In plastic surgery, ‘informed consent’ is simply an illusion of control

THE sad death of a Limerick woman during cosmetic surgery in the United States made my mobile phone work overtime, this past week, as journalists worked on follow-up stories. The questions came thick and fast.

Did I know Dr Sachs, the surgeon involved? No. Had I been on a Late Late Show with him? No. Had I had anything done by him? No.

With every "no," I felt a mixture of guilt and relief. Guilt because I could be of such little use to the individual journalists. Relief because, several years ago, when I published a book about my own extremely positive experiences with plastic surgery, I had left out the names of all the surgeons involved. Even though some of them were doing wonderful work and I wanted to recommend everybody I knew to go to them, I also knew that if I endorsed a named surgeon, it would return to haunt me.

First of all, surgery, by its nature, has risks. Surgery which attracts a preponderance of older people as clientele (although this is changing) has very particular risks: a general anaesthetic for a forty-year-old has demonstrable hazards attached to it, but not such predictable perils as a general anaesthetic for an eighty year old. And eighty-year-olds, these days, have face-lifts.

Secondly, good surgeons are like Volvos: very safe if they're kept serviced.

The difference is that surgeons don't have self-diagnostic systems which announce to their users when some of their competences begin to fail. The history of surgery includes a few notable examples of men who went from super-competence to complete incompetence as they developed Alzheimers, their behaviours in the operating theatre mystifying their colleagues and endangering their patients.

No system is in place anywhere to alert patients to diminishing skills on the part of a surgeon. Nor does it require something as major as senile dementia to erode surgical competence, as I found out a couple of years ago.

During a consultation before a procedure with one surgeon who'd already worked on my face, I asked a question which didn't get answered. It wasn't an important question and there seemed no discourtesy in the surgeon's moving on to some other issue. But when he paused for breath, the nurse who was present said "Terry's anxious about X." In effect, she re-asked my question. The surgeon gave an immediate and complete answer. After he was gone, the nurse winked at me.

"Goin' a LITTLE deaf," she announced. "But not ready to wear a hearing aid, just yet. Don' you worry, Hon, I'll look out for you." I re-read the Informed Consent form in a new light. It told me that because of any number of naturally occurring and unpredictable complications of any kind of surgery, I might die, have a disabling stroke, be grievously unhappy with the end results of the surgery, develop post-operative infection. It didn't tell me that the surgeon, because of a touch of vanity, might not hear the anaesthetist trying to draw his attention to the fact that my vital signs were disimproving. Unless this particular smart nurse was a member of the surgical team, and unless I had noticed my question not being answered, I was going to sign a form testifying to my understanding of something I couldn't have fully understood, but which would in the event of a bad outcome preclude me from suing the surgeon, assuming I survived. Informed Consent? Yeah, right.

Informed consent is one of those concepts whose perceived value greatly outweighs its reality. Particularly, but not exclusively, for cosmetic surgery. The drill is that before you go under the knife, or, if it's liposuction, under the cannula, you're handed a clipboard with as many as ten pages. Most of the ten pages are filled with negative possibilities.

However, of necessity, they are GENERAL negative possibilities: bad stuff that might happen to anyone undergoing this procedure, anywhere at any time.

They do not address the competence, basic, referred or developing, of the specific surgeon.

Basic competence is validated, in the United States, by being "board-certified." Many medics with no plastic surgery training are now doing procedures for which they are not board-certified, but the informed consent form never says "And have you checked that the surgeon you're about to trust with your face and your life has been certified for the task?" Sometimes, although board-certified, a surgeon may have only referred competence in a particular area.

LAST week, I attended a seminar on a new procedure in the HQ of cosmetic surgery, Florida. The new procedure, Thermage, much plugged on programmes like Oprah, is an expensive and painful waste of time, but that's a side-issue. The main point is that the surgeon explaining it to about 80 potential customers started the proceedings by impressing them with his indubitably formidable three decade history as a pioneering eye-surgeon attached to a north-eastern university hospital. A man in his seventies, seated at the back of the audience, put up his hand.

"Why would a guy with your surgical history move into this kind of stuff?" he asked.

The surgeon bloviated about developments in this area and how cutting-edge Thermage was, despite the obvious fact that poking a plastic gun at someone's forehead to send radio waves to tighten up the underlying layers of skin could be and is being done by make-up artists under supervision.

Everybody present knew the truth: Florida is a pleasant place in which to semi-retire, if you're a surgeon in your late fifties, and there's gold in them thar cosmetic surgery hills. So never mind that you have no direct experience of cosmetic surgery sure isn't all surgery much the same, really? And you don't have to put on the informed consent form that your real skill is in doing things to the inside of people's eyes, whereas you're a neophyte on the service you're now proposing to offer, which includes all forms of facial plastic surgery.

Informed consent forms, for the most part, are a ritual dance.

The surgeon puts in every imaginable negative complication of the procedure: Don't say I didn't warn you. The patient, already made nervous by the impending surgery, gets through the tick-lists as quickly as possible, their mind skating off the awful realities implicit therein. Paradoxically, the very fact that so many worst-scenario outcomes are listed makes the totality of the list seem unlikely. It's as if the Met Office person finished their broadcast by saying "So, scattered showers and fresh breezes tomorrow. But I can't rule out thunderstorms, tornadoes and cyclones, which, in rare situations, have occurred." In theory, informed consent lessens risk and creates a therapeutic partnership between physician and patient. In practice, there must be doubts about that partnership outcome. Consultants not necessarily working only in cosmetic surgery maintain that forcing patients into a dialogue about grim implications of a procedure (particularly post-mortem procedures on relatives) can actually destroy trust and possible partnership. Patients, or relatives of patients, can feel abused by being forced, when already emotionally fraught, into consideration of painful further implications.

An illusion of control over the uncontrollable. That's what Informed Consent is, most of the time.