In the HR/Management session at last year’s BEVA Congress, one of my VDS colleagues, Tim Phillips, gave an excellent presentation with the title “Managing the top five difficult situations in equine practice”. As ever, the selection of the situations was arbitrary as it is somewhat personal, but the five situations chosen by Tim likely reflect the main issues we deal with on behalf of colleagues at VDS: informed consent; sedating horses for clipping or for para-professionals; trainers, keepers, owners: client confidentiality and clinical records; PPE on horses known historically to the practice; and giving permission for a physiotherapist to treat a client’s horse.
Tim in fact spent the entire presentation on the topic of informed consent. There is no doubt it is an important subject and one that has evolved considerably in recent years. When one combines that with the fact that our regulatory body considers it of vital importance and central to how we provide appropriate veterinary care, it is worth studying the subject in an equine context.
If we look at the human medical field, the NHS states that “consent to treatment means a person must give permission before they receive any type of medical treatment, test or examination”. This must be done on the basis of an explanation by a clinician. It goes on to state that for consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.
Voluntary implies that the decision either to consent or not to consent to treatment must be made by the person, and must not be influenced by pressure from medical staff, friends or family.
Informed means that the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead.
Finally, capacity signifies that the person must be capable of giving consent, which means they understand the information given to them and can use it to make an informed decision.
Consent can be given verbally or in writing. In certain circumstances, such as an emergency treatment to save their life or where there is a risk to public health, then it may not be necessary to obtain consent.
Whilst the veterinary profession often usefully extrapolates from the medical profession, the author does not believe informed consent in the veterinary context can be wholly understood in the context of what is applicable for medical colleagues. The obvious example is that we are dealing with animals unable to give consent themselves. During a panel discussion at BSAVA Congress in 2017 on the topic, it was generally agreed that informed consent is centred on good communication. The point was well made by Ian Ramsey that for consent to be valid it must be voluntary and informed, and the person consenting must have the capacity to make the decision. Carol Gray, who was working on a PhD on informed consent, was also a panellist and suggested it would be prudent for practices to ensure full disclosure of risks of treatment and to document that disclosure.
What level of risk needs to be considered in discussions with owners during the process of obtaining informed consent? This is unclear and may be affected by a recent ruling in the medical profession: Montgomery v Lanarkshire Health Board (Supreme Court 2015).
In the veterinary profession, it is accepted that what risks associated with a procedure or treatment should be known to a vet is a matter falling within the expertise of that vet. As such it will be governed by the “Bolam” test. This is a well-established legal principle whereby a vet has to make a reasonable decision or behave reasonably. It does not have to be what the majority of his or her colleagues would have done, rather it needs to be what a reasonable number of similarly qualified vets would have done, or not done, given all the same circumstances. It is perhaps fortunate that reasonable number lacks a precise definition.
However, the Montgomery ruling found that what risks need to be conveyed to the patient is a matter for a court to determine rather than by reference to medical opinion alone. Exactly how the Montgomery ruling will apply to the veterinary profession is not known. There is no doubt it is important for all equine vets to spend time ensuring owners are aware of all risks and benefits of procedures or treatments before proceeding.
