Page 3 - Consent for Surgical Intervention
As per Indian law, mature adults above 18 years of age can make independent decisions regarding the surgical procedures they wish to undergo and obtaining their parents’ consent is not mandatory. The consent of the parents or legal guardian is required for patients below 18 years of age. As for mature adult patients, it is up to them to tell their families, relatives or friends about any surgical procedure they wish to undergo. Maintaining the patient’s confidentiality is of the utmost importance. If the doctor has any doubts about the psychiatric health of the patient or if the patient is known to suffer from any psychiatric condition, they might not be fit to take an informed decision. The doctor can advise the patient to bring their family members for a clinical interview, but the patient has the final say as to whether the family members should be involved in the decision-making process. Documenting this in the clinical notes could save the doctor from an embarrassing situation in the future. The importance of contemporaneous documentation cannot be overemphasised. A consent form that is signed by the patient and clearly mentions the benefits, possible problems and complications of the procedure is important and valid.

It is important to know the reasons that the patient gave for wishing to undergo limb lengthening surgery despite being 5 feet 7 inches tall. Was there any peer pressure? Was a greater height required for participation in specific sporting activities? Was it an occupational requirement? Was the patient short compared to other men in his community? It is equally important to know the final height that the patient wanted to achieve. Was the aim to achieve the particular height reasonable or beyond reasonable limits? If the patient had unreasonable expectations, preoperative counselling could possibly have been of some use. As per the newspaper report, the wish to increase one’s height by 3 inches (7.6 cm) is reasonable and in accordance with results on height gain published previously.

Suggestions For The Future
Patients should be assessed by a psychologist to ensure that their perceived short stature is affecting them psychologically. The perceived short stature must be severe enough to affect the person’s mood most of the time. This condition is called height dysphoria. Detailed preoperative psychological analysis helps to rule out dysmorphophobia or any other psychiatric illness which might affect the patient’s ability to make a sensible judgment and give legally valid consent. Psychological evaluation by a psychologist was performed as a part of the preoperative evaluation in all three studies (2–4). This was done to rule out psychological disorders such as dysmorphophobia, in which patients perceive of their body as being completely out of shape and undergo various surgical interventions to correct their body form. In severe cases, they become suicidal and may need to be admitted to hospital several times. It is important to note that in one study, the psychologist recommended height gain surgery only in 52 (50%) out of 104 patients (4). In the case under discussion, it is unclear whether the subject underwent detailed psychological evaluation. Psychological evaluation helps to understand why the patient wants to undergo cosmetic height gain surgery. Considering that previously published studies had utilised psychological evaluation, it is advisable to specify psychological evaluation in such surgeries in India. The possible reasons include occupational (some jobs require a person to have a minimum height), social (other men of the same community could be taller than the subject; peer pressure; perceived problems regarding one’s height in one’s relationship with one’s partner); and inability to participate in certain sports due to one’s relatively short stature. There could also be other genuine reasons for leg lengthening and it is up to the treating surgeon to consider whether the reason given is valid.

If the patient specifically tells the doctor that his/her family must not be informed, this must be clearly documented in the case notes and if possible, the patient should be requested to sign a special consent form. This might save the surgeon from embarrassing questions from the family. Family involvement was specifically mentioned in only one study (3).

It is better to have several clinical encounters with the patient rather than making a decision based on the first clinical interview. This helps to evaluate whether the patient’s intention to undergo leg lengthening is sincere. We propose that for such procedures, informed consent be videotaped and saved to spare the clinical team from future embarrassment and legal complications. Applying the rigor of funded clinical trials to uncommon elective and planned surgeries with legal implications might be a worthwhile idea.