syllabus Essay Example

syllabus Essay Example syllabus Essay syllabus Essay El Paso Community College Syllabus Instructors Course Requirements l. Course Number and Instructor Information HECO 1322 NUTRITION AND DIET THERAPY INSTRUCTORS NAME CAMPUS AND OFFICE NUMBER Evelin achier, MS, RD, LD Rio Grande No office TELEPHONE NUMBER (cellphone) (575) 642-1850 OFFICE HOURS TO be announced E-MAIL Communication with instructor should be done through the class message system, not through the college e-mail address II. Text, Materials, Links You will need the following materials for the Course: Blackboard MindLink for MindTap Nutrition Instant Access for Sizer/Whitneys Nutrition: Concepts and Controversies, 13th Edition Purchase your Instant Access Code here for $80. This is the only place you can find it for this price. cengagebrain. com/micro/l-1 MI MKVN B. The course is offered through El Paso Community College using Blackboard format. 1. The student must have access toa computer with internet access. If the student does not own a computer, the computer lab and library computers will work fine. 2. The student must use a word processing program for some of the work. Some word processing programs are not compatible with the instructors software nd if that is a problem, the student will be notified early in the semester to change software. 3. The system information and required hardware and software needed for Blackboard can be found on this URL: www. epcc. edu/DistanceEd For assistance getting started with an online course and technical support, contact the 800-630-8849. EPCC Blackboard Help Desk available 2417 (Toll Free) A. How the course works: Students must arrange their schedule to include computer time to complete and submit the work that is required for the course. Our discussion will include the roles that both the Financial Accounting Standards Board (FAST) and the Securities and Exchange commission (SEC) Till In tens process. We wall also review a sample AT corporate Telling required by the SEC. These filings are required of all public entities; those whose securities are listed on any stock exchange in the U. S. Next, we will spend some time becoming familiar with the Abss Accounting Standards Codification (the Codification or ASS). This Codification Project was finalized during the summer of 2009 and the ASS includes all relevant authoritative accounting literature (GAP) issued by both the FAST and the SEC. The ASS will be your source for all accounting research assignments during the quarter. Your familiarity with the ASS will make you much more proficient in your ability to complete accounting research projects as you begin your professional careers. Regarding accounting research, one of my main objectives in this course is to get you out of your so-called comfort zone insofar as financial accounting is concerned. In most financial accounting courses you have been expected to find the one, correct answer in a given set of circumstances. For example, you were expected to learn the one, correct way to calculate the amount of interest to accrue on a note receivable or payable. Similar expectations characterized your tax courses in that you were expected to identify the precise tax treatment for investment income or charitable contributions. In this course you will quickly learn that in many areas of financial accounting and reporting, as in tax accounting, there is not always one obviously correct answer. As a matter of fact, you may discover that in some situations multiple correct answers can be supported. The time that you dedicate to learning how to perform accounting research in an efficient and effective manner will be valuable to you in discovering solutions to obscure accounting issues and learning how to use the authoritative literature to support the conclusions you reach regarding these issues. The portion of the course dedicated to accounting research will often not be as concerned with the black and white areas of financial accounting as it will be with the gray areas. In your careers, you will quickly learn that there are numerous gray areas in financial accounting. The course will also address various financial accounting topics including revenue recognition, fair value measurement and disclosures, and earnings quality issues as they relate to financial reporting. Revenue recognition is one of the most abused financial accounting principles in that businesses may be tempted to manipulate revenue recognition rules to manage or smooth their earnings. The trend toward the use of fair values in financial reporting is growing and we will review current authoritative literature related to this topic. Interestingly, many have blamed the most recent economic crisis, particularly in the banking industry, on disclosures related to fair values. We will also spend time identifying the factors that contribute to the overall quality of reported earnings and what factors detract from that quality. In March 2008, the SEC began allowing foreign companies to file uncial statements prepared in accordance with International Financial Reporting Standards (FIRS) without reconciliation to US GAP. Before March 2008 reconciliation was required. As a result, the significance of FIRS will be emphasized in the course. You will be given an assignment on the first day of class that requires you to read and answer questions related to several documents issued by the SEC concerning the use of FIRS in SEC filings and the possibility that FIRS will ultimately be adopted in the United States. The assignment will be due toward the end of the quarter. At that mime, we will examine a under AT accounting topics Ana compare Ana contrast tenet treatment between the requirements of US GAP and those found in FIRS. Part of this discussion will focus on distinguishing between rules-based and principles- based accounting systems. We will conclude the course with an overview of key issues as they relate to ethics in accounting and auditing. I realize that most of you are taking this course as you complete your MESA Program approach graduation. Keep in mind that although the end of your academic experience at Default is approaching, this course requires a significant commitment on your part and my expectations for your participation and performance during the term are high. In reality my expectations for this class are similar to those that your employer will have once you begin your careers. You will be expected to read, perform research, draw conclusions and support these conclusions using the authoritative literature, participate in group assignments, write effectively, ask questions, and, above all, to commit to continual learning. You can help insure your success in this course by setting high expectations for yourself. I can assure you that the level of meaningful input and conscientious effort that you devote to this course will have a significant impact on what you learn. And, what you learn will translate into your course grade. In other words, your level of personal commitment to the challenges of this course will be closely related to the payoff for that commitment. CLASS STRUCTURE: The format of a particular class meeting will vary from week to week. I will spend a number of class meetings presenting lecture material. Other classes meeting will be used for group presentations, either formal or informal. Certainly, in every class I ill attempt to initiate classroom discussions where any and all input will be encouraged and given full attention. Given the above flexible and changing class format structure; I have identified the following list of responsibilities or expectations for you as graduate accounting students in a professional program at a major university. Commit to learning rather than grades. It is incumbent on you to recognize the benefits of learning. If you have not already, you will soon discover that if you are genuinely committed to learning, your objective for making a good grade will almost certainly be realized. This commitment requires that you a make a complete and conscientious effort on every assignment and exam. Commit to your group. A significant portion of your grade (35%) will be based on work you submit and/or present as a group. It is your responsibility to make a conscientious commitment to your group on all assignments. Making deals within a group where a certain member or members is excused from work on a particular project in return for doing more work on another is not what I expect. When you begin your careers and are asked to participate in group projects, I can assure you that this arrangement will not be acceptable. Your commitment to learning (see above) requires commitment to each and every group activity. Preparation. Be familiar with the class material to the extent possible before coming to class. I will provide you with an outline for note-taking purposes on DEL prior to each class when I will be lecturing. Your familiarity with the lecture material prior to class will make learning much sealers Ana wall needle you to participate more Tally In classroom Locutions. You should have ample