Informed Consent in Mental Illness
The presence of a mental illness does not per se preclude the ability to give an informed consent to medical or surgical treatment. The general requirements are the transfer of relevant information concerning goals, realistic expectations, and potential complications. There should be a lack of coercion.
In general, a mental disorder should not prevent a patient from:
understanding what is being consented;
choosing decisively for or against the intervention;
communicating the consent; and
understanding the need for a medical intervention.
Some mental disorders prevent patients from understanding the nature and purposes of a medical or surgical intervention, prevent patients from choosing decisively, or prevent patients from communicating their consent. Examples are dementia and learning disability of sufficient severity. A manic episode or a major depressive episode, for example, may entail marked indifference, ambivalence, or indecisiveness, any of which may prevent a patient from choosing decisively. Psychotic illnesses might also prevent a patient from giving a proper consent. An example is schizophrenia with frank psychosis and disorganized thoughts.
Informed Consent in Lynn G. v. Hugo
The practice of cosmetic surgery has a perplexing number of ethical and practical considerations. These arise because the nature of the practice involves the subjective perception of the patient balanced against preconceived notions. These can be greater and more demanding than those involving surgery performed for noncosmetic reasons. Many questions arose in the aftermath of Lynn G. v. Hugo:
When is an ethical line crossed?
Is there such a thing as too much cosmetic surgery?
Does the surgeon have a duty to seek a second opinion from a psychiatrist if a patient is excessively depressed or shows signs of a condition such as BDD?
If the patient has given an informed consent, can that be rescinded after the fact because of the diagnosis of BDD?
The answer to the last question is "no." The case was dismissed. No other published cases have followed in a decade. So there appears to be no clear threat from this kind of litigation. What the future may bring is unknowable. The other questions are not easily answered.
Areas of concern include procedures done for miniscule cosmetic deformities, or those done repetitively on the same area seeking some degree of "perfection." The surgeon should be suspicious of this kind of situation.
Neither the American Medical Association nor the American Academy of Cosmetic Surgery provides recommendations concerning the ethics of multiple procedures or those performed for minimal or imaginary physical aberrations. Cosmetic procedures provide no medical benefit. Therefore, the only possible medical result is harm, and the surgeon must proceed with particular caution. This is murky advice at best.
Conclusion
It is important to be aware of the many facets of BDD. Although the threat of litigation is probably small, patients experiencing this condition are more likely to seek cosmetic procedures and may be more inclined to be unhappy with the results. Psychiatric referral may be in order in some of these cases before proceeding with an elective cosmetic treatment. As always, documentation is the key. In general, the law will presume that the consent was adequate. However, as in the case of Lynn G. v. Hugo, this may be enough to prevent a protracted litigation process.
Medscape Plastic Surgery © 2012 WebMD, LLC
Cite this: Tony E. Francis. Informed Consent in Body Dysmorphic Disorder - Medscape - Feb 22, 2012.
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