{"id":4437,"date":"2023-07-19T14:43:52","date_gmt":"2023-07-19T13:43:52","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=4437"},"modified":"2023-07-19T14:43:52","modified_gmt":"2023-07-19T13:43:52","slug":"the-supreme-court-on-consent-for-treatment-practical-but-unfair","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2023\/07\/19\/the-supreme-court-on-consent-for-treatment-practical-but-unfair\/","title":{"rendered":"The Supreme Court on consent for treatment: practical but unfair?"},"content":{"rendered":"<p>By Abeezar I Sarela.<\/p>\n<p>On 12 July 2023, the Supreme Court issued its judgment in <a href=\"https:\/\/www.bailii.org\/uk\/cases\/UKSC\/2023\/26.html\"><em>McCulloch v Forth Valley Health Board<\/em><\/a><em>. <\/em>This judgment resolves a contentious issue in contemporary legal and ethical paradigms of consent for medical treatment; so, it requires careful attention.<\/p>\n<p>In an earlier <a href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2023\/06\/06\/consent-for-medical-treatment-what-is-reasonable\/\">blogpost<\/a>, I discussed that, as per the ruling of the Supreme Court in <a href=\"https:\/\/www.bailii.org\/uk\/cases\/UKSC\/2015\/11.html\"><em>Montgomery v Lanarkshire Health Board<\/em><\/a><em>, <\/em>doctors are obliged to inform patients of \u2018material risks involved in any recommended treatment, and of any reasonable alternative or variant treatment\u2019 (para 87). Accordingly, provision of information about alternative treatments is fundamental to the <a href=\"http:\/\/dx.doi.org\/10.1136\/medethics-2021-107347\">duty of consent<\/a>. But, the meaning of a \u2018reasonable alternative\u2019 has been hotly debated. This debate engages a central question in legal and political philosophy: what is \u2018reasonable\u2019?<\/p>\n<p>The notion of being reasonable is commonly anthropomorphised as a <a href=\"https:\/\/doi.org\/10.2307\/825941\">\u2018reasonable person\u2019<\/a>. Being reasonable, then, is being able to justify an action or proposal to this reasonable person. For instance, in order for treatment B to be regarded as a reasonable alternative to treatment A, the justification for\u2014the argument in favour of\u2014treatment B must be acceptable to the reasonable person. If the justificatory argument\u2014the logical relationship of premises leading to a certain conclusion\u2014is not acceptable to the reasonable person, then treatment B would be unreasonable.<\/p>\n<p>The critical issue is the identity of this reasonable person. This issue is critical because justifications that might be acceptable to one audience of persons\u2014one constituency\u2014may not be acceptable to others. So, it is necessary to know to <em>whom<\/em> the justification has to be provided. It has been long-established that a doctor\u2019s action is reasonable if this action is acceptable to a body of that doctor\u2019s professional peers. This legal principle is commonly referred to as the <a href=\"https:\/\/uk.practicallaw.thomsonreuters.com\/D-016-0979?transitionType=Default&amp;contextData=(sc.Default)&amp;firstPage=true\"><em>Bolam<\/em><\/a> test. The principle is grounded in <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2265366\/\">sociological theory<\/a> that any profession involves certain unique knowledge and skills such only the members of that profession\u2014the professionals\u2014can decide correct practice. Thus, per <a href=\"https:\/\/uk.practicallaw.thomsonreuters.com\/D-016-0979?transitionType=Default&amp;contextData=(sc.Default)&amp;firstPage=true\"><em>Bolam<\/em><\/a>, the \u2018reasonable person\u2019 is a constituency of reasonable doctors\u2014the peers of the patient\u2019s treating-doctor.<\/p>\n<p>Notably, the <a href=\"https:\/\/uk.practicallaw.thomsonreuters.com\/D-016-0979?transitionType=Default&amp;contextData=(sc.Default)&amp;firstPage=true\"><em>Bolam<\/em><\/a> test does not require the reasonable doctor-constituency to include <em>all <\/em>peers of the treating-doctor. The law acknowledges differences in professional opinion. Accordingly, it requires the reasonable doctor to comprise one body of opinion\u2014one constituency only\u2014within the medical profession. Provided that the logic of the justificatory argument that was acceptable to this constituency was not flawed, the existence of other bodies of logical opinion would not render the treating-doctor\u2019s action to be unreasonable. Thus, the law allows the existence of a plurality of reasonable doctors.<\/p>\n<p>Until <a href=\"https:\/\/www.bailii.org\/uk\/cases\/UKSC\/2015\/11.html\"><em>Montgomery<\/em><\/a>, the \u2018reasonable doctor\u2019 standard applied to all aspects of medical practice, including consent. In <em>Montgomery<\/em>, an obstetrician had not informed a pregnant patient of certain risks of vaginal delivery; and this omission was acceptable to a group of the obstetrician\u2019s peers, that is, the omission passed the reasonable doctor (<a href=\"https:\/\/uk.practicallaw.thomsonreuters.com\/D-016-0979?transitionType=Default&amp;contextData=(sc.Default)&amp;firstPage=true\"><em>Bolam<\/em><\/a><em>)<\/em> test. But, the Supreme Court rejected the <em>Bolam<\/em> test in this situation. Instead, it inquired whether the omission was acceptable to reasonable person in the pregnant woman\u2019s position. In doing so, the Supreme Court shifted the identity of the reasonable person\u2014the one to whom justification had to be provided\u2014from the doctor to the patient.