time to review the outline prior to class. Participate in class. I want to know your opinions and viewpoints regarding the various accounting issues we cover. Oftentimes, students have perspectives that their peers (and l) may have not considered. Your input is essential to the overall learning process. View our class as a learning community rather than as a group of disparate individuals without common interests. In a learning community, all members have the responsibility to not only learn but to contribute to the learning of others in the community. Have a positive attitude. A good attitude about learning will make a world of difference. Provide constructive feedback to me and to your classmates. Our classroom discussions will often involve reacting to the views or presentations of others. Your moments are welcome and encouraged and should always be made professionally and respectfully. Ask questions. Try not to be concerned that your questions are stupid or that everyone else already knows the answers. Part of any learning process involves thinking about issues in ways that you are not accustomed. To get the most from this aspect of the learning process, it is critical to have an environment where questions are openly asked and welcomed by all. COURSE REQUIREMENTS As the discussion above indicates, group work, including presentations, will be significant component of this course. In addition, your participation in discussions in al class sessions is critical to your success. As a result, regular attendance is not optional. In particular, you must be present for all of your groups scheduled presentations to receive credit. In other words, if you miss class when your group is scheduled for a presentation, you will not receive credit for that presentation regardless of how much you contributed to the preparation of the presentation materials. If you discover that you must miss ANY class, let me know before that class. If the class you must miss is a presentation date for your group AND you have informed of your absence beforehand, you may ask me to prepare a make-up assignment to ensure that you have learned and understand the material missed and to allow you to receive credit for the presentation. Any make-up assignments will include an oral presentation. Absent extraordinary circumstances, I will not allow anyone to make up work for more than one missed presentation. Finally, arriving for class on time and not leaving early or during class except for scheduled breaks is a matter of personal and professional responsibility and respect for your classmates and me. As a result, I expect all of you to be on time and I strongly request that you tot leave class at any time other than during the scheduled class break. If you anticipate having to leave class early or at any time other than at the break, please let me know before class. Should you fail to exhibit responsibility and respect in this regard, you and I will meet to discuss the issue. Group Assignments: A glance at the Assignment Table should make it obvious that you will have a number of opportunities to complete group work. The group assignments will include both writing exercises and oral presentations and will focus on assigned readings, research, and materials covered in class. Assignment of students to groups will be made at my discretion. I expect all group members to contribute in a meaningful way to all assignments and I anticipate giving the same grade to all members off group for all group assignments. Arrangements where a group member gets a free pass on an assignment in return for extra work on another is not acceptable and I expect to be informed immediately if this is happening. These arrangements serve no purpose except to insure that not everyone learns the relevant material. In order to encourage the behavior described above, I will ask each of you to complete a peer evaluation twice during the term; once in mid-October and once at the end of the term. The peer evaluation will provide each of you the opportunity to let me know if there is not a balanced effort and level of contribution from all of a groups members. If I am not informed of non- contributors via peer evaluations or otherwise, there is nothing I can do to rectify the situation. If I become aware of these situations, I assure you that I will address them immediately. If I am not made aware of situations where group members are getting a free ride, the result is that participating members are doing more work than is expected and non-contributors are receiving grades for work they do not complete. This is not what I intend and it is not fair for anyone involved. Finally, I reserve the right to reduce anyones course grade up to two letter grades if he or she is consistently rated poorly in peer evaluations. I expect all members of a group to be completely familiar with all aspects of an assignment. For example, when I ask questions following an oral presentation, be prepared for me to address the question to anyone in the group rather than only the individual who presented the information that is the focus of my questions. Group presentations will be of two types: formal and informal. Each group will prepare and deliver one formal presentation. This presentation will cover topics introduced in More Than a Numbers Game. Your groups presentation should mimic a professional presentation or a Job interview in terms of your attire, your presentation materials, etc. Each group should: (a) prepare discussion materials (e. G. , Powering slides) to accompany its presentation; make sure that there is consistency in terms of font, margins, headings, billeting, etc. Articulacy if slides are prepared independently; (b) upload our slides to DEL prior to your presentation so that your classmates have ample time to download them and bring them to class; if we are in a computer classroom your classmates will not need a hardcopy. A Forum will be available under the Discussions tab on DEL for this purpose; (c) assign specific speaking parts to all group members; (d) present (do not read) your remarks in a coherent and co hesive manner; (e) dress in a manner fitting of the formal scenario; your attire will count as part of your presentation grade. If you are not sure what constitutes attire appropriate for these presentations, ask me. On the date of your groups formal presentation arrive in class early enough to insure that you are ready to begin Immolate at ten Declining AT class. As you prepare Tort your Doormat presentation, imagine that it is being delivered too client or superiors at your workplace. My evaluation of these presentations will take into consideration (a) the content of the presentation materials including their quality, accuracy, and completeness, (b) the quality of the presentation itself in terms of the presentation skills that each group member exhibits including the overall flow of the presentation from speaker to beaker which is enhanced when all presenters are familiar with the entire presentation, (d) the overall professionalism of the presentation including attire, (e) the length of the presentation with respect to my directives, and (f) whether your group was completely prepared to begin its presentation on time. I will post an example of the evaluation rubric that I will use to assess your presentations on DEL. Finally, each group must email its presentation slides (with any revisions I suggest) to me within 48 hours after the presentation (6:00 p. M. On the Wednesday following your presentation). Do not post the revised slides to DEL; I will do so after I have reviewed them. The purpose of this requirement is to allow me to make the corrected slides available on the course website in a timely fashion to allow your classmates the opportunity to review the presentation content for exam purposes. Failure to meet the 48-hour deadline will result in a one letter grade reduction of your presentation grade if I receive the slides within 24 hours of when they are due; a two letter grade reduction will occur if the slides are more than 24 hours overdue. For informal presentations, each group should be prepared to lead a class discussion elated to the assignment and share its answers with the class. Evaluation of these presentations will primarily take into consideration the content, completeness, and accuracy of the information communicated as well as the effectiveness with which it is presented. Like formal presentations, all group members should have a speaking role and all group members should be completely prepared to answer questions related to any part of the assignment. With these presentations, you my dress in any way you choose and although I will provide general guidelines as to the duration of our presentations, no points will be deducted for longer or shorter presentations relative to the guidelines as long as the all relevant issues are adequately addressed. Several group written assignments are also required. These assignments are due at the beginning of the class period that they are due. If a particular assignment is due on DEL it must be posted before class