CAERS SUBSTACK ARTICLE #21
CAERS SUBSTACK ARTICLE #21
I have alluded to consent in previous articles. In particular, in Article #19 (‘Doctoring’) I focused on disclosure, one of the three elements of consent, the other two being capacity and voluntariness. In this article I will explore voluntariness and later I will explore capacity.
For an individual to act voluntarily there is no requirement that they do so in isolation. In fact, most of us make a point of making decisions, especially important ones, by checking other sources first. For example, we tend to consult those who we know well, or those we trust, or those who appear to have more knowledge and experience than we do with respect to the issue at hand.
You have likely been in the situation where you check multiple sources and receive different, or even conflicting, advice. How do you decide? Sometimes sources advocate their perspective aggressively. How do you reassure yourself that your decision is truly still yours, not someone else’s?
There are several signs that indicate that a source providing advice respects the importance of you being in control of your choices. One is that the person offering you the advice has nothing to gain or lose in your decision. A salesperson who is going to garner a larger commission the more expensive your purchase is clearly in a position to gain from some decisions you make more than others.
The more a source offers you both sides of the story, and acknowledges the good and the bad of all possible options, the more able you are to make your own balanced decision.
Even better is when your advisor makes the point that they do not want to pressure you in any way, often by being transparent with respect to their own biases. Your source suggests that you carefully weigh all of the possibilities and feel totally free to choose as you see fit. They respect that your decision is an important one and must be done in the context of your own values and priorities since you will be the one living with the consequences.
It is perfectly acceptable for someone to offer you a well-reasoned argument in favour of one decision over others, something referred to as persuasion, provided that they accept whatever you ultimately decide. However, it is quite another for someone to pressure you into one decision over another using intimidation, threats (obvious or veiled), coercion, extortion, bribery or blackmail. ‘Emotional blackmail’ is a common mechanism used to circumvent voluntariness, and the emotions commonly manipulated are guilt and fear. If you really loved me you would do ‘x’. If you don’t choose treatment ‘y’ then you are not being a good citizen and there will be consequences. Voluntariness is compromised if your ‘advisor’ benefits from certain choices you can make and attaches additional positive or negative repercussions to those choices only. The playing field is no longer level, so to speak, because not all decisions can be judged on their own merits alone.
Medical mandates don’t fit very well with the voluntariness aspect of consent. That does not necessarily mean that they are always wrong, but they should make us strongly question their justification. If you have an uncontrolled seizure disorder, there is good scientific justification for you not to be allowed to pilot an aircraft; however, there is much less justification to prevent you from flying in a plane as a passenger.
Do you feel that consent is important? During the pandemic, have you felt that your ability to make decisions voluntarily and freely in the context of your values has been ignored to some degree? Are you concerned that this element of consent has been compromised because of certain ‘strings’ that have been attached to some decisions and not others without strong enough justification?
The importance of voluntariness is one reason that consent has developed in the last sixty years of medical practice. The third element of consent, capacity, is also critical. But before I explore it, my next article will explain a concept upon which capacity depends, one that we all recognize but perhaps have a hard time defining.
J. Barry Engelhardt MD (retired) MHSc (bioethics)
CAERS Health Intake Facilitator
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