Supreme Court passed judgements on two cases, both of which showed changing trends in doctor-patient relationship
- Nadine Montgomery, a molecular biologist gave birth to a baby with severe disabilities, she was
uninformed of her options
- Dr Hadiza
Bawa-Garba, a junior paediatrician was convicted of
manslaughter for gross negligence.
In clinical practices, medical practitioners seldom consider non-clinical influences during a clinical
consultation. Patient-centred factors like patient's quality of life, characteristics and
interaction with professional community, socioeconomic status, patient's expectations
and wishes, may well play a
major role in the decisions taken by the medical professionals.
Should the medical professional take the
final decision based on the medical evidences alone or should the patient also
be consulted based on his/her background? Today, practicing medicine has
shifted from 'paternalism' to 'patient-centered care', which
typically means that decision-making is shared between the medical professional
and the patient.
‘The UK Supreme Court recently passed judgements on two cases, that showcased how trends in doctor-patient relationship are changing. These judgements have become benchmarks that will change the way medicine is practiced.’
Decision-making may be the biggest obstacle to the
reality of practicing evidence-based medicine. In a patient engagement discussion published in NEJM
Catalyst, Kevin Volpp, Director of the Center for Health Incentives and
Behavioral Economics at the University of Pennsylvania asks, "Where do we draw
the line between improving people's health behavior in the direction that we
want, versus leaving them happy with what they have?"
"If a patient makes a well-reasoned, well-informed
decision not to change an unhealthy behavior, maybe we shouldn't push that
suggests Volpp. However,
if the patient is in fact in danger, David Kirchhoff, CEO of Snap
Kitchen and former CEO of Weight Watchers argues that clinicians can't shy away
from a serious discussion.
Recently, the UK
Supreme Court passed judgements on two cases, both of which showed changing trends in doctor-patient relationship. These cases - Montgomery v Lanarkshire Health Board 2015
and Dr Bawa Garba v GMC, have become
benchmarks and will shape the way medicine is practiced in the UK and in Asian
countries as well, including India.
Case 1: Montgomery v Lanarkshire Health Board 2015
In October 1999, Nadine Montgomery, a
molecular biologist at the Glasgow University, gave birth to a baby boy in Lanarkshire. She was small in stature with insulin dependent diabetes
mellitus and pregnancy had required intensive
monitoring. Babies born to mothers with diabetes
mellitus are at risk of being large for gestational
age. The baby is at risk of shoulder dystocia
(when the baby's head emerges but a shoulder gets stuck during labour), and the
mother is also at risk of other labour related problems. Despite such a grave
situation, the mother was not informed that having a caesarean
section was a possible alternative to vaginal delivery, which can reduce
After about 12 minutes the baby was born with severe disabilities and was diagnosed as suffering from cerebral palsy due to hypoxic damage to
the brain (when the brain is deprived of oxygen supply) due to umbilical cord
occlusion. All of the baby's limbs were affected by
the cerebral palsy. He also suffered a brachial plexus injury resulting in
claimed damages on behalf of her son for the injuries which he sustained
alleging negligence on the part of her obstetrician and gynaecologist
responsible for her care during her pregnancy
and labour, who also delivered the baby.
In its final
judgement, the UK Supreme Court said, "An adult person of sound mind is entitled to decide which, if any, of
the available forms of treatment to undergo, and her consent must be obtained
before treatment interfering with her bodily integrity is undertaken. The
doctor is therefore under a duty 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."
On the issue
of disclosure of risks, the Court ruled that "there can be no doubt that it was incumbent on Dr McLellan to advise
Mrs Montgomery of the risk of shoulder dystocia if she were to have her baby by
vaginal delivery, and to discuss with her the alternative of delivery by
caesarean section. The risk of shoulder dystocia was substantial around 9-10%.