time. The assignment of responsibilities and the completion of these assignments are up to the discretion of group members within the guidelines mentioned above related to participation by all group members. Specific instructions will be made prior to each assignment. Keep in mind that for exam purposes, all group members are responsible for the content of all group oral and written assignments unless I specifically exclude the content of one or more assignments. Other: In-Class Discussions: As you begin your careers you will learn how important it is for you to have effective verbal communication skills. A significant portion of your communication Walt toners In your Tall Ana Walt clients will De vernal. As a result, the development of verbal communication skills is given a high priority in this course. No doubt improving these skills within our learning community is an important step award mastering them in preparation for your professional careers. Dont feel as if you have to offer insight related to every topic discussed in class. Effective verbal communication requires that one knows when to speak as well as what to say and how to say it. Speak out when you have something to contribute. Should you not do so voluntarily, I will provide a little prodding. Course Grade: Your course grade will be determined as follows: FIRS Term project Written Group Assignments (likely 4 or 5) 15% Formal Group Presentation Presentations (likely 2 or 3) 10% 10% Informal Group Research Assessment Mid-term Exam Final Exam Total 5% 25% 100% As a rule, I do not give make-up exams. However, I do not object to anyone taking an exam early if your situation prevents you from taking it when scheduled. If you have what you feel is a legitimate reason for missing the midterm exam and cannot schedule it early, you must let me know of your situation before the exam is given. Should I allow you to miss the midterm exam, your final exam will count for 50% of your total course grade. Only in the most extraordinary of circumstances will you be allowed to postpone your final exam. A final comment with regard to grading: keep in mind that the grade of Incomplete s not designed for students who have fallen hopelessly behind in a course and who have little chance of catching up. This grade is reserved for students who are making satisfactory progress in a course and, due to unforeseen circumstances that are beyond their control, are not able to complete the course. Please do not ask me to give you an incomplete unless this applies to you. In addition, do not ask me to assign you extra-credit work so that you can improve your grade. There is absolutely NO chance that I will do so. You have any number of ways to earn points toward a passing grade. Again, there will be no opportunity of any kind to do work above and beyond the requirements of the course. Lastly, I realize that most of you are very close to graduation. Your nearness to graduation will have nothing to do with how I grade your performance in this course. Academic Integrity and Personal Ethics: Academic integrity requires a commitment to complete and absolute honesty in your intellectual endeavors. The University has a website dedicated to Academic Integrity.

Technology effect essays

Technology effect essays In the article Cybergrace: The Search for God in the Digital World, ¡ Jennifer Cobb wonders if a collective and self-reflective intelligence,  ¡Ã‚ °God ¡ isn't embodying itself in cyberspace. She observes the God-like nature that humans may gain in cyberspace and warns that we must proceed with caution. To me, the only thing I could think about with technology is it ¡Ã‚ ¯s ability to make almost anything possible such as, genetic engineering, nanotechnology, robotics, and increasing computer power, decreasing computer size. In last decades, the modern technology industry relies very explicitly on faith that the software will work, that the demo won't crash, and that the market will keep going up. Technology is technology; it is a means for communication and transportation over space, and nothing more. Technology that plays a significant role in all aspects of my life today, for example a computer, allows me to use technology benefits me by enhancing my learning capabilities and development in my college education. As a future engineer, the technology makes our life much easier, and it can be a powerful tool for educational use. During my high school years, or even now, a computer is the one of instructional tools that provides the discovery and exchange of information, communication, exploration, learning, and teaching. However, after I read Cobb ¡Ã‚ ¯s article, I must admit a little concept as I begin to see a growing awareness of spirituality in our relationship to machines even in this most secular of worlds. At first, this article starts comparing unlikely subjects that is the Internet and the divine, in Cobb's able hands, a seamlessly woven web of connection. Cobb urges us not to abandon the online world to commercial forces but to realize that "through the medium of computation, our spiritual experience can be extended in profound ways."(160) She proceeds toward an in-depth discussion of the nature of divinity. ...

Law of Business Transactions assignment Essay Example | Topics and Well Written Essays - 2000 words

Law of Business Transactions assignment - Essay Example nited Floors Ltd had included an exclusion clause in its contract, which required intimation of any alleged defects within three weeks of fitting the carpets. As such, it had included a clause, whereby its liability per contract was to be restricted to five hundred pounds. Peter is seeking refund of the two, thousand, three hundred pounds paid by him and compensation for the business lost, during the time the carpet was being replaced. United Floors Ltd refuses to accept and relies on its exclusion clause. An exclusion clause can be enforced by resorting to adhesion contracts or standard form contracts. The party which draws up such contracts offers negligible choice to the other party to the contract. In the words of Downes, an authority on contract law, wherever, there is great disparity in the bargaining power of the parties to the contract, exclusion clauses can prove to be extremely prejudicial.1 Legislation like the Unfair Contract Terms Act 1977 or UCTA and the Unfair Terms of the Consumer Contract Regulations 1999 or UTCCR have been enacted, in order to exercise stringent control on the use of exclusion clauses. The UCTA makes a business liable for not fulfilling obligations or duties that are consequent to what has been done or is to be done in the normal course of business2. Peter’s contract with the United Floors Ltd is subject to the UCTA, because consumer contracts fall under its purview3. In contractual terms reasonableness is of paramount importance and the UCTA verifies as to whether an exclusion clause, after taking into consideration the circumstances that should have normally been known to the contracting parties, is rational4. In this manner the UCTA grants wide discretion to the courts, in determining whether an exclusion clause is reasonable or not. If a contracting party wishes to take recourse to an exclusion clause in the contract, then the onus of establishing its reasonableness rests on it5. The UTCCR deals with all the contractual

Tourism and Holiday Leisure Design Essay Example | Topics and Well Written Essays - 1500 words - 1

Tourism and Holiday Leisure Design - Essay Example The basic design of the tourism and holiday leisure product has to take into consideration the size of the product on offer, the facilities available and/or the quantity and level of services. This is to say that the tourism design package can either be big or small depending mainly on the tastes of the customers. The type of facilities available will also determine how the tourism product is designed. For instance, if the facilities are world-classes and top of the range tourist sites, then the design should reflect this. In some places the level of tourism services is very low while in some areas it is quite high. Therefore, the design of the tourism leisure product or service is likely to differ depending on the priority of tourism in a particular area (Williams and Buswell, 2003). The presentation of the tourism product available in a particular place will depend on the standard of services available. To keep people interested in the tourism package on offer, the standards of ser vice must also be high. Good services in the tourism sector are very important as they determine how well people respond to the tourism offers. If the services are poor, then most likely people will avoid that particular tourism destination and opt for one where they will get satisfactory services. Most product designs in the tourism sector include a wide range of vacation options. Also included in the designs of most travel and tour packages is consumer protection. Vacationers are normally out to enjoy themselves and the problem of insecurity is usually the last thing they would want to deal with (Pikketmaat and Weiermair, nd).  

