Consent and Capacity

For consent to be valid, three things must be present. The person must have the capacity to make the decision, they must have enough information to make it, and they must give it voluntarily, free from pressure. Consent can be written, spoken or implied by a person's actions, such as holding out an arm for an examination. Implied consent is appropriate for straightforward, low-risk examination or care, whereas invasive treatment or procedures call for express consent. The form matters less than whether these three conditions are met.

Giving enough information means a conversation rather than a signature: the nature of the proposed assessment or treatment, its purpose, the material risks and benefits, and the reasonable alternatives, including doing nothing. What counts as a material risk is judged from the patient's point of view, so a risk that matters to this particular athlete should be discussed even if it is uncommon. Consent is also an ongoing process, not a single event, and a person may withdraw it at any time. The person providing consent should be someone with the knowledge to answer questions about the proposed treatment, and the discussion, not just the outcome, is what should be recorded. Consent must also relate to the specific intervention proposed, since a general agreement to be treated does not cover every procedure.

Capacity is the ability to make a specific decision at a specific time, and it is assumed to be present in an adult unless shown otherwise. It is decision-specific, so a person may have capacity for one choice and not another, and it can fluctuate, for example with pain, medication or an acute head injury. Assessing capacity asks first whether there is an impairment of the mind or brain, and then whether that impairment stops the person understanding the relevant information, retaining it, weighing it, and communicating their decision. The detailed legal framework differs across the UK, with separate capacity legislation in England and Wales, in Scotland and in Northern Ireland, though the underlying principles are similar. A person is not to be treated as lacking capacity simply because a decision seems unwise. Where an adult lacks capacity, decisions are made in their overall benefit rather than by another person overriding them for convenience. Children and young people are a distinct situation. A young person aged sixteen or seventeen is generally presumed able to consent to their own treatment, while a child under sixteen may consent if they have enough maturity and understanding to grasp what is involved, an idea sometimes described as Gillick competence. Otherwise a person with parental responsibility usually consents, always with the young person's welfare as the priority. Before deciding that a person lacks capacity, reasonable steps should be taken to support them to decide, such as giving information in a way they can understand and choosing a time when they are best able to engage.

The sporting setting adds its own pressures to consent. An athlete may feel driven to agree to an injection or a procedure to keep playing, so the doctor must be satisfied the decision is truly voluntary and well informed, not shaped by the fixture or by others. At the pitch-side, decisions are often made quickly, but the same principles apply, adapted to the urgency. Consider an athlete offered an injection to allow them to continue in a match: valid consent means explaining what the injection is, what it will and will not do, the risks, and the alternatives, and checking the athlete is deciding freely. In a genuine emergency, where a seriously injured athlete cannot consent, the doctor may provide the treatment that is immediately necessary to save life or prevent serious deterioration, limited to what cannot wait. An athlete with capacity may also refuse assessment or treatment, and that refusal must be respected even if the doctor disagrees, provided it is informed. Where consent is taken under time pressure, it is still worth confirming the athlete has understood the key points and noting what was discussed, so the record reflects a real conversation. With young athletes, consent involves the young person and, where they cannot consent themselves, a person with parental responsibility, and the young person's own views still carry weight.

A frequent error is to treat a signed form as consent in itself, when the conversation is what matters and the form only records it. Another is to assume capacity is all-or-nothing or fixed, missing that it is specific to the decision and can fluctuate. Doctors sometimes underplay risks that matter to the particular athlete, or fail to offer the alternative of not proceeding. In sport, the voluntary element is easily overlooked, so that pressure from a coach, an agent or the occasion is not recognised as undermining a free choice. Finally, a refusal by an athlete with capacity is sometimes not accepted, which is a breach of their autonomy rather than an act of care.

• •Valid consent requires capacity, sufficient information and a voluntary decision.
• •Consent is a process and can be written, spoken or implied; it may be withdrawn at any time.
• •Capacity is decision-specific and time-specific, and is assumed in an adult unless shown otherwise.
• •Assess capacity by understanding, retaining, weighing and communicating, after checking for an impairment.
• •In an emergency, treat only what cannot wait when a person cannot consent.
• •Respect an informed refusal by an athlete with capacity, even if you disagree.