Authenticity of informed consent in anaesthesia : ethical reflection on the dilemma of informed consent in anaesthesia

Potgieter, Helet Elizabeth (2020-03)

Thesis (MA)--Stellenbosch University, 2020.

Thesis

ENGLISH ABSTRACT: Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment (Appelbaum 2007: 1834). Health Care Professionals should obtain informed consent from the patient before proceeding with the proposed treatment. Therefore, the anaesthesiologist should obtain informed consent from the patient before proceeding with the anaesthetic. The requirement of informed consent implies that certain pre-requisites should be met. The patient should be competent to understand the information given to him/her. The patient should be adequately informed and thereby be able to decide, without being influenced, and should also have the right to refuse the treatment. These requirements of obtaining informed consent prompted this investigation into the authenticity of informed consent in anaesthesia and the ethical dilemma faced by the anaesthesiologist. In order to examine this dilemma in anaesthesia the thesis firstly investigates the origin and establishment of informed consent, both in biomedical ethics and in the law. It starts by investigating the concept of autonomy and the development of respect for autonomy as the basic premise for the development of the informed consent process and elucidates the move away from the paternalistic approach in medicine to the current patient centred approach. To expound the unique nature of informed consent consultation in the peri-operative environment, anaesthesia as a speciality is examined. This investigation into the history and origin of anaesthesia leads to an acknowledgment of the unique moral status of the anaesthetised patient. The patient transits from the patient-as-person to the-patient-as-body while undergoing anaesthesia, as was alluded to by the first users of anaesthesia who experienced this transition firsthand. This unique moral status questions the validity of consent in this exceptional environment. The unique ethical dilemma the anaesthetists faces in the peri-operative setting is further investigated, keeping in mind the requirements for informed consent as stipulated in bioethical literature as well as in legal and regulatory guidelines. The guidance of current thought leaders in informed consent, as well as bioethical principles as published in bioethical literature are used as tools to examine the dilemma of informed consent in anaesthesia. In an attempt to find ethical solutions to this dilemma, ethical alternatives to informed consent in anaesthesiology are investigated. Phronesis and the ethics of responsibility, virtue ethics as well as medical professionalism offers some solutions to the ethical dilemma, and if promulgated could alter the construct of informed consent in anaesthesiology as it currently exists. The unique moral status that being anaesthetised infers upon a patient also has interesting potential implications for altering the construct of anaesthetic informed consent. Lastly practical solutions to satisfy the responsibilities that current legal, regulatory and bioethical guidelines place on the anaesthesiologist are investigated. Ultimately the reality of the difficulties in obtaining authentic informed consent in anaesthesia remains a dilemma in its current form and one looks forward to future development in the bioethical and legal fields to be able to develop an authentic anaesthetic informed consent consultation.

AFRIKAANSE OPSOMMING: “Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment “(Appelbaum 2007: 1834). Dokters en ander mediese terapeute behoort ingeligte toestemming te verkry van pasiente voordat hulle voortgaan met behandeling. Dit impliseer dan ook dat ‘n narkotiseur ingeligte toestemming van ‘n patient moet verkry voordat die pasient narkose ondergaan. Dié vereistes vir ingeligte toestemming impliseer dat daar aan sekere voorvereistes voldoen moet word: Die pasient moet in staat wees om die inligting wat aan hom/haar verskaf word te verstaan. Die pasient behoort voldoende inligting te ontvang sodat hy of sy bevoeg sal wees om ‘n besluit te neem, sonder om beïnvloed te word in terme van sy/haar keuse, en die pasient moet ook behandeling mag weier. Hierdie voorvereistes vir ingeligte toestemming, en die dilemmas wat dit bring vir ‘n narkotiseur het dié ondersoek geïnisieer, met die uiteindelike doel om die outentisiteit van ingeligte toestemming vir narkose te ondersoek. Om hierdie dilemma in narkose te ondersoek, word die oorsprong en vestiging van ingeligte toestemming ondersoek, beide uit ‘n bioetiese en ‘n wetlike oogpunt. Eerstens word die konsep van outonomie en die ontwikkeling van die beginsel van respek vir outonomie ondersoek. Dit is die basiese boublokke wat die ontwikkeling van die ingeligte toestemming proses beïnvloed het. Om die uniekheid van die ingeligte toestemming konsultasie vir narkose te ondersoek, word toepaslike aspekte van die spesialiteit van narkose bepreek. Die geskiedenis en oorsprong van narkose word ondersoek en dit lei na ‘n herkenning van die unieke morele status van die pasiënt onder narkose. Die pasiënt verskuif van ‘n pasiënt-as-persoon, na ‘n pasiënt-as-liggaam tydens narkose, soos wat die eerste gebruikers van narkose eerstehands ondervind het. Die unieke morele status van die pasiënt onder narkose bevraagteken die geldigheid van kontemporêre toestemming in hierdie unieke peri-operatiewe omgewing. Die unieke etiese dilemma wat die narkotiseur ondervind word verder bepsreek, terwyl die vereistes vir voldoende ingeligte toestemming, soos voorgeskryf in etiese literatuur en wetgewing verder ondersoek word. Die huidige denke oor ingeligte toestemming, asook die bioetiese beginsels soos gepubliseer in die bioetiese literatuur, word ingespan in ‘n poging om die dilemma van ingeligte toestemming in narkose op te los. In ‘n poging om etiese oplossings vir dié dilemma te vind, is etiese alternatiewe ondersoek. Fronese en die etiek van verantwoordelikheid, deugde etiek en mediese professionalisme bied sekere oplossings vir die etiese dilemma en kan potensieel die struktuur van ingeligte toestemming vir narkose totaal verander. Die unieke morele status waarin die pasiënt onder narkose hom/haar bevind het ook interessante potensiële implikasies vir die verandering van die struktuur van ingeligte toestemming vir narkose. Laastens word praktiese oplossings, om aan die vereistes van voldoende ingeligte toestemming vir narkose, soos dit huidiglik verwag word, te voldoen, ondersoek. Ten slotte word die realiteit van die dilemma om opregte, outentieke ingeligte toestemming te verkry vir narkose beklemtoon, en word daar uitgesien na verdere ontwikkelinge in die bioetiese en wetlike vakgebiede om outentieke ingeligte toestemming te bevorder.

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