Case Study Example | Topics and Well Written Essays - 250 words - 24

Case Study Example The NLRB had a justifiable reason to protect the employees based on the labor relations Act (National Labour Relations Board, 2014). If the case happened at the workplace, employees discontented with the working conditions would have the courage to protest. By that decision, employees would be possible that the NLRB addresses their welfare concerns (Nairns, 2011). As long as employees accurately present their case, they would have protection for their welfare. Employee relations in the work place improved because of the NLRB decision to protect the rights of the five employees. The decision set precedent that employers will lose to the NLRB if such a case happens again (Twomey, 2012). Proper communication channels need to be established between employees and employers to allow them air their complaints. If such channels do not exist, then employees are justified to present their grievances through the social media, as long as they are accurate. If the social media is to be used by employees then the information disclosed should be objective, unbiased and be justified by NLRB under the labor relations Act. The requirements allow the employees to access justice justified by the

Hot Seat Chapter 16 Essay Example for Free

Hot Seat Chapter 16 Essay 1 . The fundamental ideas associated with the mercantile theory were: that everything was to benefit the mother country, each nation was trying to achieve self-sufficiency, colonies and agriculture would improve economy and raw materials, and the country must benefit at the expense of others. For the most part, these ideas along with a few other minor pieces helped European nations to conquer much of the New and old world. Great Britain was the most successful with a vast overseas empire through North America, the West Indies, Africa and into India. They governed their colonies effectively and efficiently maximizing power and economic strength over the world. The least successful would probably be Portugal. They initially started out strong, finding trade routes along Africa into Asia and conquering Brazil, however by the 18th century their empire had diminished to slight control of Brazil and almost no other colonies. 2. The main points of conflict between Britain and France in North America were in the St. Lawrence River valley and the Ohio River valley. These areas were huge enters of trade and influence of the Native Americans that both the French and English desired. In the West Indies the conflict was mainly over crops and through naval battles. These skirmishes affected overseas trade and the flow of resources. In India, the conflict was mainly restricted to port cities and factories set up by the early English and French settlers along the Indian subcontinent. 3. Triangle trade was an extremely useful trading method to transport goods, raw materials, and resources between Europe, the Americas, and Africa. European sailors ould travel down to Africa and exchange weapons (mostly) for African slaves from West African kings. These slaves were typically prisoners of war that the rival African cities wanted to get rid of. Europeans would transport these slaves to the West Indies and North American colonies were they would be traded for bullion and raw materials found and grown in the New World. Finally those ships would take the materials back to Europe were they could be sold and traded to the rest of the world. Triangle trade was an effective way for mercantilist empires to become more self- ufficient and grow economically. 4. Initially, the Spanish conquered and controlled the largest empire in the Americas. They had colonies in much of the rich West Indies, all throughout Central America, most of South America, and the South West of North America. They would split much of their territories into Judicial councils called audiencias. Each audiencia had a local official loyal to the Spanish crown called a Corregidor. Before the Bourbon reforms, Queen Isabella had assigned much of the colonial control to the Council of the Indies, hich nominated viceroys for the New World. Trade was mostly ruled by a flota system of yearly shipping with Spain. With the Bourbon reforms, Charles Ill attemoted to reassert Spanish control over the colonies. He allowed more than one Spanish city (Cadiz) to trade with the New World and opened more Caribbean ports. colonists) as the heads of society. They were the elites while the creoles were subordinate. 5. Slavery was introduced to the Americas through the triangle trading networks where large numbers of blacks were brought over form Africa. This wasnt the first nstitution of slavery, however it is one of the worst recordings of slavery throughout history. Slavery became a fundamental part of the plantation system and completely necessary to the New World colonies economies. Without slaves, much of the intense economic growth experienced by the New World and Europe would not have occurred. The plantation system helped drive inhumane treatment of slaves because they were then seen as property, farm tools, that could be replaced. When they misbehaved or didnt function properly, the plantation owners would either fix them through torture) or kill them. Despite the harsh treatment of slaves, our country and many others would arguably never have gotten to where it is today without them. 6. By the end of the Seven Years War, France and Austria came out defeated. In Europe, almost no borders or politics changed. Germany was still disputed and Prussia remained a strong power with England at its back. In North America, France lost all of their colonies and possessions. England and her North American colonies defeated the French and with the Treaty of Paris, cast them out. The only real foothold France now held in the New World were through its West Indies possessions. Great Britain now came out as a world power and probably the strongest nation up until the USAs uprising. 7. Many European, especially British, events and ideas helped influence the American Revolution and drive the colonists to rebel. The John Wilkes affair which challenged the Kings power and the influence of Parliament. John Wilkes criticized the peace negotiations with France after the Seven Years War and gained much support from mall property owners and the nobles who wished to drain the kings power. America saw these demonstrations of proof as to the tyrannical nature of a monarchy. The Glorious Revolution also showed to the colonists how sometimes a new government must be instated to protect the people. Thinkers like John Locke and Thomas Paine also widely influenced the minds of many Americans. The American Revolution also caused a domino effect over much of the New World colonies like Haiti and other South American areas. It displayed the Enlightenment characteristics and helped inspire the French revolution. Great British political radicals saw that taxation of their North American colonies as far and Just. England had protected and defended them throughout the Seven Years War and they must share some of the burden. Also, American colonists paid significantly less taxes than the English citizens in Great Britain so they had no reason to complain. Americans were outraged because they were only represented through virtual representation. They felt that if the Parliament wished to tax the colonies, they must give them fair representation in Parliament, no taxation without

Analysing the Concept of Informed Consent in Healthcare

