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Paternalism Reigns!: Assessing Capacity to Consent to Treatment

McElveen, Anthony J. MRCPsych MRCGP, MBChB, DRCOG

International Journal of Gynecological Cancer: May 2014 - Volume 24 - Issue 4 - p 622
doi: 10.1097/IGC.0000000000000099
Letters to the Editor

National Health Service Kilmarnock, United Kingdom

The author declares no conflict of interest.

To the Editor

In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 20031 states that a person can “make a decision no prudent person would” and is not necessarily mentally disordered.

It is with much concern that I write to highlight an issue that I suspect is prevalent in surgical specialties, namely, that of capacity to consent to a proposed course of treatment when the patient does not follow the recommendation of her doctor.

Allow me to set the scene for you. I received a letter from a consultant gynecologist asking for an assessment of capacity of a 66-year-old woman with endometrial cancer. It is stated that she has declined surgical treatment and opted for hormonal therapy. She has in the past been given a label of having “personality disorder” by a psychiatrist decades ago. She has had no contact with mental health services for years, lives independently, and has no suggestion of cognitive impairment.

The gynecologist has questioned whether she has the capacity to refuse surgery. He informs me that the best course of action would be to have surgery. However, if she had agreed to surgery, would the issue of capacity ever have been raised?

Moreover, she has been deemed to have the capacity to consent to hormonal treatment by the gynecologist; at least, he has commenced hormonal treatment, and she is not being treated subject to adults with incapacity legislation.

Her reason for not choosing surgery is that she does not wish to have an operation and the risks of general anesthetic.

People are allowed to make decisions no prudent person would. Yes, it is frustrating to watch, but we cannot live their lives for them. It is a bit like watching your children make choices we would not encourage, but they do not wish to take our advice, although they can understand it. We can provide them with the necessary information. We must check that they understand, retain, and can weigh up the advantages and disadvantages of their decisions. They must then communicate their decision. However, we cannot be so risk averse that we do not allow people to exercise their basic human rights.

Anthony J. McElveen, MRCPsych


National Health Service

Kilmarnock, United Kingdom

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1. Mental Health (Care and Treatment) (Scotland) Act 2003.
© 2014 by the International Gynecologic Cancer Society and the European Society of Gynaecological Oncology.