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Consent, Capacity and Jehovah's Witnesses - Medical Ethics & Law for interviews

2017-12-21 · Long video (solo, talking head or whiteboard) · Ali, Charlotte, Molly Hunt, a guest · recording, 25:45 · watch on YouTube

Topic: Medicine and his doctor years · mode: Explanation and tutorial · tags: Aimed at students

In the second video of his medical ethics series for medicine interviews, Ali and his friends Charlotte and Molly explain the law of consent: valid consent must be voluntary, informed and competent (Re T, the Bolam test, Montgomery), how capacity is assessed, consent in under-18s (Gillick competence), and advance directives, LPAs and best-interests decisions.

What is said

The parts of the video and what is said in each (★ — how much it matters to the video).

00:00:00 — Ali introduces the consent, capacity and Jehovah's Witnesses video of his medical ethics series

  • ★ Ali presents a video on consent, capacity and Jehovah's Witnesses as part of his Medical Ethics for Interview series. — 00:00:00 · Medical ethics

00:00:29 — Thirty-second summary of consent and capacity

  • ★★★ Ali says doctors need consent before they operate or do anything to anyone, because otherwise it is assault. — 00:00:29
  • ★★ Ali says that for a patient without capacity doctors look for an advance directive or a lasting power of attorney, and if there is neither, as most of the time, act on a best-interests principle. — 00:00:58 · Advance directive, Best interests

00:01:27 — Charlotte and Molly introduce the case: a woman withdraws consent to a caesarean section

  • ★★ a guest: In the opening case, a pregnant woman at term whose baby is in distress first consents to a caesarean section, then withdraws her consent at the last minute because she is terrified of needles. — 00:02:17

00:02:45 — Re MB as a classic interview case and why the three components of valid consent impress

  • ★★ Ali says the case of the woman refusing a caesarean, Re MB, is a very classic case that interviewers might ask about. (hedged) — 00:02:45 · Medicine interview
  • ★★ Ali says applicants can probably make up the four principles (autonomy, beneficence, non-maleficence, justice) on the spot, so the video covers the specifics of capacity and consent instead. — 00:03:14 · Four principles of medical ethics
  • ★★ Ali says consent scenarios are surprisingly common in interviews, and saying that valid consent needs three things, informed, voluntary and competent, looks very impressive. — 00:03:14 · Medicine interview
  • ★★★ a guest: In law, consent is valid only if it is voluntary, informed and competent. — 00:03:43

00:04:05 — Voluntary consent: Re T and Jehovah's Witnesses

  • ★★ a guest: Re T was a legal case of 1992 about a young pregnant woman who needed a blood transfusion after a car crash. — 00:04:12 · Re T
  • ★★ a guest: T came from a family of Jehovah's Witnesses, who have historically opposed transfusion of blood products for religious reasons, which can make doctors' decisions difficult. — 00:04:36 · Re T
  • ★★ a guest: Both consent and the refusal of consent are valid only when they are voluntary. — 00:05:06
  • ★★ a guest: In Re T, after time with her Jehovah's Witness mother T refused the transfusion; because doctors felt her mother had pressured her, the refusal was deemed invalid. — 00:05:06 · Re T

00:05:53 — Informed consent: the Bolam test and the Montgomery case

  • ★★ a guest: For consent to be informed, doctors must give patients all the information needed for a reasoned decision, including the possible benefits and all the complications and risks. — 00:06:16
  • ★★ a guest: Under the Bolam test, used historically to decide how much information to give, a doctor was legally in the clear if another group of reasonable doctors would have done the same. — 00:07:03 · Bolam test
  • ★★ a guest: The Montgomery case began in 1999, when Nadine Montgomery gave birth to her son Sam. — 00:07:42 · Montgomery ruling
  • ★★ a guest: During the vaginal delivery Nadine Montgomery's son Sam got stuck and was deprived of oxygen for over 10 minutes, and developed cerebral palsy. — 00:08:04 · Montgomery ruling
  • ★★ a guest: Nadine Montgomery took the case to court, saying she should have been warned of the risk of shoulder dystocia. — 00:08:42 · Montgomery ruling
  • ★★★ a guest: Since the Montgomery case the standard for informing patients has moved from what a reasonable doctor would tell a patient to what a reasonable patient would want to know. — 00:09:07 · Montgomery ruling, Bolam test
  • ★★ a guest: What a reasonable patient would want to know is judged case by case: for a patient already blind in one eye, the risk of losing sight in the other eye matters far more. — 00:09:50
  • ★★ a guest: Informed consent means the patient has been told the benefits and risks to the level a reasonable patient would expect. — 00:10:27

00:10:55 — Competent consent and the Mental Capacity Act

  • ★★ a guest: The Mental Capacity Act, written in 2005, tells doctors how to assess someone's capacity to make a decision. — 00:11:06
  • ★★ a guest: All adults are assumed to be competent unless proven otherwise. — 00:12:08

