Under review

Systematic use of the following questionnaire may facilitate the process of obtaining a free and informed consent:

  1. Is the person fit to give his consent?
  2. Has the person  received all the information relative to the proposed investigation and treatment (benefits, risks, other treatment options)?
  3. Has the person understood the information relative to the proposed investigation and treatment?
  4. Does the person have questions to ask?
  5. Did the person receive satisfactory answers to these questions?
  6. Does the person now agree to undergo the proposed investigation and treatment?

The principle of autonomy and the inviolability of the person, protected by the Canadian and Québec charters of human rights and freedoms, are at the heart of this process. Every medical act may be interpreted as an infringement on the integrity of the person and may not be performed without the person’s consent, even if the act seeks the well-being of that person.

However, when an emergency puts a patient’s life in danger, the integrity of the patient is threatened by the emergency itself; thus, the presumption of beneficence must prevail, compelling the physician to take action.

Sometimes the patient himself may become a threat. Suicide comes to mind as well as agitation and all the conditions where a patient puts himself and others in danger. In these situations, seeking the patient’s consent no longer has the same pertinence. But even in these situations, the  physician must act within strict guidelines aimed at minimal restraint of the patient while ensuring his safety and that of others. The use of restraints for agitated persons follows the same logic and must be a measure used exceptionally.

When the patient becomes a danger to others due to mental illness or the risk of contagion, the public must be protected. To deal with these situations, the legislative framework provides for precise mechanisms allowing one to bypass free and informed consent as well as professional secrecy, a  topic that will be addressed in the next section.

Thus, the circumstances when the fundamental rights of a patient may be restricted are well defined. But how do these alter the ethical obligations of physicians? In such cases, physicians must give precedence to  the security of others in the patient’s environment; this precedence represents a choice expressed in legislation granting privileges and assigning obligations to designated persons. The medical profession is therefore party to a special social contract. Its roots go back to a time when people were looking for ways to control epidemics. In order to protect communities against the threat of contagion from plague and cholera, for example, persons or groups of persons were quarantined. These age-old methods to protect the public were also applied, albeit on another scale, against present-day infections such as acquired immunodeficiency syndrome (AIDS) and severe acute respiratory syndrome (SARS).

To summarize, consent, the conditions it calls for and the particulars for its substitution, have gradually imposed themselves on the physician-patient relationship, which has long been characterized as beneficent. In today’s context, the exceptions to obtaining consent also impose themselves,  since the physician-patient relationship does not operate in isolation, but within the spectrum of other social relationships.