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Court ruling impacts on alternative treatment options

Over the years, the concept of consent has not changed. Providing treatment without consent is still deemed unlawful and can be considered as battery.

Clare Lawrence - Indemnity team
Clare Lawrence BDA Dento-Legal Advisor

However, subsequent court rulings have had an impact. While 'Bolam' was once considered reasonable practice, as healthcare professionals, dentists need to consider the case of Montgomery v Lanarkshire Health Board [2015] for issues surrounding consent.

Obtaining consent

The claimant solicitors view consent as something to be obtained from the patient. Often, the records will state 'patient gives their consent', however, clinicians should obtain consent from the patient through a specific process.

First, an assessment must be carried out. This should be a thorough process, which includes taking the necessary special tests, such as vitality testing and radiographs.

The next step is for a diagnosis to be made. If a definitive diagnosis cannot be reached, it is reasonable to define a differential diagnosis. Based on those findings, the options can be discussed with the patient, before creating a treatment plan.

In the case of Montgomery, the Supreme Court concluded that a doctor/dentist 'is 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.'

And while this is still accepted and applicable when gathering consent, after the assessment and diagnosis, attention should be given to the reasonable alternative treatment options.

When is alternative treatment reasonable?

In the appeal at the Supreme Court in McCulloch and others (Appellants) v Forth Valley Health Board (Respondent) Scotland [2023] UKSC this specific issue was considered by the judge. The court was asked the question: 'What test should be applied when assessing whether an alternative treatment is reasonable and requires discussion with the patient?'

The specifics of the case involved Dr Labinjoh, consultant cardiologist employed by Forth Valley Health Boards, and whether the death of Mr McCulloch was caused by the doctor's negligence. Mr McCulloch died of cardiac arrest at his home. The issue in question was whether Dr Labinjoh had to discuss the option of using NSAIDS with Mr McCulloch, and if not doing so fell below the required standard of reasonable care. In Dr Labinjoh's view the alternative option was not reasonable, while the appellants stated that, in line with 'Montgomery,' Dr Labinjoh was required to discuss it with the patient.

An appeal was made to the Supreme Court after the decision at the Lower Courts, holding the duty in 'Montgomery,' that a clinician who has applied their professional skill and judgement, supported by a reasonable body of medical opinion, does not need to discuss unreasonable options. The Supreme Court dismissed the appeal and concluded on 12 July 2023 that the 'Bolam' standard of what a reasonable clinician would do in the same circumstances should still be applied when establishing reasonable alternative treatment.

Common sense prevailed, providing relief to healthcare practitioners. Clinicians should only have to offer treatment options consistent with their knowledge, expertise, and guidance as a healthcare professional. The material risks of each option, as set out in 'Montgomery', need to be explained in line with each patient.

The doctor is not negligent by not informing the patient about the possible alternative treatments. The narrowing down from possible alternative treatments to reasonable alternative treatments is an exercise of clinical judgment to which the professional practice test, or 'Bolam' test, is applied.

How does this apply to dentistry?

In a typical scenario the patient will attend the dentist as an emergency, looking to treat their pain. Is it reasonable then to discuss the option of 'doing nothing'? Dentists who offer the option must explain the associated risks as with any other. The reasonable options may not include invasive treatment, however, the option of 'doing nothing' could be deemed unreasonable. If so, there is no need for it to be considered or offered.

Whilst each patient and their presenting symptoms require assessment on their own merit, this judgement can help to provide greater clarity in cases where the reasonable treatment options and the associated issue of consent are questioned.