A Crucial Blow to Medical Paternalism?

A bit of medical background first to explain the context; Shoulder dystocia is an obstetric emergency and occurs in 1% of all vaginal births. During birth if the shoulders fail to deliver shortly after the baby's head there is a serious risk to the baby due to compression on the umbilical cord. Obesity and diabetes are two of the most common risk factors.
Most people would agree that when a mother-to-be has diabetes she really should be aware or informed of the increased risk of shoulder dystocia at birth, and in these circumstances she may well want to consider other birthing options.
The reason for this brief preamble is that it sets the scene for the UK’s Supreme Court judgement that it was for patients to decide whether the risks of treatment and alternative options have been adequately communicated. Nadine Montgomery, who has diabetes, was not told of the risks of shoulder dystocia to her baby boy, who subsequently developed cerebral palsy. Her obstetrician justified holding back this information on the grounds that it might have discouraged her from having a vaginal delivery.

Fully Documented Discussion about Treatment Options

As reported in the BMJ, the new ruling means that doctors will have to take “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments.” Doctors are advised to make extra certain that the discussion is fully documented.

The BMJ go on to say that this is a "crucial blow to medical paternalism. Instead of a responsible body of medical opinion, the judgment now rests with “a reasonable person in the patient’s position.” The Court now makes clear that the law now obliges “even those doctors who have less skill or inclination for communication, or who are more hurried, to pause and engage in the discussion.”

The BMJ goes on to comment that , "The days should be long gone when obtaining consent was left to the most junior trainee, tasked with getting the patient’s signature on a standard form, like a salesperson on commission. But how well things are done will vary from person to person and place to place. These days, in the best centres, patients who are considering undergoing a major procedure or course of treatment are invited to a specialist clinic, where experts in communicating risk spend time going through the options, including the option of doing nothing."

Court Endorsing Best Medical Approach

However, as far as most senior Consultants on Total Health are concerned, the Court is pushing at an open door. Consultants from the teaching hospitals have been extending their educational remit to the public and been actively involved in patient-facing communications (in plain English) on sites such as Total Health.co.uk

From a clinical perspective there has always been an onus on patients or their relatives to start taking greater personal responsibility with the medical decision. This is just part of the normal patient-doctor partnership that is encouraged at many levels. Therefore the new court ruling is not necessarily as the BMJ reports a, "crucial blow to medical paternalism". The move simply emphasises the need for doctors to discuss the pros and cons of all appropriate options. This should happen anyway. Hundreds of senior Consultants (especially surgeons!) for some years have been trailblazing the way by providing proactive details of the different treatment options, along with detailed information on their own preferred approaches and philosophies to patient care. This information is freely accessible on patient facing sites such as Total Health.co.uk.

If the required information isn't there, or requires further explanation - all anyone needs to do is ask. However, the Consultants from the top Teaching Hospitals such as University College Hospital in London and The Royal Free Hospital go even further to ensure that patients have the opportunity to understand the various treatment options, including the 'do nothing' option. Patients are proactively encouraged to do their own research and prepare their questions in advance of the consultation - see Medical Consultation Checklist - http://www.totalhealth.co.uk/articles/medical-consultation-checklist and - Cardiologist Consultation Checklist - http://www.totalhealth.co.uk/articles/medical-consultation-checklist

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