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INFORMED CONSENT
No profession enjoys more trust and admiration than the medical
profession. From birth to death, the doctor is often the first
and last person to attend to our physical needs. Most people
quite literally place their lives in the hands of their doctors.
Countless thousands of people are alive today, because of effective
medical intervention. No one knows how many people suffer or
die as a result of ineffective medical treatment. Sometimes disease
is doctor-induced. This is known as iatrogenesis. Not infrequently
medical treatment kills patients. In fact, doctors are the third
leading cause of death in the US (See:http://www.mercola.com)
Nowhere is this more true than with cancer treatment which invariably
makes patients feel worse than the disease does and in most cases
(about 62 per cent) fails to save patients' lives. See The Cancer
Conspiracy: http://members.shaw.ca/jmoelaert Over
a million patients are injured in US hospitals each year, and
approximately 280,000 die annually as a result of these injuries.
Therefore, the iatrogenic (doctor-caused) injury rate dwarfs
the annual automobile accident mortality of 45,000 and accounts
for more deaths than all other accidents combined." (JAMA,
July 5, 1995, 274:29-34.)
This death rate is about equal to three loaded jumbo jets crashing
and killing everyone aboard every two days. Can we do better?
Almost all health providers agree that good preventive care must
start at home. The dispute arises over where to draw the self-
care line. It is a big jump from eating less fat to, say, curing
pneumonia with 20,000 milligrams of vitamin C an hour, but both
can be done.
About 90% of the patients who visit doctors have conditions that
will either improve on their own or that are out of reach of
modern medicine's ability to solve." (New England Journal
of Medicine, Feb 7, 1991)
It is of crucial importance to understand the role and limits
of modern medicine. Only then is it possible for a patient to
make an informed decision about accepting or rejecting medication
or a medical procedure recommended by a doctor.
The first step is to understand the limitations of modern medicine.
To begin with it must be recognized that medicine is not an exact
science like mathematics. It is largely a belief system in which
guesswork is a major component. If one drug doesn't work, another
is prescribed which basically reduces the patient to a guinea
pig. Well-known US physician Dr. Isadore Rosenfeld said during
a CNN interview (January 23, 1997) that 80 per cent of patients
get better whether they see a doctor or not. Fellow American
Dr. Ralph Moss points out in his book The Cancer Industry that
medical misdiagnosis is so common that people are often treated
for and "cured" of a disease they never had in the
first place. It is important to understand that no doctor has
ever healed a patient, only the body can do that. Doctors can
and do, of course, help and sometimes hinder the healing process.
As Dr. Rosenfeld and other physicians have pointed out, 80 per
cent of the time a body will heal itself with or without medical
intervention. What this adds up to is that in the vast majority
of cases people get medical treatment they don't need. But in
most cases a patient who takes prescribed drugs will credit their
doctor and the medication for getting better even though in most
cases they would have gotten better anyway without the treatment.
Since life is a one-track experience it is impossible to know
how many patients get better because of medical treatment and
how many despite it. While it is widely accepted that in 80 per
cent of all cases it makes no difference whether a person gets
treatment or not, in ten per cent of all cases, medical treatment
(like setting a broken leg) is indisputably effective and the
other ten per cent of patients will die regardless whether they
get treatment or not. In other words the overall medical success
rate is only ten per cent!
In some cases such as terminal cancer, no treatment is the best
treatment, except for painkillers. Dr. Hardin Jones, Professor
of Medical Physics at the University of California, discovered
after 33 years of statistical research that cancer patients who
were not treated lived up to four times longer than treated patients.
In the summer 1998 issue of Lancet, Britain's prestigious medical
journal, an article states that lung cancer patients who received
radiation treatment had a 20 per cent higher mortality rate than
non-radiated lung cancer patients. According to a McGill University
study most doctors who prescribe chemotherapy for terminal lung
cancer patients said they would refuse such treatment for themselves
or members of their family if they had terminal lung cancer.
Clearly there is no medical or ethical justification for subjecting
terminal cancer patients to either chemotherapy or radiation
since both treatments make patients feel even worse and debilitate
their already critically weakened immune system. But while neither
provides medical benefits for patients, there are major financial
benefits for members of the Cancer Establishment. After all cancer,
is not only a terrible disease, it is also a multi-billion dollar
industry....
How does one decide whether to accept or reject medical treatment?