Analysing the Concept of Informed Consent in Healthcare Chapter 1-Introduction 1.1 In modern society, everyone has the basic right to consent to medical treatment. However, this is a recent development as consent was not always considered a critical issue in medical treatment. Hippocrates himself, advised doctors that they should conceal the effects of medical treatment from their patients, his reasoning being he believed that when patients were given relevant information they would take a turn for the worse. It was not standard practice for patients to question a doctors decision or authority. Recent changes have contributed to this change in attitude and as such altered the method of practice of a doctors obligation. The final years of the twentieth century as witnessed the most dramatic shift in the reputation of the medical profession within the United Kingdom, due to scandal after scandal plaguing doctors. Major news headlines left the doctor-patient relationship in a state of concern, for example, Doctors who steal organs face jail.This headline refers to the Bristol and Liverpool Hospital where it was discovered that they were retaining childrens organs, without consent or knowledge of the parents. It became apparent in the Bristol and Liverpool reports that organ retention, of both children and adults was widespread practice. Another significant humiliation for the medical profession was the case of Harold Shipman, a general practitioner who was convicted of murdering fifteen of his patients. Whether these circumstances are due to the actions of individualist or media influence makes little difference to the effect they had on societys viewpoint. There was need for change and this brought about the introduction of regulations and guidelines that protected both the patient and the doctor. 1.2 Informed consent was seen to break the doctor knows best concept and established a liberated choice for the patient. The locus classicus for informed consent is contained within the case Schloendroff v Society of New York Hospital, where it was held, â€Å"Every person being of adult years and sound mind has a right to determine what shall be done with his own body.† There are many examples within the UK system which confirms this principle of law, one being the case Re A (Minors) in which Robert Walker L.J stated, â€Å"Every human beings right to life carries with it, as an intrinsic part of it, rights of bodily integrity and autonomy The principle underpins the common law concerning consent to treatment within the UK. The consent that a patient has the right to choose is a fundamental part of receiving medical treatment. No considerations need to be examined whether the choice is rational or irrational, as the patient has an absolute right. 1.3 The Department of Health 1993 stated, â€Å"Consent is the voluntary and continuing permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature and likely risks of the treatment including the likelihood of its success and any alternatives to it.† Meaning any permission given under any unfair or undue pressure is not consent. Consent may be expressed or implied, however the validity of informed consent does not depend upon the form in which it is given 1.4 This dissertation will firstly consider the development of informed consent, as the English courts initially had reservations of its establishment and for this reason was gradually introduced in stages, until the case of Chester v Afshar which saw the full acceptance of the doctrine. It needs to be considered how the medical profession dealt with this change and in addition how patients themselves are exercising such powers. The effect in which the Human Acts 1998 has had on the courts decision making process will also be analysed to observe the relevance this may have had on informed consent. Another factor of informed consent includes giving sufficient information and the patients understanding of this. For informed consent to exist, the patient must have all the relevant information and capability to make an informed choice as to the treatment they decide to receive. This was made apparent in the case Reibiu v Hughes, where Laskin J stated, â€Å"the genuineness of consent to medical treatment depends on proper disclosure of the risks it entails† For informed consent to exist within the UK; provisions need to be made for those who are simply unable to give an informed choice. The capacity of a patient needs to be considered and if they lack this then a doctor must make a decision as to what is in the patients best interest. This can be seen to restrict informed consent as it goes against its true principle, however if a patient can not make an informed choice for themselves then it is only passable that someone has to act on their behalf. This dissertation will examine the procedure for this and how the law enables decisions to be made fairly and respectably. Chapter 2-The Development of Informed Consent 2.1 The area of law that needs to be established is the nature and scope of the duty to inform and the extent to which this has been incorporated into the English legal system. The existence of a duty to warn came about when the relationship between a doctor and the patient, which was based solely on trust, began to erode. There was a need for scrutiny and examination within the medical profession and this was achieved through the development of the law. The scope of the doctors duty of care is determined by a reference to the Bolam case. Mr Bolam agreed to electroconvulsive therapy to help improve his depression. He suffered fractures in the course of the treatment. The risk was known to his doctor, but he had not informed Mr Bolam of such. Mr Bolam alleged that the failure to warn him of the risk was negligent. The judge found that the amount of information harmonized with accepted medical practice and dismissed his claim. The judge, McNair J, directed the jury to the principle that, â€Å"A doctor is not guilty of negligence if he has acted in accordance with the practice accepted as proper by a responsible body of medical men skilled in that particular art† Therefore, the defendant doctor had conformed with a practice which was approved by a responsible body of medical opinion. This test was known as the Bolam test and it determines whether the doctor fell below â€Å"the standard of the ordinary skilled man exercising and professing to have that special skill† 2.2 Where there is a difference of judgment between two differing medical opinions, the defendant will be given the benefit of the doubt. As a result a doctor would not be found negligent if the court is satisfied that there is a responsible body of medical opinion that considers the doctor had acted appropriately. This responsible body need not be the majority of the profession. It appears that the courts allowed the medical profession to set their own standard. A doctor simply needed to provide an expert testimony and the courts assumed that it must be responsible. In exceptional cases, the courts perceived some established practice to be substandard, however it appears that only one reported case has materialized where such a judgement has occurred. The case, Hucks v Cole, where a woman contracted puerperal fever due to her doctor failing to treat her with penicillin for her septic toe and finger. Although a number of distinguished doctors gave evidence that they would not have administrated penicillin, the Court of Appeal found the defendant to have been negligent. The Judge, Sachs LJ, commented that the courts have to be in a position to verify that the medical opinion stood up to logical analysis and that they are not merely tailored to fit the requirements of the respective parties cases. This judgement was one of rarity, as Judges would not ordinarily cross examine a doctors opinion on a logical basis. 2.3 Often cases were even more favourable to the doctor, as is witnessed in the case Hatcher v Black. In this case Lord Denning stated, â€Å"As a matter of law it might be justifiable for a doctor to tell a lie, when he only does that which many a wise and good doctor would do.