{"id":229,"date":"2010-05-15T10:07:26","date_gmt":"2010-05-15T09:07:26","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=229"},"modified":"2010-05-15T10:07:26","modified_gmt":"2010-05-15T09:07:26","slug":"consent-and-consensus","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/05\/15\/consent-and-consensus\/","title":{"rendered":"Consent and Consensus"},"content":{"rendered":"

For the past week, the news in the UK has been all about coalitions, compromise, consensus and that sort of thing.\u00a0 The hung Parliament has been heralded as ushering in a new era of politics-by-agreement, rather than by the traditional Westminster model of simply flattening everyone else.\u00a0 And a lot of people seem to think that such a change in tone is a good thing.<\/p>\n

But it’s not just in politics that consensus has its supporters.\u00a0 You occasionally see it popping up in medical contexts – specifically, when it comes to questions of consent.<\/p>\n

A couple of papers that I’ve read recently that grapple with everyday dilemmas in clinical practice have recommended negotiation, compromise and consensus as means of easing dispute. \u00a0In his recent\u00a0Autonomy, Informed Consent and Medical Law<\/em><\/a>,\u00a0Alasdair Maclean makes a bid for seeing consent as something reached by agreement between HCP and patient: he recommends that both parties should try to decide on a course of action that is mutually acceptable. (Incidentally, you can see my full review of the book in the <\/a>MLR<\/a><\/em>.) \u00a0And, not so long ago, I was speaking with some medics who were talking favourably about strategies of negotiation and compromise as a way of settling disputes between what\u00a0the patient wants and what the HCP wants or is prepared to give.<\/p>\n

For example, one of the conversations, a medic was describing a situation in which information had come to light that the patient did not want sharing with her family, but which the medic thought it important to share for all kinds of reasons.\u00a0 This particular medic’s response to that situation had been to try either to get the patient to disclose that information herself, or to get her approval for the release of limited information on her behalf.\u00a0 The point is that the medic had attempted to get the patient to see the world from another perspective, in the hope that this might alter her preferences about what to do.<\/p>\n

I can see why people might be attracted to this idea of mutual decisionmaking.\u00a0 But I\u2019m very suspicious of it. \u00a0This is for what I think is a couple of reasons – although they’re so closely related that they might be versions of the same reason.<\/p>\n

One consideration is that the insistence on negotiation shifts the balance of power from the patient back to the medic, and as such it undermines the patient’s absolute rights over his body that are supposed to be protected by consent to begin with. \u00a0It also gives a slightly strange picture of the medic’s role: as if he’s dying to operate, and it’s only the mean-spiritedness of the patient that’s stopping him. \u00a0But that’s not, of course, how medicine works. \u00a0In reality, the patient says, “It hurts here<\/em>,” and the medic replies, “Well, I think that the best options would be this<\/em> or this<\/em>“; and if the patient decides that he doesn’t like the sound of either, then he can take the third option and decide he’ll have neither. \u00a0That is to say, the patient is looking for a service to be done, and has the ability to decide that he doesn’t want it after all; the medic is, in this sense, a service provider.\u00a0 It\u2019s not obvious why anyone would want to add negotiation to the mix, or what would be achieved by it – except diluting the patient’s sovereignty.<\/p>\n

Moreover, it means that the patient\u2019s initial decision is rendered suspect – and, potentially, that the patient has to justify not giving consent.\u00a0 This isn\u2019t a hyperbolic worry: Maclean, bizarrely (I think), seems to accept this possibility:<\/p>\n

While the law should not force patients to change their decisions, it should require the healthcare professional seek both reasons and explanations for the decision<\/strong><\/em>. (p. 146; emphasis mine)<\/p><\/blockquote>\n

Um… no.\u00a0 This isn’t an arrangement we’d want in any other relationship. \u00a0You don\u2019t have to justify your decision not to buy the washing machine, or your decision not to have sex.\u00a0 There\u2019s nothing to negotiate.\u00a0 The same, I think, applies here.<\/p>\n

The small concession is that I can see that it might be politic to try to persuade when there\u2019s a public health aspect.\u00a0 If the doctor can persuade the patient to tell his partner about his STD, then that\u2019s probably a good thing.\u00a0 But, still \u2013 if the doctor is sufficiently worried, I think that there\u2019s a moral case for saying that the right thing to do isn\u2019t created by conversation; and there may be times when saying, \u201cNuts to your privacy, matey, I\u2019m telling, like it or not\u201d is perfectly in order.\u00a0 To talk about arriving at a mutually acceptable courses of action seems either to be platitudinous or simply the wrong decision. \u00a0And, of course, to advert to the Harm Principle or something appreciably like is always an option in cases like this.<\/p>\n

The other objection to negotiated solutions to disagreements is that they reward the person who cares more about the outcome, or who is simply the more stubborn; and so frequently these \u201csolutions\u201d don\u2019t do anything but waste time anyway.\u00a0 If I want x<\/em> and you want ~x<\/em>, and if I know that you\u2019re open to negotiation, then all I have to do is dig my heels in and wait for you to come to me.\u00a0 If both parties know this, it means that the \u201cnegotiation\u201d will be no such thing; ditto if only one does.\u00a0 It\u2019s only if both parties are willing to negotiate that negotiations achieve anything; but in those cases, it looks like neither party cares much about the outcome anyway, so the victory that we give to consensus is fairly pyrrhic.<\/p>\n

Where does this leave us?\u00a0 I\u2019m not sure.\u00a0 But, wherever it is, it\u2019s with a suspicion of aiming for consensus in every decision. \u00a0I don’t want to compromise on being uncompromising. \u00a0Still, I’m happy to wait for you to see things my way.<\/p>\n","protected":false},"excerpt":{"rendered":"

For the past week, the news in the UK has been all about coalitions, compromise, consensus and that sort of thing.\u00a0 The hung Parliament has been heralded as ushering in a new era of politics-by-agreement, rather than by the traditional Westminster model of simply flattening everyone else.\u00a0 And a lot of people seem to think […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1081,563,1266,472],"tags":[],"class_list":["post-229","post","type-post","status-publish","format-standard","hentry","category-consultation","category-language","category-shameless-self-publicity","category-thinking-aloud"],"yoast_head":"\nConsent and Consensus - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/05\/15\/consent-and-consensus\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Consent and Consensus - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"For the past week, the news in the UK has been all about coalitions, compromise, consensus and that sort of thing.\u00a0 The hung Parliament has been heralded as ushering in a new era of politics-by-agreement, rather than by the traditional Westminster model of simply flattening everyone else.\u00a0 And a lot of people seem to think [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/05\/15\/consent-and-consensus\/\" \/>\n<meta property=\"og:site_name\" content=\"Journal of Medical Ethics blog\" \/>\n<meta property=\"article:published_time\" content=\"2010-05-15T09:07:26+00:00\" \/>\n<meta name=\"author\" content=\"BMJ\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"BMJ\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"5 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/05\\\/15\\\/consent-and-consensus\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/05\\\/15\\\/consent-and-consensus\\\/\"},\"author\":{\"name\":\"BMJ\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\"},\"headline\":\"Consent and Consensus\",\"datePublished\":\"2010-05-15T09:07:26+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/05\\\/15\\\/consent-and-consensus\\\/\"},\"wordCount\":1021,\"commentCount\":5,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#organization\"},\"articleSection\":[\"Consultation\",\"language\",\"Shameless self-publicity\",\"Thinking Aloud\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/05\\\/15\\\/consent-and-consensus\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/05\\\/15\\\/consent-and-consensus\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/05\\\/15\\\/consent-and-consensus\\\/\",\"name\":\"Consent and Consensus - 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