A physician’s duty has been succinctly described in medicine’s famous oath “To Do No Harm.” Although this concept may seem straightforward, defining harm can be more complex. A physician is in a unique position, possessing knowledge of the possible harm that may occur as a result of a procedure, which must then be communicated to the patient. There are many types of informed consent, which are generally based on the risk of the procedure to be performed. Traditional informed consent depends on the patient’s capacity to comprehend and appreciate the nature and consequences of a decision regarding medical treatment; however, even routine situations can be complicated when they involve patients with individual needs and challenges. Our ultimate goal as physicians is to have open communication with informed and engaged patients. We will address how physicians can do their utmost to appropriately inform every patient in their practice about the risks inherent in the procedures that have been recommended for them, with emphasis on ways to improve the informed consent process.
UNDERSTANDING CONSENT: THE BASICS
Obtaining proper consent is of paramount importance in dermatologic surgery. By obtaining consent for treatment, a physician invites the patient to take part in medical decision-making. Consent can fall into the categories shown in Figure 3-1.
Implied consent is typically employed in basic office situations, where a patient’s conduct can be considered to be an inferred acceptance of a proposed medical intervention. Examples include the following:
■ A patient does not withdraw or object when the medical assistant obtains the vital signs.
■ A patient removes his or her shirt to show a skin lesion prior to the examination of the area.
■ A patient applies sun block when advised to protect the skin from ultraviolet light.
In these situations, the patient’s agreement is assumed by his or her conduct in response to the proposed intervention. This type of implied consent, otherwise known as simple consent, is appropriate for low-risk decisions. Accordingly, it is an accepted practice for the dermatologic surgeon to explain the low-risk intervention in simple terms and to accept the patient’s implied consent.1
As circumstances become more complex, however, it becomes more precarious to rely on implied consent alone. This is because the burden of proof usually lies with the physician to show that the patient consented through his or her conduct.2 Even in some low-risk situations, it may be wise to obtain express consent. Examples include the following:
■ Performing a physical examination of a sensitive area.
■ Low-risk procedures that are potentially painful (i.e., cryotherapy, intralesional injection).
■ Prescription medications that pose some risk of an undesirable result (i.e., topical chemotherapy).