† It can be concluded from this that it is entirely for the individual doctor to determine what to inform his patient, even if the doctor went so far as to opt for what his lordship termed a therapeutic lie. Professor Michael Jones expressed the state of play as a football score, â€Å"In six medical negligence claims before the House of Lords between 1980-1999 the score stood at Plaintiffs 0, Defendants 6†. 2.4 The Bolam test which was adopted by English law focused on accepted practice and responsible profession opinion. The story was very different in America, as the American Courts rejected the professional medical standard and instead emphasised the patients right to know what the risks are inherent in the treatment. In Canterbury v. Spence a US Court stated that the prudent patient should prevail and its the doctors duty to disclose to their patient any material risk in a proposed line of treatment. The prudent patient principle emphasises what the doctor needs to inform the patient, according to what the average reasonable patient would want to know about potential risks and treatment options. This is made evident when the Judge commented, â€Å"A risk is material when a reasonable person†¦.is likely to attach significance to the risk† Contrary to the English Courts, the USA placed more importance on the patients rights and exigencies than those of the doctors. However, soon after the Bolam decision the English law was making changes towards incorporating this American style of law, to incorporating the doctrine of informed consent. 2.5 The question that needs to be examined is to what extent the Bolam test does or should apply to the duty to inform. Sidaway v Board of Governors of the Bethlem Royal Hospital was the subsequent, leading case to appear before the House of Lords that approached such a matter. While the majority of Lordships legitimatised the traditional test expressed in the case of Mr Bolam, the individual judgements were small steps towards informed consent. Four out of the five Law Lords rejected the transatlantic test that a duty to inform a patient should be based on the reasonable or prudent patient and Lord Scarman alone favoured this manner of law. 2.6 Lord Scarman made it apparent that he considered the patient to have the right to choose what happens to his body, which signified the patient needs to know the risks so can exercise an informed choice. He went on to express what he held to be the suitable relationship between a doctor and his patient, â€Å"There is room in our law for a legal duty to warn a patient of the risk inherent in the treatment proposed†. He went on to consider the doctrine of informed consent and its relevance in the Canterbury case, â€Å"I think the Canterbury propositions reflect a legal truth which too much judicial reliance on medical judgment tends to obscure† Lord Scarman acknowledged the patients rights and that the prudent patient principle made the doctors much more accountable for their actions. As such he rejected the current medical practice that a patient will be informed if he needs to be, as opposed to if he wants to be. Doctors, in Lord Scarmans view, should be liable where the risk is such that in the courts view a prudent person in the patients situation would have regarded it significant. He appears to suggest that the onus proof rests on the doctor to satisfy the court as to the reasonableness of any non-disclosure and therefore suggesting a support for informed consent. However, it must be noted that he did not find in favour of Miss Sidaway, on the basis that she failed to establish that the less than one per cent risk was such that a reasonable patient would consider significant. 2.7 In spite of this the speech of Lord Scarman has stood as a symbol of hope to those who argue for informed consent to be introduced into English law. Lord Diplock rejects Lord Scarmans scrutiny, as he maintains that the Bolam test covers all aspects of the doctors duty to care to his patient. However, he distinguished from the position where a patient asks a question about treatment, by stating â€Å"if the patient in fact manifested this attitude by means of questions the doctor would tell him whatever it was the patient wanted to know.† This illustrates that while Lord Diplock believed doctors were not be required to inform the patient of risks, he does not fully discount the patients rights. Lord Bridge also rejected the notion that a patient should be warned of all risks, yet â€Å"when questioned specially by a patient of apparently sound mind about risks involved in a particular treatment proposed, the doctors duty must, in my opinion, be to answer both truthfully and as fully as the question requires.† This gives the patient the option of asking for information from the doctor and if the doctor failed to do so then his duty of care could be in breach. However, Lord Templeman, expressed that this is not clear cut, as â€Å"the court will be slow to conclude that the doctor has been guilty of a breach of duty owed to the patient merely because the doctor omits some specific item of information.† It was important that Lord Scarman recognised the doctrine of informed consent and that the remaining four judges recognised the meaning of a patients ability to enquire and the doctor responsibility to notify. 2.8 It seemed that English legal system was initially hesitant to adopt informed consent into medical law. However, the approach taken in the case Gold v Haringey Health Authority contradicts that expressed by their Lordships in Sidaway. The claimant, in this case, indicated that she did not wish to have any more children and was advised to undergo a sterilisation operation after the birth of her third child. The operation was carried out but the claimant later became pregnant and gave birth to her fourth child. The Judge at first instances applied his own analysis as to what information the doctor should have given and found the defendant negligent. Upon appeal, Lloyd L.J held that the Bolam test should be strictly applied and he dismissed the view of the judge prior to him. He asserted that for the purposes of establishing the test as to the duty of care owed by a doctor to a patient no distinction needed to be made between advice given in a therapeutic and non-therapeutic context. In reference to Sidaway he stated, â€Å"the House of Lords could have adopted the doctrine of informed consent favoured in United States of America and Canada, but the House of Lords decided not to follow that path.† It seems clear from the Sidaway judgement that the nature to inform is more extensive than that of the Bolam test where no information is required. The decision in Gold repealed any progress been made towards informed consent and the judgement seemed to convey patient autonomy to be rather trivial 2.9 The view of Diplock in Sidaway has been regarded as the authoritative statement regarding the extent of the doctors duty. There has been a move away from the Diplock approach as seen in the case Pearce v. United Bristol Health Care NHS Trust which altered the analysis of a doctors obligation. Mrs Pearce, who was expecting her sixth child, was two weeks past her due date of delivery. She discussed the possibility of induction with her obstetrician who warned her of the risks of induction and caesarean surgery, but did not tell her that there was a 0.1 to 0.2 per cent risk of stillbirth associated with non-intervention. Mrs Pearces child was stillborn and she alleged that failure to warn her of the full risks was negligent. Lord Woolf, in this case, held that the patient had the right to know and stated the doctor should normally inform a patient of â€Å"a significant risk which would affect the judgment of a reasonable patient.