gms | German Medical Science

Obtaining informed consent (IC) from patients contemplating neurosurgical procedures is an important process in preoperative care. In treatment after low grade aneurysmal subarachnoid haemorrhage (SAH) special circumstances arise that require specific action on the part of the surgeon to fulfil his duty to provide IC. In this paper certain legal and ethical issues confronting neurosurgeons in their day-to-day practice to obtain appropriate IC in case of SAH are critically discussed.

A review based on a Medline search using the phrases "informed consent" and "neurosurgery" was carried out. The papers were analysed with respect to suggestions for IC in case of SAH. Our own management was matched with the German legal practice and the recommendations of the DGNC.

The steps in IC to be considered are: full disclosure of information (1); understanding by the patient (2); competence of the patient to decide (3); voluntary choice (4) and decision and consent (5). A surgeon who performed an operation without his patient's consent commits an assault for which he is liable in damages. Exceptions of informed consent are medical emergencies, patient waivers and therapeutic privilege. Last is controversial, it contains withhold of information that would have countertherapeutic consequences e.g. physical, psychological or emotional. Circumstances which would be true for patients suffering from aneurysmal SAH.

In the area of conflict between legal duty of disclosure and medical fiduciary duty for a critical ill patient we perform an alleviated consent interview, which is conform with the German legal practice ("rechtmässiges Alternativverhalten"). Neurosurgeons should outline the discrepancy and conflict between the requirements of medical practice in law courts and the actual interests of patients. Research to establish what is real appropriate informed consent should be promoted.