The Challenge of Informed Consent
Article Outline
- How Informed Was This Patient's Decision?
- Did a Single Psychiatric Assessment Meet a Duty of Care?
- Prognosis of Terminal Illness
- Transmission of Hopelessness
- References
- Copyright
Euthanasia was legal in the Northern Territory, Australia, between July 1, 1996 and March 25, 1997. Four citizens died under the ROTI Act.1 Terminal illness was only defined as a death that would occur “in the normal course and without the application of extraordinary measures.” Two medical practitioners were required to certify that the patient was of sound mind and making his or her decision freely, voluntarily and after due consideration. A psychiatrist needed to confirm that the patient was not suffering from a treatable clinical depression resulting from the illness. The Regulations required that the patient be provided with information about the availability of palliative care.
How Informed Was This Patient's Decision?
In contrast with the Provisions of the Oregon Death with Dignity Act,2 there was no requirement for counseling within the ROTI Act, and the psychiatrist had to judge whether any depressive disorder was treatable. While she clearly met DSM-IV diagnostic criteria for a major depressive episode, the psychiatrist implied she was untreatable, but did not demonstrate consideration of other treatment options including responsiveness to alternative antidepressants, counseling, and family therapy. Her mood appeared to have been “normalized” as a predictable response to her medical condition. Acceptance that she had an autonomous right to euthanasia may have prevented this clinician from considering his or her duty under the Mental Health Act to protect a suicidal patient from endangering herself, the former Act taking precedence over ROTI. A severe depression, the intensity of which was defined by her suicidal ideation, influences a person's reasonable judgment about self and the value of life, leading to the likelihood of an uninformed decision about the probable results of treatment, and any feasible alternatives influencing prognosis. She might have been judged “incapable” under the influence of her severe depression. The voluntariness of her choice for euthanasia was influenced by her not being informed of the availability of effective treatment for depression nor being given the opportunity to have her suffering alleviated.
Did a Single Psychiatric Assessment Meet a Duty of Care?
There are risks associated with a single psychiatric assessment. In one Oregon survey,3 only 6% of psychiatrists indicated that they could complete a competent gate-keeping task from a single assessment. This assessment role may be perceived as adversarial and not conducive to the development of a therapeutic alliance, upon which successful counseling must depend. Duty of care requires an appropriate trial of proper treatment, with thorough attention to diagnosis, choice and dose of medication, length and variation of therapy, and second opinion if the clinician is unfamiliar with the clinical circumstances present.
Prognosis of Terminal Illness
Accurate appraisal of prognosis is notoriously difficult, particularly when the future may yet involve months or years. In this case, there was difference of opinion among clinicians regarding how terminal she was, yet no means within the safeguards to protect the misinformed patient. Wanting to end her life, she sought further opinions until someone certified what she desired. There was no notification process for a nonterminal status under the ROTI Act, and the coroner failed to take action when an orthopedic surgeon, not a practitioner with expertise in the management of mycosis fungoides as required by the regulations, made the certification regarding her prognosis.
Transmission of Hopelessness
Any capable patient has a clear right to decline medical treatment including palliative care, but the pragmatic challenge is to provide the patient with comprehensive information regarding options. The message that no more can be done is harmfully delivered by some clinicians attempting to communicate primarily about chemotherapy. This was evident in her management and is likely to have exacerbated her hopelessness. This transmission of hopelessness and helplessness to spouse, family, other care-providers, and the community becomes a systemic problem necessitating a family-centered approach to care, usually supported by a well-functioning multidisciplinary team. Alas, care of this quality was not available to this patient or her family. Clearly, medical practitioners have a responsibility to monitor their personal attitudes to a patient and the clinical problem to ensure that they do not unwittingly transmit negative countertransference feelings in a harmful manner.
The clinical experience observed during the brief life of the ROTI Act could be regarded as an experiment in which the legislation that supported the practice of euthanasia can be examined for its effectiveness.4 This patient generated a range of ethical concerns regarding the nature and quality of her medical care. Her story demonstrated the inadequacy of the provisions of the ROTI Act and suggested that the vulnerable cannot be safely protected by such legislation.
References
- . Northern Territory of Australia. Darwin: Government Printer; 1995;
- Oregon Death with Dignity Act, Oregon Revised Statute 127.800–127.897.
- Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry. 1996;153:238–242
- . Seven deaths in Darwin (case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia). Lancet. 1998;352:1097–1102
PII: S0885-3924(00)00122-6
© 2000 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
