7.6 Voluntariness, coercion and consent
Consent, Gillon tells us, is a `voluntary and un-coerced decision'. By making this
explicit he is not implying that health care professionals are in the business of
directly coercing patients or forcing them into involuntary choices, but rather that
the context within which decisions are made might not always enhance the
voluntariness of the decision, and might sometimes be coercive. Furthermore the
broader context within which the patient operates might have limiting effects of
which the health care professional should be aware.
By definition patients have concerns about their health, and despite greater
access to medical information the health care professional is still the expert upon
whom they depend. Hospitals can be intimidating and alien environments within
which people are stripped of many of their usual props, and where those aspects of
their identity which give them confidence can be undermined. The sense of health
care as a scarce resource might also have an impact, with individuals worrying
about the consequences of their actions upon how and when they will be treated.
In broader terms patients do not shed their other social identities when they
enter the hospital setting. For some individuals their ability to consent may be
compromised by their position within their cultural group. For example, women
within certain cultures might have the capacity to consent, but would not expect to
have the right to determine what happens to them due to cultural norms and
expectations. Individual women might therefore be unpractised in exercising
choices of the type involved in consenting within a health care setting [3]. This
could pose difficulties when they are faced with difficult choices such as whether
to accept an offer of pre-natal screening for genetically inherited diseases common
to their ethnic group [4].
It is of course important to avoid stereotypical assumptions and to determine in
the particular case whether an individual is subject to such pressure. However,
particularly in situations where consent is being discussed through an interpreter,
it is important to explore whether a patient is being allowed to make a voluntary
decision, or whether he/she is subject to coercive influences, be they overt or
subtle.
7.7 Consent and autonomy
According to Gillon's definition, consent is the domain of `sufficiently autonomous
people'. This immediately affords us a class of patients unable to consent, but it
also allows for less clear cut cases where a person's autonomy might be compro-
mised or undeveloped, but the question remains about whether they are
sufficientlyautonomous to operate in the current situation. It also raises the
profoundly important question of what to do in the absence of sufficient
autonomy.
Autonomy is a fundamentally significant concept in Anglo-American bioethics,
and the importance of respecting patient autonomy is clearly highlighted in the
codes of ethics governing the main health care professions. There are many
reasons why autonomy has become such a dominant concept, some historical,
122 Nursing Law and Ethics