Seeking and obtaining consent is commonly represented as a single act. The patient presents, and the clinician explains what he or she wishes to do and seeks the patient’s agreement to implement investigations and treatment. The paperwork is signed, the forms sent off and consent is complete. This routine conceptualization of consent does not capture a significant component of proper consent, namely that it is continuing or ongoing. Merely because someone once agreed to, or indeed refused, an investigation, procedure or treatment, it does not mean that consent endures indefinitely. Yet like the requirement that consent be voluntary, the value of ensuring that consent is continuing is often overlooked in the literature. Where it is discussed in detail, it is most likely to be in the context of research where a participant’s ongoing willingness to be part of a trial or study is often built into the protocol and emphasized as part of the process of obtaining ethical approval. This chapter will consider the concept of continuing consent in the context of clinical practice rather than biomedical research, and will discuss some of the issues and challenges that can arise.
Continuing consent and the process of healthcare
As discussions in earlier chapters have stressed, healthcare is increasingly systematized. The majority of patients will have contact with a number of healthcare professionals. The journey through the healthcare system commonly begins in primary care. It may take several visits to a GP practice before referrals are made and those primary care consultations are likely to involve history taking, investigations and some treatment. If a referral is considered to be appropriate, this may happen some time after the patient originally presented and is likely to be at an institution that is new to the patient. When the patient attends for his or her referral appointment, the process of history taking, examinations and investigations resume leading perhaps to surgery, treatment or procedures. Further referrals may follow, sometimes accompanied by requests to participate in teaching, educational activities, service evaluation, audits or research. The patient may encounter many people along the way: GPs, nurses, hospital doctors, phlebotomists, radiographers, physiotherapists, physician assistants, anaesthetists, ward clerks, occupational therapists, auxiliary staff, clinical and non-clinical managers, healthcare students, speech and language therapists, receptionists, secretaries and pharmacists may all contribute to an individual’s care. Healthcare is rarely, if ever, a one-off transaction between an individual practitioner and patient. It is almost always a process over a period of time involving many people.