Medical Matters: Informed consent

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By Dr. Micheal Howard-Tripp, Deputy Complaints Director, Professional Conduct

CPSA’s Professional Conduct team has observed a recent increase in complaints involving informed consent.

As a cornerstone of ethical and legal medical practice (particularly for invasive or sensitive procedures), informed consent is the fundamental right of individuals to determine what happens to their own bodies. For consent to be valid, it must be voluntary, informed and given by a person with the capacity to decide.

We encourage all physicians to review CPSA’s Informed Consent standard of practice, along with the companion Advice to the Profession documents for adults and minors.

Common issues we’ve seen that have led to complaints:

Lack of information: To be informed, patients or their substitute decision-makers must be given all the information a reasonable person would want to know. This includes the diagnosis, the nature and purpose of the proposed intervention, expected benefits, material risks (including rare but serious ones), alternatives and the consequences of refusing treatment. Physicians must encourage questions and ensure understanding, particularly where language barriers or emotional factors may impact comprehension. Any indication of discomfort or distress during a procedure may signal withdrawal of consent and should be discussed.

Capacity concerns: Capacity is assessed not only by age alone, but also on the patient’s ability to understand relevant information and appreciate the consequences of their decisions. In most of Canada, capable minors may consent to treatment, however, recent Alberta legislative changes have introduced specific restrictions.

Advance Care Planning can help individuals reflect on and communicate their healthcare wishes should their capacity diminish, which could include a Goals of Care Designation, a medical order that documents the overall focus and preferred setting of care. Alberta Health Services has resources available to help guide these kinds of conversations with patients. In emergencies where consent cannot be obtained and there is imminent risk to life or health, physicians may proceed with necessary treatment, while respecting any known prior wishes of the patient. Outside of such circumstances, treatment without valid consent may result in legal liability.

Lack of consent for virtual care and AI use: Informed consent extends to evolving areas of care, including virtual medicine. Physicians must explain the limitations, benefits and privacy risks of virtual care, discuss alternatives and ensure patients understand that in-person follow-up may be required. Similarly, consent must be obtained before using tools such as AI Scribe to record or transcribe clinical encounters. Patients should be informed of the purpose and risks related to privacy and potential inaccuracies, and this discussion must be documented.

Lack of thorough documentation: Patients should be confident that their care providers are properly documenting their health concerns. Accurate documentation is essential for any healthcare provider and is part of establishing trust, which is an important part of informed consent. While electronic medical records (EMRs), templates and dictation tools improve efficiency, they can introduce errors if not carefully reviewed. Physicians must ensure records accurately reflect clinical encounters, as inaccuracies may compromise patient care and increase medico-legal risk. A signed consent form supports the process but does not replace the critical dialogue, and documentation of the same, between a physician and their patient.

Lack of confidentiality: Confidentiality is another key component of patient trust and informed consent. Patients are often at their most vulnerable when accessing care, divulging personal, sometimes painful information. Physicians are ethically and legally obligated to protect patient information, though exceptions exist. Disclosure may be required or permitted in cases such as suspected abuse or when there is an imminent risk of serious harm to an identifiable person or group. These situations require careful judgment, balancing patient trust with public safety obligations.

Family disputes: Family disputes, whether involving separated parents of a child, disagreements among relatives of an elderly patient with declining capacity, or conflicts after a patient’s death, can leave physicians uncertain about who is authorized to consent to treatment or access medical information. These situations may also involve requests for medical opinions on capacity or the validity of a will, which can place physicians in uncomfortable and difficult positions. The Canadian Medical Protective Association (CMPA) has advice for physicians on navigating family disputes while staying focused on safe patient care.

Ultimately, informed consent is an ongoing process grounded in communication, respect and patient autonomy. By ensuring patients are fully informed and actively involved in decisions regarding their health care, physicians uphold both ethical standards and high-quality care. When in doubt, registered members are encouraged to contact CPSA or obtain legal advice from the CMPA.