End of life decisions – practical applications of the ethical principles of consent and patient autonomy

Abstract

Prior to the mid 1840’s, before the advent of anaesthesia, surgical procedures were limited and confined mainly to amputations for traumatic lower limb injuries and drainage of abscesses. With the advance of ether/chloroform anaesthesia, the scope and extent of elective surgery increased dramatically. The landmark US Schloendorff v Society of New York Hospitals case in 1914 stated the patient requirements to give consent and the consequences for the surgeon who operates without the patient’s consent . Judge J Cardozo ruled that “ every human being of adult years and sound mind has the right to determine what shall be done with his own body; and a surgeon who performs an operation without the patient’s consent commits an assault for which he is liable in damages” In the middle of the 20th century society changes had a major impact on the culture and practice of consent. The Nuremberg trials exposed the barbaric nature of Nazi experiments done in the name of medical science when inmates of concentration camps were immersed in iced water to determine how long they would live. This led to the Nuremberg Code adopted in 1947 and the subsequent World Medical Association’s Geneva Declaration on consent. Subsequent Declarations included Helsinki (Research), Sydney (Organ Donation) and Tokyo (Torture). Patient consent is one of the most complex and evolving considerations in clinical practice. Consent can come in different guises. It may be expressed or positively affirmed in writing or may be implied by the conduct or silence of the person whose consent is required. There may be times when obtaining consent is impossible in emergency or extreme situations or when consent, although given by the patient, is based on incomplete or inaccurate information.