Applying the approach which we have described, the exercise of reasonable care
undoubtedly required that it should be disclosed. Shoulder dystocia is itself a
major obstetric emergency, requiring procedures which may be traumatic for the
mother, and involving significant risks to her health."
It was argued
on behalf of the doctor that
decision not to disclose
information about the risk of shoulder dystocia to her
patients was because they may request for a caesarean section. And the risk of serious injury in this case was
small; 0.2% risk of a brachial plexus injury and less than 0.1% risk of cord
However, the UK Supreme Court ruled that
Mrs Montgomery should have been informed of the shoulder dystocia risk for her baby and also should have
been give the option of a caesarean section.
Mrs Montgomery, in all
likelihood would have opted for a caesarean section, if she had been told of the
risk of shoulder dystocia. She was awarded £5.25 million in damages.
The Montgomery v
Lanarkshire Health Board case saw a landmark judgement by the UK Supreme
Court, which reflected a change in the doctor- patient
relationship. The " Bolam test"
which determines if this decision is acceptable, given the medical evidence was
not applicable to the issue of
'provision of information to the patient
' in any case of alleged negligence in UK
. However, Mrs Montgomery
prove that the damage was a direct result of breach of duty.
Bolam test was previously
used in cases of medical negligence such as the
judgement in Bolam v Friern Hospital Management Committee in
1957. It is the
"standard of the ordinary skilled man
exercising and professing to have that special skill. A man need not possess
the highest expert skill, it is well established law that it is sufficient if
he exercises the ordinary skill of an ordinary competent man exercising' that
art (a health care professional), is not guilty of negligence if he has 'acted
in accordance with a practice accepted as proper by a responsible body of
medical man skilled in the particular act
The Bolam test, requires that
the adequacy of information given to the
patient for consent must be in accordance with the practice accepted by a responsible
body of medical opinion. The UK Supreme Court, in the Montgomery case ruled that the doctor
has a duty "
to ensure that the
patient is aware of any material risks involved in any recommended treatment,
and of any reasonable alternative or variant treatments".
is defined as a risk which a reasonable person would consider significant or
which a doctor knows that the patient would consider it significant.
In the judgement that was
passed the doctor is privileged to use his/her discretion on
whether the patient would be affected by the disclosure of
information, an if so, to withhold the same.
Case 2: Dr Bawa Garba v GMC
The case which involved Dr Hadiza Bawa-Garba, rocked the medical circles, as the
junior paediatrician was convicted of manslaughter for gross negligence. She was stripped of her medical
licence and given a two-year suspended sentence for mistakes which led to the death
of a six-year-old boy, Jack Adcock, with Down's syndrome
. Dr Bawa-Garba's name was erased from the medical register and was debarred from
practicing medicine for life for system failures.
Many in the medical community argued, that as medical practice has become
defensive practice, were such mistakes made in the Dr Bawa Garba case real
enough to be called manslaughter?
Jack Adcock, was referred
to Dr Bawa-Garba by a general practitioner (GP) for nausea, vomiting, and diarrhea and low BP. A speculative diagnosis of
fluid depletion from gastroenteritis was made by Dr
Bawa-Garba and the boy was given intravenous fluid
bolus immediately. The doctor had sent the blood sample to test the blood
count, renal function and inflammatory markers, she took
blood gases which showed that Jack was acidotic with a pH of 7
and a lactate of 11. A chest radiograph was also requested.
Jack's metabolic profile confirmed a diagnosis of shock from
gastroenteritis; however, according to the tests pneumonia was also a possibility. Post the initial fluid bolus, Jack's metabolic profile
seemed to be moving in the right direction, where his
repeat blood gas showed he was less acidotic, with a pH of 7.24, heading
towards a normal pH of 7.4.
Delay in Chest x-ray and Antibiotics
Bawa-Garba was able to check the chest x-ray at 3 pm, which
confirmed that the boy had pneumonia. The
antibiotics which Dr Bawa-Garba prescribed
were given at 4 pm.