† It was decided, however, that while a doctor is under an obligation to warn, the 0.1 to 0.2 per cent risk of stillbirth was not classed a significant risk. While the Pearce judgment did not go so far as to fully accept the doctrine of informed consent, it adopted elements of the reasonable test. The judgement goes a certain distance to reconcile the approaches of Lord Scarman, Lord Bridge and Lord Templeman in Sidaway. It isolated Bolam, which by Professor Margaret Brazier,who has wrote many publications on issues of medical law, was considered good as Bolam was â€Å"out of control and out of context, it came close to acquiring democratic status in some quarters.† The test for duty to warn was now suggested to be that the reasonable doctor must tell the patient what a reasonable patient wanted to know. The judgement signified a more patient-friendly approach and made greater demands on the level of disclosure. Chapter 3: Further development towards the doctrine of informed consent 3.1 The medical professional has taken steps to further achieve the full introduction of informed consent into the medical world. The General Medical Council (GMC) produced comprehensive guidance to, doctors on seeking the patients consent in Seeking Patient Consent: The Ethical Considerations February 1999 (appendix I). These guidelines make particular reference to the requirement on doctors to attain informed consent, a doctrine which a few years earlier was alien to English law. Since 1992 Professor Sir Ian Kennedy LLD, a former member of the GMC, has been arguing that doctors need specific guidelines on what constitutes good practice. At that time he was the voice of the minority, however due to dramatic change in the doctor-patient relationship the GMC recognised guidelines needed to be established. The standard adopted in these guidelines resembles elements of the prudent patient test specifically that of the judgment made by Lord Scarman in Sidaway. Guidance from the GMC directs doctors to†¦take appropriate steps to find what patients want to know and ought to know about their condition and its treatment. Andrew Hockton believed that the guidelines, â€Å"should now be considered to amount to more an ethical obligation: they provide at least, a starting-point for measuring the extent of a doctors duty of care to patients† It appears that the guidelines are considered to be a benchmark for doctors to monitor their legal duty of care, to which the Bolam test fails to create. This dissertation professes that perhaps this is the responsible body of medical opinion and it seems the medical profession are setting a higher standard for both themselves and the patient. 3.2 It must be noted the development of the Human Rights Act 1998, has extended the doctrine of informed consent in medical treatment. Incorporation of the European Convention of Human Rights under the Human Rights Act encourages the courts to focus more on the patients rights. This area of law includes Article 2 (the right to life), Article 3 (prohibition on inhuman or degrading treatment) and Article 8 (the right to respect for private and family life which includes the right to bodily integrity). The case R(on the application of Wilkinson) v Broadmoor Hospital illustrates how the introduction of the rights affected certain aspects of medical law. A mental patient appealed concerning a decision to administer treatment without his consent and under restraint. He claimed it infringed his rights under the European Convention of Human Rights 1950, Art.2, Art.3 and Art.8. The judge allowed the appeal stating that under the 1998 Act, it was no longer appropriate to forcible treat detained patients without a court judgement granting so. While the decision in this case would not have been so without the introduction of the Human Rights Act, it had little effect on the majority of medical consent cases. The Act was expected to have a great impact upon issues of medical consent, however it does not seem to have made a dramatic difference on the Courts decision making. 3.3 The most recent case that has dealt with the issue of informed consent is Chester v Afshar, where the claimant underwent surgery and suffered nerve damage leading to paralysis. The surgeon failed to warn Miss Chester of the inherent risk in surgery and the House of Lords decided that the risk was of sufficient quantity to determine the defendant had inadequately warned. The case is considered to show the importance the courts attached to the principle of autonomy, as Lord Hope reiterates when he states, â€Å"the duty to warn has at its heart the right of the patient to make an informed choice as to whether and if so when and by whom to be operated on.† The claimants evidence verified had she been warned of the risk she would not have agreed to surgery without at least seeking a second opinion on the necessity and risks of surgery. Therefore, a causation link was adopted by the courts to further prove negligence by the doctor. 3.4 In this case it was sufficient for her to prove that, if properly warned, she would not have consented to the operation. Dr Afshar was found to violate her right to choose, which meant she was unable to seek further advice or alternatives. Therefore, a claimant pursuing a claim in this area must prove if the information had been given, their decision as to the treatment would have caused extra consideration. Lord Steyn asserted that individuals have a right to make important decisions affecting their lives for themselves†¦in modern law paternalism no longer rules. This case was a ground breaking decision by the House of Lords, as it introduced fully informed consent and it addressed the purpose and rationale behind a doctors duty to warn. 3.5 Historically the law as taken the view that doctors are honourable and true, essentially allowing the medical profession themselves to dictate the duty to disclose. As a result of the decision made in Chester v Afshar this outlook has changed somewhat and it appears to provide a new dawn for patients rights. It has created a remedy for patients who have received insufficient information, where previously the majority of case had failed to provide such a remedy. The days of Lord Denning are long gone, meaning the doctor-friendly Bolam principle has practically been condemned worthless. While the judgement can be seen to address the reality of responsible expectations of society, it seems the judgment leaves the court with a difficult job determining who, between the patient and the doctor, is effectively legitimate when it comes to what information is disclosed. More specifically the outcome is likely to be met with distaste from doctors and there is already evidence of growing concern from within the profession. Despite the doctors concern the law of informed consent has moved on considerably from the reality where the majority of cases would fail to offer a remedy for those who had not been completely informed. As was stated by Sarah Devaney in a Medical Law Review, that back then, â€Å"It did not matter whether or not doctors were wearing the flak jackets of consent, as patients wishing to make claims about lack of information were in any event carrying unloaded guns. However, after cases, time and the materialization of certain events the doctrine of informed consent began to take effect in English law. Chapter 4: The Degree of Sufficient Information 4.1 Informed consent is based on the requirements of appropriate information to allow patients to make an informed choice. The law fails to formulate a standardize figure which can be consider significant and therefore it can only be gauged on previous cases and what the accepted amount has or has not been within these circumstances. More specifically, as no clear indication has been articulated, the judgement will be dependant on the individual facts of the case, as long as this coincides with the authoritative case law. What is clear is that failure to advise sufficiently as to the nature and purpose of the procedure may give rise to an action against the doctor. If the patient is given inadequate information, then how they able to make an informed decision and therefore be said to have given real consent? 