for obtaining the patient’s consent.

Recommendations
The working party made the following recommendations:
Recommendation 1: all doctors have a duty to familiarise themselves with and adhere to the ethical and legal principles relating to obtaining informed consent.

Recommendation 2: the whole process of obtaining patient consent must be thoroughly re-assessed. Greater emphasis needs to be placed on the initial explanation given to the patient, with provision for continuing opportunity for discussion in order that the patient can raise any concerns and/or questions.

Recommendation 3: the working party strongly recommends that trusts develop their own guidelines and policy statements for obtaining informed consent that adequately reflect the principles laid down by health professionals’ regulatory bodies.

Recommendation 4: the working party welcomes the use of information materials, in written, tape and video form in the process of seeking patient consent as an aid to, but not as a substitute for, discussion. It calls on the NHS executive to fund the development and evaluation of high-quality patient information materials covering common clinical problems.

Recommendation 5: the current inadequacy of interpreter facilities throughout the UK remains an issue for concern. Ensuring that patients have understood the information that has been given to them is a crucial factor in obtaining valid consent. Health authorities must ensure that they have adequate interpreter facilities in their area and that health professionals know how to access such services.

Recommendation 6: it is crucial that doctors and those employing doctors recognise that seeking valid consent requires both time and resources and that they act upon this. In particular, this fact should be reflected in service contract agreements. In recommending this, the working party notes the resolution of the 1999 senior hospital medical staff conference: “that this meeting believes that the requirements of the GMC and the health services ombudsman for obtaining of valid patient consent can only be met with current NHS manpower resources if there is a reduction in the numbers of operations and procedures performed and that the NHS executive should give all trusts an instruction to make plans to comply from a given date.”

Recommendation 7: medical students should be aware of the importance of patient consent from the very beginning of their undergraduate education. The need to respect patient consent should be reinforced at every opportunity.

Recommendation 8: the working party considers that a key way of improving the practice of seeking consent is through medical students receiving formal tuition in a clinical environment. The working party recommends the introduction of formal reflective learning on the consent process as a specific element of the review of clinical attachments, preferably taking place on a one-to-one basis.

Recommendation 9: ideally, seeking consent should be addressed in both formal ethics and law teaching as well as forming a key component of communication and clinical skills education. Teaching should focus on both the theoretical and practical aspects of consent.

Recommendation 10: teaching of consent should address the practical difficulties that doctors may face in the clinical environment including the difficult issue of assessing competence. It should also address cases where a doctor considers that he or she lacks the necessary skills to seek consent in relation to a particular medical intervention.

Recommendation 11: the working party considers that there should be greater involvement of senior clinicians in formal teaching of consent.

Recommendation 12: doctors involved in teaching junior doctors about obtaining consent should receive adequate training in how to do so. Training packages should be developed in order to facilitate this.

Recommendation 13: doctors in training should receive continuing formal education in obtaining consent.

Recommendation 14: the working party considers that all doctors should be able to demonstrate that they can seek consent as a key component of their continuing professional development.

Recommendation 15: doctors should be encouraged to recognise their changing needs as both their career and their specialty develop and to keep their communication skills, as well as their clinical skills, up to date.

Recommendation 16: NHS funding should be provided for training of all doctors working in the NHS in both communication skills and the practice of obtaining consent.

Recommendation 17: royal colleges and medical schools should develop ways of assessing doctors’ practice in obtaining informed consent.

Access the Consent Toolkit here.

Membership of the consent working party
Dr Michael Wilks (chairman) chairman, Medical Ethics Committee
Dr David Cairns member, Central Consultants and Specialists Committee
Dr Andrew Carney, member, Medical Ethics Committee
Dr Peter Dangerfield, member, Medical Ethics Committee
Dr Nizam Mamode, member, Junior Doctors Committee
Dr Caroline Marriott, member, Central Consultants and Specialists Committee
Dr Trevor Pickersgill, member, Board of Medical Education
Dr Jane Richards, member, Medical Ethics Committee
Ms Rosie Wilkinson, Royal College of Nursing observer, Medical Ethics Committee

Editorial board
Head of professional resources and research group: Professor Vivienne Nathanson
Project manager: Lucy Heath
Written by: Lucy Heath
Edited by: Veronica English
Editorial secretariat: Ann Sommerville, Gillian Romano-Critchley, Patricia Fraser

Further information may be obtained from:
Medical ethics department, BMA, BMA House, Tavistock Square, London WC1H 9JP
Tel: 020 7383 6286
Fax: 020 7383 6233
Email: ethics@bma.org.uk