00:12:38 — Ali introduces Fraser guidelines and Gillick competence

00:13:02 — Consent in 16 and 17 year olds and Gillick competence in under-16s

  • ★★ a guest: Under the Family Law Reform Act 1969, a 16 or 17 year old who can understand, retain, weigh and communicate a decision gives consent as valid as an adult's. — 00:13:32
  • ★★ a guest: A 16 or 17 year old can consent but cannot refuse treatment: if a parent consents, the operation can go ahead despite their refusal. — 00:14:00
  • ★★ a guest: Gillick competence and the Fraser guidelines came from Victoria Gillick's court case to stop her daughters under 16 getting contraception or contraceptive advice without her knowledge. — 00:14:44
  • ★★★ a guest: Under Gillick competence, a child under 16 who can understand, retain, weigh and communicate a decision can give consent as if they were an adult. — 00:14:44
  • ★★ a guest: A Gillick-competent child under 16, like a 16 or 17 year old, cannot refuse treatment. — 00:15:28
  • ★★ a guest: A child under 13 is unlikely to be deemed competent to make a decision. — 00:15:28
  • ★★ a guest: Capacity depends on the decision: a 14 year old may have capacity for a blood test or an injection but not for a bigger decision such as an organ transplant. — 00:16:15
  • ★★ a guest: Capacity also varies over time, as when a confused patient with an infection recovers on antibiotics, so doctors must keep reassessing it. — 00:16:45

00:17:06 — Summary for under-18s and patients without capacity

00:18:05 — Advance directives, lasting powers of attorney and IMCAs

  • ★★ Molly Hunt: Molly explains that an advance directive is written by the patient while they have capacity and says what they would and would not consent to in the future. — 00:18:34 · Advance directive, Molly Hunt
  • ★★ Molly Hunt: Molly says an advance directive refusing life-saving treatment must be signed, dated, co-signed by a witness and must state specifically that the patient refuses life-saving treatment. — 00:19:03 · Advance directive, Molly Hunt
  • ★★ Molly Hunt: Molly says a lasting power of attorney is either for health and wellbeing or financial, and a financial LPA makes no difference to medical decisions. — 00:19:33 · Molly Hunt
  • ★★ Molly Hunt: Molly says that with a health and wellbeing LPA the patient has nominated someone to decide for them, and doctors must be satisfied that this person acts in the patient's best interests. — 00:20:18 · Best interests, Molly Hunt
  • ★★ Molly Hunt: Molly says that if doctors doubt the LPA, they can refer to an independent mental capacity advocate (IMCA), someone unknown to the patient whose job is to represent the patient's best interests. — 00:20:47 · Molly Hunt

00:20:58 — When a patient has neither an advance directive nor an LPA

00:21:30 — Best-interests decisions by the multidisciplinary team

  • ★★★ a guest: Without capacity, an advance directive or an LPA, doctors make a best-interests decision, taking into account what the patient may have wanted, and must talk to friends and family about the patient's religious and cultural beliefs. — 00:21:36 · Best interests
  • ★★ a guest: A best-interests decision is never one doctor's alone: the whole multidisciplinary team, from junior doctors and the consultant to nurses, physios and occupational therapists, makes it together. — 00:22:11 · multidisciplinary team, Best interests
  • ★★ a guest: Best-interests decisions can be very hard, as when sending a patient to intensive care for ventilation is judged not in their interest while the family wants them kept alive. — 00:22:40 · Best interests

00:23:34 — Charlie Gard and a summary of consent and capacity

  • ★★ Ali says the best-interests argument was one of the key points of the Charlie Gard case at Great Ormond Street this year (2017), essentially a best-interests decision by the doctors. — 00:23:34 · Charlie Gard case, Great Ormond Street Hospital, Best interests
  • ★★★ Ali says that for consent to be competent the patient must be able to understand, retain, weigh up and communicate their decision. — 00:24:05
  • ★★★ Ali says applicants need not know case names and dates, but citing even vague details of a case, such as Re T when asked about Jehovah's Witnesses, looks really impressive and shows commitment to medicine. — 00:24:35 · Re T, Medicine interview

00:25:04 — The next video and goodbyes from Charlotte and Molly

Threads in this video

Where the stories that moved here went next

Mentioned

Central: Best interests · Jehovah's Witnesses · Medical ethics · Mental capacity · Valid consent

Also: People: Charlotte · Molly Hunt · Nadine Montgomery · Victoria Gillick

Works: Family Law Reform Act 1969 · Mental Capacity Act 2005

Organizations: Great Ormond Street Hospital · University of Cambridge

Concepts: Advance directive · Assisted suicide · Bolam test · Do not resuscitate · Euthanasia · Four principles of medical ethics · Fraser guidelines · Gillick competence · Independent mental capacity advocate · Lasting power of attorney · Medicine interview · multidisciplinary team

Events: Charlie Gard case · Montgomery ruling · Re MB · Re T

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