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Theories of consent
Alderson and Goodey (1998) provide an excellent review of the different theories of consent and how they pertain to current healthcare.
“Real consent” is described as a positivist approach based on factual concepts defined through either achieving a certain level or not. It allows standards to be set and for consent to be researched in a scientific or systematic way.
However the standards are high for patients to reach the expected levels of knowledge and for professionals to pass on the information in an effective manner. It is therefore particularly unhelpful in borderline cases such as sedation at the end of life.
“Constructed consent” looks at consent from a range of social constructs. They suggest that understanding is put forward as the most predominant factor in modern health care, but that voluntariness needs much more consideration. Complex desires and resistances may either confuse or enrich understanding. Patients may initially be anxious over the thought of invasive or risky treatments as an immediate reaction but in time balance this against the anxieties over the situation they will remain with if they decline the intervention. Increasing trust in their health care team helps such a process.
In addition, if we consider the individual identities and experiences that make up the person then consent moves further away from the emotionless “real” approach. Abilities to understand are not fixed personal attributes but instead “responses in relationships partly influenced by the professional’s ability to explain, respect and support”. This may allow both to move towards a position where patients are regarded as competent to make certain treatment decisions whilst sharing or deferring other aspects. An ability to decide is different to wanting to be the responsible decider.
Coercion traditionally is seen as a bad thing with the “real” approach trying to limit the interference of outside influences. In this social construct it is recognised that such outside influences cannot be excluded and patients may want to include them as part of their decision-making. For example a patient considering sedation at the end of life might state: “She wouldn’t want to see me agitated, she always said she wouldn’t want to see me suffering so I want to use high doses of sedation”. In this situation the patient may be seen to have undue influence indirectly exerted by his partner, alternatively this could be part of his reasoned and autonomous decision-making.
By this method consent becomes a process rather than an event. The influences in the patients’ life can be varied including family, professionals, past memories, media, friends and all these help to produce the final outcome.
“Functionalist consent” is described by the authors as a “polite ceremony” where consent is a routine process whereby the smooth running of healthcare is unaffected and responsibility for the consequences of a decision pass from the professional to the patient.
Conversely “critical theory” sees consent as a “necessary protection for patients against useless, harmful and unwanted interventions”. This promotes medical accountability and rather than being a one way passing of medical information, consent is seen as an exchange of knowledge so that informed decisions can be made together.
Finally the authors consider “postmodernism” and its influence on consent. They describe the increasingly frequent approach to patients as consumers and the need to offer choice. Individuals who are used to extensive choices in the day to day consumer market expect the same in health care, but the values and decision-making processes people utilise when buying a new television or choosing clothes cannot be the same as when making important healthcare decisions. The authors raise the question as to how patients do approach such decisions. They suggest choice can be too onerous when people are uncertain how to make autonomous decisions or balance their values and rules in the process.
In summary these theories show the complexities of consent and the need for more than just one approach. Constructed theory of consent appears most relevant to the decisions regarding sedation at the end of life, though other theories also have some role. For example, There is a need to maintain some idea of the “real” approach in order to have some validity and generalisability.
The information in this section is level IV or V.
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