Reconciling the principle of patient autonomy with the practice of informed consent: decision-making about prognostication in uveal melanoma

Abstract

Background  Influential views on how to protect patient autonomy in clinical care have been greatly shaped by rational and deliberative models of decision-making.

Objective  Our aim was to understand how the general principle of respecting autonomy can be reconciled with the local reality of obtaining consent in a clinical situation that precludes extended deliberation.

Method  We interviewed 22 patients with intraocular melanoma who had been offered cytogenetic tumour typing to indicate whether the tumour was likely to shorten life considerably. They were interviewed before and/or up to 36 months after receiving cytogenetic results. Patients described their decision-making about the test and how they anticipated and used the results. Their accounts were analysed qualitatively, using inconsistencies at a descriptive level to guide interpretative analysis.

Results  Patients did not see a decision to be made. For those who accepted testing, their choice reflected trust of what the clinicians offered them. Patients anticipated that a good prognosis would be reassuring, but this response was not evident. Although they anticipated that a poor prognosis would enable end-of-life planning, adverse results were interpreted hopefully. In general, the meaning of the test for patients was not separable from ongoing care.

Conclusion  Models of decision-making and associated consent procedures that emphasize patients’ active consideration of isolated decision-making opportunities are invalid for clinical situations such as this. Hence, responsibility for ensuring that a procedure protects patients’ interests rests with practitioners who offer it and cannot be delegated to patients.