Informed consent

Patients have a right to information about their condition and the treatment options available to them. The amount of information given to each patient will vary according to factors such as the nature of the condition, the complexity of the treatment, the risk or side effects associated with the treatment or procedure, and the patient’s own wishes. Informed consent is legislated under the National Health Act, the National Patients’ Rights Charter; the Health Professions Act; the Ethical Rules of Conduct for Practitioners Registered under the Health Professions Act; and the ethical and philosophical principles, such as the right to individual autonomy and self-determination.

Practitioners are required to inform patients about the cost of services or treatment provided as part of seeking consent from patients. The majority of complaints against practitioners received by Council are related to the fees and most of these complaints arise because patients were not informed about the costs of treatment or services rendered by practitioners. As a result, the Council offers some guidance to practitioners on obtaining consent from their patients.

The Council’s view is that informing patients about the cost of services should not be separated from clinical decision-making processes as it may impact upon decisions made on available treatment options. The information should be contextualised within a clinical consultation and be an interactive process between a practitioner and the patient, especially where clinical decisions may impact upon financial decisions.

From the analysis of complaints it appears that patients want to receive the details of all procedures associated with their treatment and their costs, including both certain and likely services. These include costs of other practitioners to be involved in their care; for example, anaesthetists in surgical procedures, paediatricians in deliveries, and medical technologists in cardiothoracic procedures. Patients want to know the overall costs co-payments for private hospital treatment, and how much of this would be covered by their medical aid. In order to assist patients with making informed decisions, patients should be advised about the costs of alternative treatments or procedures, such as hospital treatment versus day clinic treatment.

The Council acknowledges that it is not the responsibility of practitioners to know about the out-of-pocket expenses or co-payments related to their services or that of the hospital, but they should assist their patients in obtaining such information from their medical schemes. Practitioners are advised that in cases where they obtain authorisations on behalf of their patients, they should exercise caution in establishing what has been authorised before commencing with treatments that may attract co-payments which the patient cannot afford. This is relevant for some novel treatment options that may attract co-payments for members of medical schemes depending on the benefit options they have with their medical schemes.

Council has noted that there are categories of practitioners who are not primary caregivers and this will pose a challenge for these practitioners obtaining consent. These practitioners which are secondary caregivers include anaesthetists and assistant surgeons working with surgeons; paediatricians working with obstetricians in emergency caesarean sections; pathologists and radiologists providing diagnostic services; and other professionals providing therapeutic and rehabilitation services. Although it is not the responsibility of the primary practitioner to provide specific information about the fees for other practitioners involved in the treatment of the patient, Council

advises them to at least inform the patient that there may be fees associated with other practitioners and even inform the patient who those practitioners are, where possible. It would be wise to provide patients with names and contact details of practitioners who will be involved in treatment of the patient and notify the relevant practitioners of the patient details to facilitate the exchange of relevant information.

Information about fees and costs for services and treatment should be provided in writing and the patient should acknowledge receipt in writing as acceptance of the fees disclosed. The information about fees should be in rands and practitioners should refrain from using the terminology such as: private rates, medical aid rates, contacted in, or contracted out as this nomenclature is not recognised by Council. In addition to providing specific information on fees and charges, practitioners should document their feecharging and billing policies which includes the following:

  • When payment will be required
  • Discounts available for early payment (or charges for late payment)
  • Acceptable forms of payment
  • Contact for discussion of payment issues and problems.

Council acknowledges that there will be circumstances where it will not be possible to obtain consent related to costs before the treatment is provided (emergency cases or admissions). In these cases information should be provided to the patient as soon as possible after treatment. Where it is not feasible to provide information directly to the patient either before or after treatment (e.g. because the patient is not conscious or otherwise incapable of receiving or understanding the information), it may be appropriate to provide the information to a close relative or representative acting in the patient’s interests.

Guidance on informed consent and cost estimate forms are available on the HPCSA website.