AAGBI Consent for Anaesthesia 2017 guidelines – a reply

I am grateful to the correspondents for their comments on the guidelines on consent for anaesthesia 1. Regarding the ‘harm threshold’, this is a term originally applied to decisions over whether to remove a child from his/her parents 2. There has been debate as to whether, at the level of principle, this concept is suited to medical decision-making, one reason against being the indeterminacy of such judgments in practice and another being that by focusing only on harms, it downplays parents’ obligation to benefit their children through treatment in their ‘best interests’ 3, 4. Estimating only the harms of treatment may be easier than doing the same for the benefits as well, but by definition is only half of the story. However, as far as the current legal framework goes, it is clear that the approach that is to be adopted is what outcome is in the child's best interests (see 1 for references), hence the use of this term in the guidelines. As for Russell's comments regarding the time constraints of consent discussions, I would respectfully point out that the Working Party does not make the law; its remit was to offer guidance to anaesthetists on how to work within the law. If there is inadequate time to have the discussions required to satisfy the courts, then the Trust Board should be made aware that the conditions are such that it is not possible to act lawfully; it is for Trusts to address this problem, not anaesthetists to rush discussions or compromise standards 5. It is also worth pointing out that the current Department of Health guidance 6 already states that the consent discussion should not take place just before surgery, hence the emphasis on consent as a process, and the establishment of pre-operative assessment clinics and provision of written information in advance of admission. Finally, there does not seem to be much difference between what the AAGBI guidance says and what Wellesley and Pownall are suggesting i.e. that referral to the courts may be appropriate in the case of 16 and 17-year-olds who refuse treatment. We are aware that the law in this area is likely to be reviewed by the Court of Appeal, and will take account of any changes in emphasis in future revisions.