Registrar’s message: consent to treatment―development of a new practice standard
The CMPA has a very comprehensive and helpful online guide for Canadian physicians on consent. In the introduction, it states that it is a basic and accepted principle that “every human being of adult years and of sound mind has the right to determine what shall be done with his or her own body.” At its core, consent is a patient’s agreement without threat or coercion to receive medical treatment.
The College recently conducted a first consultation with registrants, the public and key health partners on a new practice standard, Consent to Treatment, which closely tracks the expectations of other regulators across the country. The summary of findings indicates that while the core principles as presented in the standard are clear, more work needs to be done to fully understand the consent process for people in all contexts, including those with disabilities, those living with dementia or mental illness, intersex and transgender people, Indigenous Peoples, and other vulnerable groups.
Considering the innate imbalance of power, and historical and ongoing abuses―such as coerced sterilization of Indigenous patients and others of colour―careful attention needs to be given to the importance of having conversations, documenting and using forms during the consent process that are culturally safe and appropriate.
This act of cultural humility is a way to avoid coercion, including the coerced sterilization reported on and denounced at the Canadian Senate hearings on human rights (2021, 2022) and in the Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls Final Report (2019).
Read a recent joint statement from the College and the First Nations Health Authority on forced or coerced sterilization.
Complexities within the medical system can create barriers to free prior consent for patients, including informed decision-making.
Uninformed consent or consent through coercion may occur when:
- A health-care provider and system bias or views impact decision-making
- Patients experience pressures of time
- Patients are under duress or threat
- Patients are under sedation
- The medical language used in conversation, during counselling or when completing forms is too complex
- Conversations occur without a patient advocate, a trusted team or a familiar provider
- The situation is not culturally safe
- The medical risk or benefit is over-emphasized to sway a decision
For free, prior consent to occur during decision-making about sterilization, for example, registrants should reflect on their own personal biases, and take steps to ensure these biases do not impact a patient’s autonomy of choice or reproductive decisions. As leaders on a care team, they should also ensure accountability for all members, including allied health, administrative, and other staff.
Care teams should also confirm that there is no obvious or subtle threat to the patient. For example, it may not be appropriate for a social worker to be present in a contraception counselling appointment as their presence could imply possible loss of parental rights and removal of children to foster care.
And, conversations and decisions regarding sterilization or other non-medically necessary and non-emergent but life-changing interventions should be done in advance, and not made under stress or duress (for example, immediately post-partum if no prior discussion and consent has occurred).
Other methods to ensure informed patient consent include:
- Objectively providing complete and unbiased information
- Recognizing innate power imbalances
- Translating medical documentation and having plain-language conversations
- Confirming the patient is emotionally ready for the conversation
- Establishing empowering conversations
- Ensuring shared decision-making over time
- Creating the time and space to have a conversation to make certain the patient can understand and articulate the nature of their condition and the proposed treatment that is being offered
The College will continue to hold discussions with registrants and patient advocacy groups on the topic of informed consent and anticipates circulating an updated draft practice standard in late fall.
As always, we sincerely thank registrants and our key health partners for providing their input into the College’s practice standard development process. Practice standards must be clear, concise, and applicable to current medical practice. We appreciate hearing from the people who are directly affected by them.
Heidi M. Oetter, MD
Registrar and CEO
Note: This article was developed with generous input from Dr. Unjali Malhotra and her team responsible for women’s health at First Nations Health Authority.
- Reclaiming Power and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls
- Forced and Coerced Sterilizations of Person in Canada: Standing Senate Committee on Human Rights
- Sacred and Strong: First Nations Health Authority Report on the Health of First Nations Women in BC
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