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Consent in Surgical Practice

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Modern surgical practice places the patient at the heart of decision-making. Surgeons must ensure patients understand their options, the associated benefits and risks, and are free to choose in line with their own values.

Since the landmark Montgomery ruling (2015), consent has shifted from a paternalistic model to one centered on patient autonomy. Surgeons must now support patients in making informed, personalised decisions, rather than simply obtaining a signature on a form.

For consent to be valid, it must be given:

  • by a patient with capacity,
  • voluntarily,
  • and after receiving sufficient information to understand the implications of each option.

If a patient lacks capacity, the surgeon should follow relevant legislation (Mental Capacity Act 2005 in England and Wales, equivalent legislation in Scotland and Northern Ireland), seeking ways to involve the patient as much as possible and making decisions in their best interests if capacity is truly absent.

Supported Decision-Making

Surgeons should presume that adult patients have capacity unless shown otherwise.

Capacity is decision-specific and time-specific. Even patients with mental illness or fluctuating cognitive ability may understand enough to choose. Respecting patient autonomy means discussing all reasonable treatment choices, including no treatment, and aligning these options with the patient’s goals. Ultimately, the patient can refuse even life-sustaining treatments if they have capacity.

Consent should be a process, not a one-off event. Begin by explaining the diagnosis and prognosis in a way the patient understands. Then explore all options side-by-side: operative interventions, non-operative strategies, and doing nothing.

Clarify expected benefits, side effects, complication rates, recovery times, and any long-term implications.

Emphasise that the patient’s own values and lifestyle factors matter. For instance, a frail elderly patient may have different priorities than a younger, more active individual. Tailor the conversation accordingly.

Material Risks and Personal Relevance

Under the Montgomery principle, a “material risk” is defined by what a reasonable person in the patient’s position would likely deem significant. Surgeons should avoid assuming what matters—each patient may value quality of life, functional outcomes, or potential adverse effects differently. The surgeon’s role is to empower the patient with information, not to steer them toward a single “correct” choice.

Documentation and Timing

While a signed form is necessary, it is not by itself sufficient evidence of informed consent. Maintain a clear record of the discussion: the options presented, the patient’s questions, and the supporting materials provided (leaflets, websites, or digital aids). Give patients time to reflect; consider sending written information in advance. When the patient decides, sign the consent form together, ensuring they know they can still change their mind right up to the start of the procedure—unless urgent intervention is required.

Special Considerations

For cosmetic procedures, a two-stage consent with a cooling-off period is essential. For children or those with limited capacity, follow legal frameworks and involve family members if appropriate, but remember the patient’s best interests and previously expressed wishes always guide decision-making.

By embracing supported decision-making, listening to individual patient values, and carefully documenting discussions, surgeons uphold ethical and legal standards, foster trust, and ensure patients truly consent to the care they receive.

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