It was argued that if the patient, Jack
was given the antibiotics, much earlier, maybe within 30 minutes, rather than 6 hours, his chances of survival would have increased
dramatically. However, the antibiotic was administered on confirmation of pneumonia.
If different antibiotics
are given in every situation that is presented, will this not amount to misuse of antibiotics?
When Dr Bawa-Garba met her
senior Dr O'Riordan in the hospital corridor at 4:30 pm, Jack's blood gas results were shown and
Dr Bawa-Garba explained the plan of action. However, Dr O'Riordan did
not see the patient.
When asked why
he did not see Jack, Dr O'Riordan said that Dr Bawa-Garba did not ask
him to; nor did she express any clinical urgency. Shouldn't the
consultant have to sniff out trouble? Wasn't this
the senior's responsibility?
Guilty of homicide for mistaking normalizing pH after a fluid
bolus for hypovolemic rather than septic shock
On hearing of delayed treatment given to
Jack, the jury was unaware of other patients being treated by Dr
Bawa-Garba in the same hospital.
When Jack's blood gases
showed clear signs of sepsis, why didn't the
consultant of the day Dr O'Riordan,
not immediately diagnose sepsis when he saw the blood
How can the blame fall on a resident, who was doing the work of three registrars? How can she be
guilty of homicide for not understanding acid-base physiology? And what does this say about the supervisor's competence?
Enalapril should have
While in the ward, Jack
was given enalapril
. However, this
medication was not prescribed by Dr Bawa-Garba, it was in fact
given by Jack's mother. Dr Bawa-Garba mentioned that
enalapril must be stopped. She strictly instructed the
nursing staff not to give enalapril. Jack had a cardiac arrest an hour after enalapril was given.
Unprescribed drugs are strictly not to
be given to a patient. This being the case the medical staff should have
informed the family that such a practice is not allowed by law.
Since, the hospital did allow the parent
to give the medicine, as they were understaffed, was this the fault of the
Several attempts to resuscitate Jack were done by Dr
Bawa-Garba, however there was a pause for just a minute, where the
doctor had stopped to see if the patient was in fact Jack. The boy was pronounced dead. Could a pause of less than a minute be the
cause of failed CPR?
Dr Bawa-Garba was depressed
and disturbed after Jack's death. She recorded her feelings in her electronic
portfolio. Without making excuses and not writing about the system failures in
the hospital, Dr Bawa-Garba recorded her
failings, without pointing fingers at others. This honest e-process log was used against her as evidence.
Was it a doctor's failure?
An investigation by the hospital trust had
identified that several system issues. However medical errors can be both
system failures and physician factors as well. While the American patient
safety movement placed their blame for medical errors on the faulty systems,
the Tort system maintains that individuals and systems can contribute: which is
reporting inadequate staff and system failures
As the hospital was understaffed, on
that unfortunate day, with Dr Bawa-Garba's supervisor, Dr
O'Riordan, not available in the city, and Dr
Bawa-Garba's colleagues away on educational leave, she covered the wards, the emergency department, and the Children's Assessment
Unit (CAU). Usually one registrar will be assigned to each one
Dr Bawa-Garba was also a
new joinee to the hospital, with no formal induction. She did not
know how things worked around the hospital. In spite of this she was expected
carry on with the work and find her way around the hospital.
In the absence of a senior resident, the
registrars are the principle decision-makers in hospitals. Since Dr Bawa-Garba was in-charge shouldn't she
have raised an alarm on the failures in the systems of the hospital?
Would she have faced an opposition from her senior and the management?
- Drawing the Line Between paternalism and Patient-Centered care - (https://catalyst.nejm.org/videos/drawing-the-line-between-paternalism-and-patient-centered-care/)
- Medical decision making: paternalism versus patient-centered (autonomous) care. - (https://www.ncbi.nlm.nih.gov/pubmed/19005314)