A prerequisite is to weigh the risks against the benefits and
consider the failure-success ratio. To enable a patient to make
an informed decision, a doctor must provide all relevant information
concerning the proposed treatment. While physicians are required
by law to do this, they often don't. In 1980 the Supreme Court
of Canada unanimously ruled that
"Physicians must disclose--unasked--what an objective,
reasonable person in the patient's position would like to know
before agreeing to a procedure or not agreeing. This includes
disclosure of all material risks."
Obviously, to make an informed decision a good patient-doctor
relationship is of crucial importance to both. Yet the role of
each is often not clear. Traditionally this relationship is seen
in oversimplified terms: a patient is a person who needs medical
attention and a doctor provides it.
A typical visit to a doctor goes something like this: the patient
describes the symptoms and history of the problem. The doctor
evaluates the information, probably asks questions and possibly
performs an examination, then prescribes a course of action which
could range from medication to surgery. If there is any doubt
the doctor may order diagnostic tests before deciding on a course
of action.
However, the ideal patient-doctor relationship is not a one-way
affair, but a partnership in which each plays a very distinct
role. The doctor's responsibility goes beyond determining the
nature of the problem and the best possible remedy. Doctors should
explain the reasons for their recommendations as well as the
benefits and risks of any proposed treatment.
Interestingly the need to fully inform patients is recommended
in the Code of Ethics of the Canadian Medical Association:
"The physician will recognize a responsibility in
advising the patient of the findings and recommendations and
will exchange such information with the patient as is necessary
for the patient to reach a decision.... A patient has the right
to accept or reject any physician and any medical care recommended...(and)
to request of that physician opinions from other physicians of
the patient's choice."
The right of informed consent is a key component in malpractice
suits. If a medical procedure results in a patient's injury or
death and it can be proven that the risks of that procedure were
not explained to the patient, the doctor involved may be held
liable, although few are ever successfully prosecuted. In Canada's
entire history only one doctor has ever been found guilty of
criminal negligence in the performance of his duties. This involved
an anesthetist who during an operation went to a pay phone in
the hallway to make a call during which his patient went into
shock and died.
A conscientious and caring physician will provide all relevant
information a patient needs to make the best possible decision.
Unfortunately this often does not happen for various reasons.
For example, a physician may not think it's necessary or doesn't
know all the risks. To illustrate the latter case: few doctors
know the amount of radiation a patient is subjected to when undergoing
specific x-ray examinations. If asked, most doctors will simply
say they are safe. They are not. X-rays are a very important
diagnostic tool and often the benefits outweigh the risks, but
x-rays are not without risk. Moreover the effects are cumulative
and depending on the type and frequency of x-ray procedures,
they can cause cancer. It is worse in cancer treatment centres
where patients are rarely given a complete account of what the
possible side effects of a prescribed treatment are nor the failure
rate of that treatment.
In all fairness it must be pointed out that doctors often find
themselves in very difficult positions, because if they fail
to recommend some form of treatment and the patient's condition
should seriously deteriorate, they could be sued for malpractice.
For this reason many x-rays are taken more for legal than medical
reasons. This shows that providing all relevant information about
suggested treatment (or the probable consequences of rejecting
such treatment) is as much in the doctor's interest as the patient's.
Informed consent is particularly important in surgery cases when
a patient is asked to sign a consent form to authorize specified
procedures. The text may include the following:
"it is understood that the physicians may exercise
judgement in emergencies and in any unforeseen circumstances,
for the good of the patient, to perform other necessary or advisable
procedures. Surgical operations, treatments and special diagnostic
procedures may involve risks of complications, injury or even
death. No guarantee can be made as to result or cure." *
This is the equivalent of signing a blank cheque. A patient
is well advised to discuss probable as well as possible scenarios
and exercise his right to define surgical limits.
In emergency cases when a patient is unconscious, medical intervention
is likely to take place without his or her consent. In such cases
doctors have little choice, for if they fail to provide immediate
medical help, they risk being held liable for the consequences.
In all other cases it should be clear that in the legal interest
of the doctor and the health interest of the patient, the fundamental
right of informed consent should not be taken lightly and be
exercised prudently whenever possible. A Living Will-- while
not legally enforceable-- is an important document that may protect
the interest of both doctor and patient. Everyone should have
one.
* Partial text of consent form used
at The Royal Jubilee Hospital in Victoria, B.C Canada.
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