Informed consent versus uninformed consent: Evidence of good practice?
Pauline Reynolds
Lecturer, Department of Family and Community Nursing, Faculty of Nursing, University of Sydney, NSW
PP: 216 - 216
Keywords
informed consent; ethical practice; health care; interpreters
Article Text
This incident illustrates how following correct procedure arrived at a poor outcome, and following incorrect procedure achieved a good outcome.
During 1994, I was working in an inner city clinic of a large American city that catered to a mixed population, including many immigrants and refugees. I was one of 3 registered nurses (RNs), who, along with several medical assistants (MAs), worked alongside health care providers comprising a mixture of doctors, nurse practitioners, physician's assistants and midwives.
I was engaged in a well-child check of a 3-week-old boy of a Ukrainian mother who had been in the United States for only a short time. This was their first visit, so I spent a considerable amount of time examining the baby, explaining what I was doing via the Ukrainian interpreter. At birth this baby had been immunised with HepB, which was routinely given to babies of immigrants and refugees. Usually a booster 'shot' of HepB is given 4 weeks after birth, and it was decided that the baby could receive the booster that day.
I broached the subject with the mother and the interpreter, explaining the importance of following up the immunisation the baby had received at birth. The mother expressed reluctance, and the interpreter explained that in the Ukraine some people believed babies should not be immunised until they are 3 years old. The interpreter explained that this is what had happened to her child! Nevertheless, after more discussion, the mother agreed to the immunisation. I left the papers explaining all information with the interpreter so that she could interpret these for the mother who could then sign her consent.
I prepared the immunisation and returned to the room only to find that the mother had changed her mind. The warnings contained in the consent form had been enough to confirm her original decision NOT to immunise! In the United States, consent information accompanying immunisation forms is designed to cover every possible side-effect, no matter how remote. This of course includes death. To expect a mother to give consent to something that might kill her baby seemed to be very strange to her.
I attempted to redress the situation to no avail. I felt that I had failed the baby, and worried about what I could have done differently to secure a better outcome. I discussed this with some of my colleagues; in particular, one of the MAs. She was Laotian and had immunised many of the Laotian babies who visited the clinic. I asked how she went about securing consent for immunisation. She said, 'I show them where to sign the papers, and tell them that they have to sign to get their babies immunised in America, and they do'!
This incident caused me to reflect on several issues, and I invite responses from anyone who has had similar experiences:
- In this era of increasing demands of evidence based practice, what in these 2 scenarios is going to count as 'evidence' of good practice - the informed decision not to immunise, or the uninformed decision to immunise?
- In an age of multicultural health care, how does one recognise and counteract the cultural bias of a health interpreter whose beliefs might be counterproductive to a patient's welfare?
- How can information accompanying consent forms be designed to cover legally and ethically all potential problems but at the same time be sensitive to cultural biases?
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