I agree with Rennie et al.;[[1]] patient autonomy is important. Central to this debate is the tension between the ideal, what is happening and what is possible. I have no problem at all with the Consensus Statement[[2]] as a statement of an ideal … for the people involved in developing the statement. However, there are other priorities that need to be considered at the same time. The Consensus Statement is an attempt to interpret the provisions of the law across a range of contexts to the students and practitioners affected by it. My paper is another attempt.

Their major objection to my paper was that they felt that I did not acknowledge that the Code of Health and Disability Services Consumers’ Rights (HDC Code)[[3]] is the law in Aotearoa New Zealand. They continued by a partial citing of the HDC Code listing rights 6 and 7 but did not include Section 3, which qualifies the Code by saying that a provider is not in breach of the Code if they have taken reasonable actions considering clinical circumstances and resource constraints.

The Consensus Statement states that “the need to gain consent cannot be set aside on the grounds of inadequate time or resource”. This appears to be a contradiction of Section 3. The question is what constitutes “reasonable actions” in relation to this aspect of practice.

Indeed, many provisions of the HDC Code hinge on the concept of “reasonable” (Right 4, “reasonable care and skill”; Right 5, “where necessary and reasonably practicable, this includes the right to a competent interpreter”; Right 6, “reasonable consumer”; and Section 3, “reasonable actions”). This is difficult for the HDC because every complainant believes that their rights have been breached and that there is something “unreasonable” about this. A key aspect of my argument is that any attempt at defining reasonable is culture bound, as discussed in my paper in relation to what level of introductions are “reasonable” on a ward round.[[4]] There is no objective standard of what is reasonable. In any area of practice, notions of what is reasonable will be structured by a set of values, purposes, expectations and ways of thinking—in short, by the culture, and we are a culturally diverse country. We agree that cultural competence/safety is of considerable importance.

Another key part of my argument is that the Quadruple Aim[[5]] should apply to medical practice, and that this has implications for how consent to student involvement in care is gathered. For each of those aims an ideal could be described. Focussing on one aim can lead to unintended consequences affecting another aim.

A good example of this is the effect of the COVID-19 pandemic. During most of the lockdowns, public health was prioritised over patient choice and autonomy and teaching, and this had considerable impact on clinician wellbeing. Our students had significantly less clinical contact during this time. At the height of a pandemic there is significant justification for prioritising public health, but it will be at the expense of the other aims; in this case less clinical teaching and less patient autonomy, clinician wellbeing and provision of routine care.

Consent for teaching is one important priority and in aiming for this ideal, judgements need to be made while also aiming for the other ideals of clinical care, wise use of resources, clinician wellbeing and public health.

I agree with much of the content of the Consensus Statement. There is a good description of the changing nature of consent from junior to more senior students. Difficulties with consent for patients who lack capacity are acknowledged. I agree that the process by which consent is obtained can and should be proportional to the involvement of the medical student and the nature of the interaction and consequent risk or inconvenience to the patient. I agree it is also an important aspect of building rapport with patients, and of maintaining the trust and goodwill that exists between patients and the health professionals who care for them—including medical students.

If gaining consent for teaching involves extra time (introducing all the staff present on every ward round to every patient, including the medical student, with detail on their level of training) and resources (for example, printing of signs, filing of signed consent forms) and there are constraints on time and resources, then a judgement needs to be made. What the right level of consent is will vary from patient to patient depending on their clinical presentation, cultural background and expectations, again requiring a judgement to be made. These judgements are more difficult in the resource-constrained environment that we are currently in.