Health – it’s a matter of consent

A few weeks ago, I watched as a father signed a consent form for his newborn twins to receive life-saving care. The babies were premature, sick and needed transporting to a bigger hospital by helicopter, and he couldn’t go with them. He’d only just met the transport doctor who needed him to agree in advance to anything she needed to do on the way. It took him only a few moments to decide to sign.

Medical consent is simple in principle: we explain what we want to do, discuss any risks, and then a patient chooses whether to agree. In reality, consent can be complicated. We might not know beforehand what procedure is needed. We might need to change direction suddenly. Often, there’s a tight timeframe. A patient may not be ready or capable of deciding.

Sometimes – often in paediatrics – someone has to make the best decision on behalf of someone else. Nearly always, emotions are running high.

Consent, therefore, is about trust and communication. The form you sign is not actually the ‘consent’ – it’s just a record of the conversation and a way to make sure we don’t miss anything important.

Real consent is dynamic. It can be renegotiated, refined, or withdrawn – for example, if the relationship breaks down or if further information comes to light. But on the flip side, a ‘no’ can turn into a ‘yes’ once there is enough trust.

This father gave his consent because of relationships. He’d already been in the room with us for several hours: watching as we worked. We invited him to stand close as we intubated, put in lines, gave drugs. We explained as we were doing, and asked him to hold his son’s hands to help us (research confirms instinct – babies, even very young ones, do better when they feel human touch). We witnessed him travel the most intense rollercoaster of emotions possible for a person to bear.

But even in such heightened environments, there are pauses, moments where we – clinicians and families – can pull down the perspex walls, share something about ourselves and bond as humans. And because he had built a relationship with us, even in that incredibly traumatic time, that father could trust someone else from the health system.

Medicine has come a long way (and it still has a lot of work to do). We’ve moved from paternalism to partnership.

When I was a medical student, we were taught reflective listening. These days, I’m in awe of new graduates who master even more techniques to communicate, plus have the agility to move between cultural norms.

Even with flashy new ‘toys’ flooding medicine, tests and fancy
drugs, it’s the old school skills that count in the end. As any wise clinical teacher will tell you, listening, communicating and building collaborations is still the core of what we do, the surest way of moving together towards diagnosis, and then solutions.

Unfortunately, that’s not the way the political leaders of our health sector seem to be going. Our Government ministers and their “health tsars” (a term they hate, but when you fire a whole board and install one person to call the shots, that’s what it looks like) have decided it’s more efficient to just decide what’s best for us.

They are missing opportunities to open conversations and grow relationships with clinicians, professional unions and patient support groups, despite these groups repeatedly reaching out. In doing so they might be missing vital information that could lead to better outcomes.

They are seeking compliance rather than consent.

Let’s zoom out – way out – and across. Now, in no way am I equating what’s happening in the Aotearoa health system to what’s happening in Trump’s America, but humour me for a moment.

Maybe you, like me, have been watching the orange wrecking ball with a mix of fear, horror and fascination. Maybe you’ve also been looking for commentary that explains the madness. You might have come across articles that point out that Trump’s flurry of executive orders, each more shocking than the last, only work because people are too stunned to resist. It’s about maintaining an illusion of power – project enough force, threaten enough and people will comply out of fear – in fact, before any actual laws have been changed.

This happens closer to home too. Recently, the National Gallery of Australia (NGA) made the news because they forced indigenous artists to cover up a Palestinian flag on a commissioned artwork that celebrated resistance movements – for ‘safety’ (read: political) reasons.

In Aotearoa, libraries are proactively cancelling drag readings because of threats, and this year Pride events were cancelled too. This is precompliance – obeying in advance.

But, effective resistance (non-consent) is evident locally and in the US. Local indigenous justice movement Kia Mau published their response to the NGA flag controversy by demanding their emblem be covered up also or the work be withdrawn altogether.

Key New Zealand health leaders have resigned recently rather than remain complicit in policies they don’t agree with. In the US, individuals are bringing court cases against Trump’s government, and many Americans are standing up to Trump/Musk in very public ways.

Power is not truly effective power when there is no consent; it is simply “power over”, which demands compliance. If a “leader” says to do something and enough people say no, then that leader’s power is reduced.

Conversely, true leadership expresses “power with” and leads to a sort of consent process. This style of leadership is collaborative, and includes a leader listening to their own internal compass and also building relationships which ultimately lead to actions.

Consent can be individual, but it can also apply to larger systems.

It’s not true that once a political leader has been elected, we citizens are powerless to change anything until the next election. We can learn from medical consent here, and engage in a dynamic, continuing, inclusive conversation.

It’s important that all players in the health system – clinicians, patients, supporting services and our governing politicians – utilise their power to question, seek clarification, and build relationships that move us towards solutions that help everyone.

After my last column, I got messages from readers asking how they could help advocate for a better, fairer health system. I am hopeful that if we understand our role in the “active consent process” based on relationships, we can end up with the best system possible – despite the constraints. Let’s not just be passively compliant – let’s engage. Surely, this is what our health politicians want too.

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