<\/p>\n<p>Although <em>Montgomery <\/em>carved out an important role for the reasonable patient, the jurisdiction of this reasonable patient remained unclear: did it pertain to the disclosure of risks only; or did it extend to the selection of alternatives, too? In <a href=\"https:\/\/www.bailii.org\/uk\/cases\/UKSC\/2023\/26.html\"><em>McCulloch<\/em><\/a><em>, <\/em>the Supreme Court clarifies that the reasonable patient\u2019s jurisdiction covers risk-disclosure only. The selection of reasonable alternatives\u2014treatments regarded as <a href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2023\/03\/07\/re-thinking-consent-for-treatment-clinical-interests-and-the-public-interest\/\">\u2018clinically appropriate\u2019 or \u2018clinically suitable<\/a>\u2019\u2014remains in the reasonable doctor\u2019s province; to be assessed by the venerable <em>Bolam <\/em>test.<\/p>\n<p>The Supreme Court\u2019s reliance on reasonable doctors for identifying reasonable treatments is in keeping with the sociological conception of professionalism. Yet, it could be argued that the <a href=\"https:\/\/www.bailii.org\/uk\/cases\/UKSC\/2023\/26.html\"><em>McCulloch<\/em><\/a> judgment is unfair; because patients have unequal opportunities to healthcare through no fault of their own. For example, consider that an operation can be done by open surgery or by laparoscopy. There are two groups of surgeons, each of whom prefers one approach; and neither is illogical. Now, if the treating-surgeon offers open surgery only, then the patient has lost the opportunity for laparoscopic surgery that she, herself, might have preferred. Yet<em>, <\/em>the patient has no grounds for complaint.<\/p>\n<p>What is the solution? It is insightful to revisit <a href=\"https:\/\/www.bailii.org\/uk\/cases\/UKSC\/2015\/11.html\"><em>Montgomery<\/em><\/a><em>. <\/em>Although <em>Montgomery <\/em>did not explicitly discuss reasonable alternative treatments, a <a href=\"https:\/\/journals.sagepub.com\/doi\/10.1177\/09685332231167147#core-collateral-self-citation\">\u2018test of availability\u2019<\/a> has been induced from this judgment. As per this test of availability, reasonable alternatives include treatments that would be acceptable to <em>all <\/em>groups of doctors in the relevant specialty; rather than alternatives that are acceptable to the treating-doctor and concurring colleagues only. This test of availability is theoretically sound and fair, but it does pose considerable practical difficulties. In <a href=\"https:\/\/www.bailii.org\/uk\/cases\/UKSC\/2023\/26.html\"><em>McCulloch<\/em><\/a><em>, <\/em>the Supreme Court explicitly rejects this test of availability, on the basis of the practical difficulties. It is likely that the medical profession, and indemnifying organisations, will welcome <em>McCulloch. <\/em>But, champions of health equality are likely to protest that justice has not been done.<\/p>\n<p><strong>Author:<\/strong>\u00a0Abeezar I Sarela<\/p>\n<p><strong>Affiliations:\u00a0<\/strong>Department of Surgery, The Leeds Teaching Hospitals NHS Trust<\/p>\n<p><strong>Competing interests<\/strong>: None declared<!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>By Abeezar I Sarela. On 12 July 2023, the Supreme Court issued its judgment in McCulloch v Forth Valley Health Board. This judgment resolves a contentious issue in contemporary legal and ethical paradigms of consent for medical treatment; so, it requires careful attention. In an earlier blogpost, I discussed that, as per the ruling of [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2023\/07\/19\/the-supreme-court-on-consent-for-treatment-practical-but-unfair\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":354,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2146,8057],"tags":[],"class_list":["post-4437","post","type-post","status-publish","format-standard","hentry","category-in-the-courts","category-medical-ethics"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>The Supreme Court on consent for treatment: practical but unfair? - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2023\/07\/19\/the-supreme-court-on-consent-for-treatment-practical-but-unfair\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"The Supreme Court on consent for treatment: practical but unfair? - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"By Abeezar I Sarela. On 12 July 2023, the Supreme Court issued its judgment in McCulloch v Forth Valley Health Board. This judgment resolves a contentious issue in contemporary legal and ethical paradigms of consent for medical treatment; so, it requires careful attention. 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