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19-09-2011 | Article

Iranian medical consent laws questioned


Free abstract

MedWire News: Iranian study results indicate that patients' preferred "substitute decision-makers" are not always those who are consulted in the event that the patient becomes incapacitated and is unable to give consent.

The findings indicate that there are no clear factors that affect patients' choices of a substitute and therefore no clear predictors that could be used in law to establish a hierarchy of substitute decision-makers, say the researchers.

Furthermore, "patients greatly wish to designate their own substitute decision-maker, and their choice may not match one chosen in clinical routines," report Fariba Asghari (Tehran University of Medical Sciences) and colleagues.

Islamic Sharia requires that patient autonomy be respected, and that in the absence of patient capacity in an adult, a legal guardian must be appointed. However, the legal process is lengthy and can interfere with medical care, thus most physicians consult a family member. Powers of attorney become invalid when an individual becomes incapacitated.

In addition, while the law does not state any explicit preference for the gender of the guardian, mothers are not recognized as compulsory guardians for children, and a woman cannot be assigned guardianship without her husband's consent; therefore, the courts lean toward male guardians.

Asghari and team conducted an interview-based study of patients attending an eye hospital (who were therefore stable and stress-free) to gauge their opinions about substitute decision-making and make suggestions about how to improve the current situation.

A total of 200 patients aged a mean 39 years responded to questions including: "Who would you prefer the physician to consult if you are too unwell and incapable of making decisions about your medical treatments?" They chose from a list of possible responses, including eldest daughter/son, younger children, mother, brother, and sister.

In all, 105 participants were men, 152 were married, and 41% (n=72) chose a woman to be their substitute. The most common choice of substitute among married people was their spouse, at 51%; among single people, fathers and brothers were the most preferred substitutes (23% chose one of the two), followed by mothers (19%).

Gender and marital status were both significant factors in choosing a substitute for decision-making, with roughly equal numbers of women and men choosing their spouses (49% and 58%, respectively). Even men with at least one adult son often chose their wife (45%).

Among single patients, single men preferred their father to be substitute (36%) and single women chose "other" (none of the specified close family members, attorney, close friend, or other relative; 33%).

Among patients aged over 65 years, and thus more likely to need a substitute decision-maker due to their increased risk for end-stage disease, only 43% chose their eldest child or spouse as substitute decision-maker; the majority (33%) chose other children.

Finally, the researchers observed that an overwhelming majority of the study participants (94%) said they would prefer to be asked by their physician about their choice of substitute decision-maker for times of incompetency.

"We suggest that patients be asked about their choice for a substitute decision-maker upon hospitalization and that legal acts allow this choice to remain valid even after the patient is incapacitated," conclude Asghari et al.

By Sarah Guy