4.2 The leading case Chester v Afshar (as discussed above) contradicted any previous beliefs of the court and that of the medical profession. The case prior to Chester was Pearce v United Bristol Health Care (as discussed above) where Lord Woolf stated that the doctor should normally inform a patient of a significant risk which would affect the judgement of a reasonable patient. It considered the balance of percentages and whether this balance would have effected the patients decision to have the treatment. The risk of 1-2 per cent in this case was not considered to be sufficient to represent a significant risk. The decision in Chester made it clear that a 1-2 per cent risk was an adequate percentage for the doctor to warn the patient. Even though, the doctor appropriately informed according to the Pearce decision and the GMC standards, Chester v Afshar brought a new way of thinking to the table. 4.3 Chester disregarded the concept of what a reasonable patient would want to know and instead looked at what each individual patient wanted to know for themselves. This meant it was more plausible for the doctor to consider the patients personality, concerns and wants and information given must be relevant to the patients decision. The involvement of the causation link enabled patients to assert their rights over decision not only on the surgery itself, but in addition on the circumstances in which it was under, for example the time, place and in whose hands the operation should be performed. The causation link made it easier for patients to receive a remedy at law, as long as they could prove that had they been sufficiently warned of the risks they wouldnt have undergone the treatment. This does not mean they need to prove that they would not have had the operation at any time, just not at that moment in time in which they did. The doctor needs to make acknowledgment to both warn of a significant risk and risks which a patient would consider relevant, even if not below significance. It left the doctors with the delicate job of determining what information individual patients wanted to know. This contemporary approach sent shock waves through the medical profession and the GMC had to amend their guidelines, as they now failed to reach a high enough standard. The new guidelines can be found In Good Medical Practice 2006. (see Appendix II) 4.4 Professional guidelines now go further and state the doctor must do his best to discover the patients individual needs and priorities to analysis what information that individual may require. When consenting to treatment patients should be aware of certain factors such as, diagnosis, prognosis, various treatment options, probabilities of success and possible side effects. This was the situation in the case Smith v Tunbridge Wells Health Authority, where a claim was brought against a 28 year old man who was not warned of the risk of impotence inherent in rectal surgery. His claim succeeded despite the risk being considered significantly low, as the judge found failure to warn such a patient of a risk of such importance to him was neither reasonable nor responsible. The doctor needed to have balanced the small risk of importance against the importance it possessed on his life. 4.5 The most effective way of obtaining consent that is currently in the English medical system is consent forms. Consent forms place emphasis on the patients rights; it gives them a sense of control and perhaps recaptures some of the faith that is said to have disappeared between doctors and patients. There is no requirement in English law that consent forms should be in writing, however the Department of Health have recommended the use model consent forms (see appendix III). The most prominent aspect is the fact it does not shy away from informed consent and instead seems to embrace it. It attempts to ensure that patients are aware that they are entitled to ask questions and expect explanations do with the medical treatment they receive. Unfortunately this way of operating is time consuming and is limited to operations and major procedures. It would not be viable for such things as checking a patients throat or examining a patients stomach, as these everyday occurrences are too frequent and considered to be too minor. Some see the consent form as purely evidential yet other believes them to signify fairness to both the patient and the doctor. It creates patient awareness of the fact that they have the right to know and for this right to be attained the patient needs to make it aware what they specifically want to know. This does not extinguish the doctors duties, he must still follow the guidelines set out in obtaining informed consent, for example, explaining the treatment and its implications. In the case Abbas v Kenny the judge stated the obligation is not placed upon the patient and it simply reaffirms their rights, yet it is still the doctors responsibility to â€Å"take into account the personality of the pati ent and the likelihood of misfortune.† 4.6 Even if a warning is given, it can not be consider a suitable warning if it is insufficiently clear to the patient and affects their ability to make a decision on information they fail to comprehend. The doctor must take responsible steps to ensure that advice is understood by the patient. To what extent is it the doctors duty to make sure the patient understands? Chapter 5: A Patients Capability to Understand 5.1 There is a rebuttable presumption that adults have capacity to consent to or refuse treatment. Therefore to make consent valid they must possess the capacity to understanding the method, consequences and benefits. If one fails to understand the information given and the inherent risks of treatment then it can not be regarded as informed consent. Care must be taken to not automatically presume those with learning difficulties are incapable; it is important for doctors to not underestimate a person from their faà §ade. Capacity is not a question of decree of intelligence or maturity of the person concerned, it incorporates elements of ability and belief. 5.2 There are different functions of what must be understood. The must frequently cited case in this context is Re C (Adult: Refusal of Medical Treatment) in which, Thorpe J, held that the person must understand the nature, purpose and effect of the procedure. In other words, sufficient knowledge constitutes the general functions of treatment. Another function that capacity can occupy is that held in Re T (Adult: Refusal of Traetment) where Lord Donaldson referred to knowledge in broad terms of the nature and effect of the procedure to which consent was given. The level of understanding was made important in this case and that this will differ according to the gravity of the decision. More specifically, the more serious a decision the greater capacity required and accordingly patients may have capacity to make some decisions but not others. 5.3 Assessment of a patients capacity is determined by reference to the Thorpe. Js three stage test in Re C it states the courts will assess the patients ability: to take in and retain treatment information; to believe it; to weigh that information, balancing risks and needs. In this case, a sixty-eight-year old patient was being detained in a special hospital, as he survived from schizophrenia. Despite this, the Judge ruled that the patient remained capable of understanding what he was told about the proposed treatment and the proposed risks involved. By satisfying the three points, a patient can verify that information can be given by the doctor, thought through and decided on and therefore the doctrine of informed c