Muhammad Asharib Arshad  ( Department of Surgery, Nishtar Hospital, Multan, Pakistan. )
Syed Muhammad Hammad Ali  ( Department of Surgery, Fatima Memorial Hospital, Lahore, Pakistan. )
Ahmad Majzoub  ( Department of Urology, Hamad Medical Corporation, Doha, Qatar. )

Informed consent is considered an essential component of medical ethics and it revolves around the principle of autonomy. Previously, a doctor used to make decisions on behalf of his/her patient, an approach better known as ‘paternalistic’. Nowadays, every patient has the right to freely express his/her acceptance or refusal to undergo any proposed medical intervention. The patient’s decision is based on the information provided by the health care professional regarding the nature and potential consequences of the treatment he or she is going to receive. However, the process is much more complex especially when it comes to the surgical domain. Almost all surgical interventions are invasive and sensitive in nature thereby demanding dexterity and timely made decisions. Complications do happen and it is therefore necessary that the operating surgeon ensures that the patient is well informed about all possible surgical risks. Nonetheless, due to their busy schedules and hectic routines, surgeons are prone to making errors and loopholes in the documentation and informed consent processes. As a result surgeons are particularly vulnerable to litigation and malpractice claims and are facing even more challenges with an ever growing public awareness through the vibrant social media of the 21st century. A 10-year survey on National Health Service (NHS) litigations in UK reported a total of 31,697 claims in all surgical subspecialties¹. While most of these claims were in orthopaedic, obstetric and general surgery fields, the majority of the successful claims related to informed consent were seen in oral and maxillofacial and plastic surgery fields. Similarly, the Canadian Medical Protective Association reported a total of 65% informed consent claims in surgery out of which 44% were successful². Another study on surgical malpractice claims in Netherlands found that most of the claims filed were related to the incidence of postoperative complications where patients felt they were not properly informed about the potential complications and consequences³. In a developing country like Pakistan, where the literacy rate is exceptionally low, the informed consent process is a mere formality⁴. Most of the times junior doctors or nursing staff members are the ones taking the consent, who themselves are unaware of the specifics of procedures or the surgical process. As a result, patients or their attendants end up signing or thumb printing a piece of paper without even reading it or at least being informed about its content. Several studies in the literature recommend specialized training courses aimed at teaching ethical and legal aspects of informed consent process and several checklists are also devised to address its certain intricate components and documentation^2,4. Authors suggested that the process of informed consent can be improved by using modern tools such as e-health projects, multimedia programmes and interventions such as shared decision making could be beneficial. Further work is required to standardize the process of surgical informed consent within the guidelines. Yet there is much more to this formal and legal process that needs to be acknowledged. This cumbersome process can be taken as an opportunity to educate patients about their illnesses in a more cordial way. Generally, a layman is unaware of most of the medical jargon and especially the internal human anatomy. As a result their concepts regarding their disease are obscure which also hinders their ability to make health related decisions autonomously. Here comes the role of a surgeon as a teacher in the society, striving to educate his/her patients. The surgeon performing the procedure must evaluate the patients’ literacy or IQ level by assessing their perceptions of their illness and expectations regarding the treatment. This process would allow the surgeon to tailor information delivery according to each patient’s intellectual level. An established practice in this regard is to provide information to the extent which a reasonable person would like to know⁵. For instance, in our routine practice, the operating surgeon uses handmade simplified anatomic diagrams which would enhance the patient’s understanding of a given procedure. In the same way every possible outcome is discussed simultaneously along with answering all the patient’s queries and concerns. This strengthens the patient-clinician relationship even more and improves patient’s compliance throughout the operative and postoperative period. Lawsuits are a financial drain on the healthcare system; however, this should not objectify the informed consent process to legal documentation or paperwork alone. Instead a more compassionate approach towards patient education and welfare can lead to better outcomes and compliance.

Acknowledgement: None.

Disclaimer: None.

Conflict of Interest: There are no competing interests between the authors.

Source of Funding: Self-funding by the researchers.

References

1. Camacho S. The Incorporating of 3-Dimensional Skills on Surgery Education Would Improve Curricula. J Invest Surg. 2019:1-3.

2. Hanson M, Pitt D. Informed consent for surgery: risk discussion and documentation. Can J Surg. 2017; 60:69-70.

3. Veerman MM, van der Woude LA, Tellier MA, Legemaate J, Scheltinga MR, Stassen LPS, et al. A decade of litigation regarding surgical informed consent in the Netherlands. Patient Educ Couns. 2019; 102:340-5.

4. Amir M, Rabbani MZ, Parvez MB. Informed consent in elective surgical procedures: "what do the patients think"? J Pak Med Assoc. 2009; 59:679-82.

5. Beauchamp T CJ, editor. Principles of biomedical ethics. 7th ed. New York, NY: Oxford University Press; 2013.