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Consent

Consent is more than "mere agreement/mere consent" - needs to be with a good quality of agreement, a special kind.

It needs to be a "valid consent", the person should:

  • Have capacity to consent (or competence) - N.B. Adults have capacity, kids have competence
  • Be able to exercise free power of choice, the decision is voluntary (free of cooercion/pressures/strains)
  • Should have significant knowledge and comprehension of the subject matter, to enable them to make an understanding and enlighted condition

These three come from the Nuremberg code

Consent could be:

  • Written - In more formal process, with legal proof
  • Verbal
  • Implied

As you go down this scale there's a greater potential for miscommunication.

Using welfare:

  • "the subject knows their own interests better than anyone else, and so is in a better position than anyone else to decide what's risky/harmful to them" - but do they really?
  • "making your own decisions, in itself contributes to welfare"

Using autonomy:

  • under deontology, without using consent, you would be treating someone as the means to an end

1) Competence - This is a decision specific issue, just because they have competence for one thing doesn't mean they have it for another, and vice versa 2) Voluntariness - Shouldn't be impaired by things like: - Coercion (physical threat, harm) - Manipulation (emotional, financial, institutional, family, witholding information) - Theres a fine line between voluntary persuasion and manipulation 3) Information

1) Full Information 2) Reasonable Doctor 3) Reasonable Patient 4) Patient Centred Approach

Makenzie and Rogers says we should listen only to AUTONOMOUS refusal decisions. Self determining, self governing, have authenticity

What about cases where:

  • Cases where there are competing wishes (where you might need to determine the "authentic" wish)
  • Cases where a persons current wishes don't reflect a settled decision
  • Cases where the patient isn't being the real them
  • Undue influence
  • Interests of others and public interest
  • Self harm
  • Protecting autonomy
  • Only respect good decisions
  • dignity
  • cost
  • impact on others

Confidentiality

Two criteria are needed for a duty of confidentiality.

  • Where the person disclosing it originally wants it kept secret
  • Where the person hearing it agrees to hold it under confidence

This is reflected in GMC/NMC guidelines

Why is confidentiality important:

  • Not undermining trust, allowing people to come forwards in the first place
  • Right to protect and control your information.
  • Breaching confidence would violate someones autonomous wishes

Confidentiality is specifically about information, privacy doesn't necessarily.

Confidentiality is generally only in a professional context.

Confidentiality is what you do with information, privacy might be how you gain that information.

You can owe duties of confidentiality to institutions, as well as individuals. Not really how that's case in privacy.

How do you use confidentiality in practice? (The GMC has 8 principles)

Including: - Using the minimum necessary personal info - How you manage and protect information

When is it ok to break?

  • Non competent patients and children
  • Patient walfare in other cases
  • Public Health?

Do the benefits to an individual or to society of the disclosure, outweigh both the patient's and the public interest in keeping the information confidential.

How do we decide when to justify disclosure?

  • Harm to patient
  • Harm to trust in Drs
  • Harm to others
  • Benefits to patient
  • Nature of the information
  • Views of patient
  • Is there another way than disclosure