From whom can consent be obtained for a patient with bipolar depression on medication who requires metabolic surgery to control diabetes mellitus (DM)?

Consent for Metabolic Surgery in Bipolar Depression

The patient herself should provide consent (Answer A), provided she has decision-making capacity as formally assessed by the multidisciplinary team including her psychiatrist. 1, 2

Decision-Making Capacity Assessment is Mandatory

The critical first step is formal assessment of this patient's capacity to consent, which must be performed specifically for this metabolic surgery decision:

• Decision-making capacity must be formally evaluated for each medical intervention in patients with psychiatric conditions, accounting for how psychiatric symptoms may impair judgment 1, 2
• The assessment requires determining if she meets all three criteria: (1) sufficient comprehension of the surgery's risks and benefits, (2) sufficient judgment to assess consequences in light of her own interests, and (3) sufficient ability to make self-governed decisions 1
• Bipolar disorder, particularly during manic or depressive episodes, can impair the "appreciation" standard even when the patient understands the information, as mood states may alter values, insight, and judgment 3, 4
• Capacity should be reassessed regularly as it may fluctuate with the course of bipolar disorder and response to medication 1, 2

If Capacity is Present: Patient Provides Consent

Providing care to competent individuals without their informed consent violates ethical norms and disrespects personhood 1, 2:

• If the patient demonstrates decision-making capacity, she alone provides consent—neither her husband, family members, nor physicians can substitute their judgment 1, 2
• The consent process must include explanation of risks, benefits, alternatives, and long-term consequences of metabolic surgery 1
• Higher severity of psychiatric symptoms (particularly positive symptoms and depression) correlates with impaired understanding and reasoning on capacity assessments, requiring thorough evaluation 4

If Capacity is Absent: Surrogate Decision-Making

Surrogate consent is acceptable only when the patient definitively lacks decision-making capacity and should represent extremely rare cases 1, 2:

• Patients who cannot give free and informed consent should generally not be candidates for elective procedures unless there is a legally authorized representative and specific governing laws 1, 2
• Even when surrogates are involved, every effort must first be made to obtain positive consent from the patient herself 1
• Surrogate decision-makers require special vigilance as they may pursue their own interests at the patient's expense 1, 2
• Local legislation governs who can serve as a legally authorized representative (typically not simply "two family members" as suggested in option D) 1

Multidisciplinary Team Involvement

The metabolic surgery decision requires comprehensive team assessment, but the team does not provide consent:

• Metabolic surgery requires multidisciplinary teams for preoperative, intraoperative, and postoperative management 1
• The team should include the treating psychiatrist to assess mental status, medication stability, and decision-making capacity 1, 2
• Complete consensus among team members regarding patient selection is mandatory before proceeding 1, 2
• The team's role is to assess capacity and provide recommendations, not to substitute for patient consent 1, 2

Special Considerations for This Clinical Scenario

For metabolic surgery in patients with psychiatric conditions:

• Patients who have mental illness that is difficult to control and lack the ability to understand risks, benefits, and expected consequences are contraindicated for metabolic surgery 1
• However, being on medication for bipolar disorder does not automatically indicate incapacity—many patients with well-controlled bipolar disorder retain full decision-making capacity 3, 4
• The surgery must be approved by the Medical Ethics Committee with the patient's informed consent 1

Common Pitfalls to Avoid

• Do not assume psychiatric diagnosis equals incapacity—formal assessment is required 1, 2
• Do not allow family members or physicians to override a competent patient's autonomous decision 1, 2
• Do not proceed with elective surgery if capacity assessment reveals significant impairment without proper legal surrogate authorization 1, 2
• Do not confuse the multidisciplinary team's role in assessment with their authority to provide consent on behalf of the patient 1, 2