Consent is an expression of a patient's autonomy and right to choose what treatment is best for them. It's important to remember that this is not always the treatment doctors think is best.

"From the legal perspective, the only difference between the surgeon and a mugger with a knife is the consent of the patient."¹

Treating patients without their consent may leave doctors open to a Medical Council investigation, disciplinary investigation, clinical negligence claim - or, at worst, criminal charges.

For consent to be valid, three conditions must be met:

the patient must have the capacity to give their consent (see our separate guide to capacity or more information)
the patient must have been provided with enough information on which to base their decision, including details of risks involved
the patient must give their consent voluntarily.

Consent is a process and not a one-off event. It involves dialogue, plus supplementary information and the completion of a consent form.

Information

The Medical Council has provided advice on consent in its Guide to Professional Conduct and Ethics for Registered Medical Practitioners. It explains that consent is a fundamental ethical and legal requirement in medical practice and is based on respect for patient autonomy.

It goes on to say that the process of consent involves dialogue between the patient and the doctor and the ongoing sharing of relevant information in relation to the patient's condition and any proposed treatment.

Doctors must listen to the patient and provide them with information in a way that they can understand. Patients should be given as much time and support as possible, and you should answer their questions as accurately and honestly as you can.

Patients must receive sufficient information about any proposed treatment in a way that they can understand. This will vary depending on:

the patient's own wishes
the patient's level of knowledge and understanding
the nature, complexity and urgency of the treatment indicated
the likelihood of success or failure of the treatment and the risk associated with taking no action or taking an alternative approach.

For consent to be valid, it must be given freely. Patients must understand that they have the right to give, decline and withdraw consent at any time.

HSE has published a National Consent Policy, which explains that a doctor is expected to provide sufficient information that is comprehensible to the patient about the potential risks and benefits of a proposed procedure. It also says that patients should be given this information at a time and in a format that will maximise their ability to understand it and communicate their choice.

The courts define 'material risk' as a risk to which a reasonable person in the patient's position would attach significance².

All of this means that doctors are required to adopt a patient-centred approach³ and tailor discussions to each individual patient when seeking their consent.

For example, a rare side effect, if it were to materialise, might have a significant effect on one patient's life but a negligible effect on another. It would therefore be essential to explain this when seeking consent from the first patient but less so when seeking consent from the second.

Voluntariness

Consent is only valid when it is given voluntarily, and doctors need to be aware that pressures on patients to provide consent can manifest in various ways. HSE's National Consent Policy refers to:

duress: this refers to pressures or threats improperly imposed by others such that the person believes they have no alternative but to consent
undue pressure or influence: this may arise where third parties, including family, friends or healthcare workers, pressurise a patient to accept or reject a particular intervention.

The HSE policy advises that if there is evidence of either, the doctor should consider meeting the patient alone in order to discuss their treatment in private and to also consider if there needs to be an adult safeguarding referral, or in some cases a report to the Gardai.

Last minute consent may not be valid due to factors like the pressure of imminent surgery, or the effects of medication/sedation.

Refusal of treatment

Giving consent goes hand in hand with the right to refuse treatment, which in Ireland is a constitutional right. This right includes the right to refuse treatment on any basis, including an irrational one, so long as the patient has capacity.

The Medical Council says at paragraph 18 of its guidance that in such circumstances a doctor should, "explain clearly to the patient the possible consequences their decision and offer them a second medical opinion."

When it may not be possible to obtain valid consent

The HSE policy says that only in life-threatening emergency situations, where treatment is immediately necessary to preserve life or health, and the patient lacks capacity or obtaining consent would unacceptably delay treatment, may a doctor treat without a patient's express consent.

The only other situation in which HSE says it may not be possible to obtain patient consent is in the small number of cases where a patient does not wish to receive information about their condition, prognosis or treatment options. The HSE policy says that such decisions should be respected if possible, but that basic information should be provided so that patients know what their treatment will involve.

Doctors should document in detail the patient's expressed wishes, and we would advise doctors wherever possible to consult with their colleagues and with the MDU before treating patients in such circumstances.

¹ Informed consent and other fairy stories (1999), 7(2) Medical Law Review 103-4

² Geoghegan v Harris [2000] 3 IR 536

³ Fitzpatrick v White [2008] 3 IR 551

Introduction to consent in the Republic of Ireland

Paying too much for your indemnity

More on Republic of Ireland

Related articles