Can medical consent be ethically valid in India today?

And why we conveniently ignore this fundamental philosophical question...

I got a news feed the other day, another hefty sum payout ordered by the venerable National Consumer Commission against a doctor and the hospital involved. There is no doubt a balancing role this iron hand plays in the complicated milieu of what healthcare is in India today. Today there are so many angles in a doctor-patient relation that you don’t even know where to start - the most relevant for the patient being the primary motive of the doctor-hospital diad and the alleged sound of cash registers ringing in their minds. 

On one hand, the patient believes the diad tries to squeeze every last living penny out of them before sending them packing back in questionable ‘good health’, temporarily at least. On the other, the diad believes every patient is nothing but a potential source of trouble and hence justified in treating them as ripe fruits for the picking - to maximise the profits both out of greed and as a insurance premium to offset any setbacks such as a potential litigation. Of course not every patient sees the doctor this way, nor do most doctors vice versa - yet even among these good folks there is some underlying tension in a real manner. The temptation lurks beneath the surface, the will to devolve into this reprehensible and repulsive game, though maybe not yet manifest.

In all of this discord there is one crucial aspect which I think is not being spoken enough - that of consent. Sometimes we take certain fundamental presuppositions in a complicated issue as granted, and I believe that the Pandora’s phenomenon of consent would be one among them. 

Let us start from the basics. It is assumed that in some particular situations the patient agrees or grants consent by implied assumption. For example when a patient walks into a clinic and lies on the couch, it is understood that consent is given for a basic physical examination - you don’t expect a signed piece of paper for that. 

However for formal procedures, it is a well established legal and ethical duty on the part of the doctor to get a formal and written consent from the patient after explaining all the risks and benefits. Sounds simple, correct? Well not truly, at least in vast swathes of India, and I will argue why.

When the doctor explains a somewhat complicated medical condition to a patient and the risks faced, the patient usually follows and keeps looking on as to how the counselling proceeds. There is usually a silence on the part of the patient, and this is assumed to be that of comprehension. Then the discussion moves (ideally at least) onto the options available, ranging from doing nothing at all to the most extreme form of surgical invasion. The patient keeps listening, often interjects, then asks questions, refuses one line over the other and finally a deal is struck on how to proceed with management. This is the Western model of consent adopted as such, perhaps with certain modifications. I purely use the term Western because for good or for worse we seem to have adopted many precepts and practices from thence, not the least of which are our Constitution and our legal jurisprudence. Moreover there is also this consensus that if for any reason the patient is not mentally competent to follow this process (including being in a state of unconsciousness), the doctor may act on his/her stead and proceed in the patient’s best interest especially in an emergency. So far so good - all happy.

Now here is my bone, which I intend to pick. There is beneath all of this the very fundamental implicit assumption that the doctor and patient are equal partners in tango, whereas in fact this couldn’t be made any more simplistic and reductionistic. In India it is the case often that if the doctor is tango, the patient is rather on a blind crawl in a dusty alley. When consent is discussed with a Western patient or with a patient educated in ‘Western thought’ (for lack of a better word), it is assumed that the patient understands several things at once again by implicit assumption. It is assumed that the patient knows that the body is made up of dozens of chemical compounds including water, that organs systems work in cohesion to keep the body functional, that to understand complication rates means to have a basic understanding of mathematics, and not the least that to choose an option you perhaps need to have an intuitive sense of how statistics can be applied in life.

This is very often not the case at least in most of rural India, and there exists a basic asymmetry in all aspects of perspectives between patients and doctors. Almost all views differ - be it world, scientific, values, social and emotional to name a few. It is almost as if they were from different planets in this regard. This implicit asymmetry unfortunately forms the foundational cornerstone of most of the edifices of Indian healthcare. The real question is how do we untangle from this knotted spool ahead?

#consent #medicolegal #healthcare #modernthought