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We read with interest the papers on informed consent published in a recent issue of the Journal of Medical Ethics.1 Whatever their differences, and however much they questioned some aspects of the duty to respect autonomy through attempting to obtain informed consent for therapeutic interventions, there was general agreement that competent adult patients are entitled to a core of basic information about their treatment options. There was also consensus that training in the process of obtaining consent is important. In our experience, two dimensions of such training are of particular interest. On the one hand, students require good theoretical understanding of the ethical and legal background to the professional emphasis now placed on informed consent. On the other hand, they need practical training in the relevant communication skills and how to apply them to obtain consent for specific clinical procedures. To do so, doctors must obviously also have a good understanding of these procedures. We recently encountered serious problems as regards such understanding in a study among junior doctors in England (Schildmann J, Cushing A, Doyal L, Vollmann J. The ethics and law of informed consent: knowledge, views and practice of pre registration house officers, submitted for publication). No matter how good their philosophical and legal knowledge, preregistration house officers (PRHOs) will not be able to deliver the minimal standards of informed consent outlined by O’Neill unless, suffice it to say, they know what—practically speaking—they are talking about.2
In contrast to Bravo et al’s results (in the same issue of the journal), almost all the PRHOs who took part in our survey had good legal understanding of the differences between competent and incompetent patients.3 This may be interpreted as a positive result of the change in the curriculum at their particular medical school, which includes extensive sessions about informed consent. These embrace ethics, law, and communication skills. However, despite their understanding, the junior doctors in our study still experienced problems about their role in the consent process. The problems pertained to pressure of time and lack of support by senior doctors, as well as pressure on them at times to obtain consent in circumstances where they had been taught that they should not. This gap between the standards of informed consent currently taught to medical students and the clinical realities they face, and into which they are thrust, is an ongoing problem.4
If informed consent is to fulfil the purpose of respecting the autonomy and dignity of patients, sufficient resources are required to train young doctors to do the job properly, especially as regards their understanding of procedures for which they are providing information and their competence as communicators. One thing is clear: if they cannot complete the task in accordance with the guidance issued by both the General Medical Council and the Department of Health, they should not be doing it at all.5,6 Trusts and colleges should ensure that all supervisory staff are aware of their responsibilities in this regard.
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