Yesterday I did some teaching for NHS HRA Research Ethics Committees in London. I took the opportunity to present the Paul Marik story and covered the pros and cons of offering this treatment “on the NHS” as even-handedly as I could. Then I asked for a show of hands on who would demand a “proper” UK-based multicentre randomised blinded controlled clinical trial before wider adoption. One hand was thrust up in defence of the Establishment view, most of the others said “well, I’d want you to give it to me/ my wife/ my mother/ Arsene Wenger if facing 35% risk of mortality”. (It was North London, Arsenal territory).
Now that I no longer retain a License to Practice medicine, I am careful to avoid offering treatment opinions. But I can offer my thoughts on the expectation of English Law, most recently expressed in a Court of Appeal case I’ll call Webster v Burton. Leagle Beagles can easily find a transcript online, or send me a request for a copy. The case was from obstetric practice, but the legal principles will apply equally to the treatment of sepsis.
- the doctor’s obligation (apart from in cases where this would damage the patient’s welfare) is to present the material risks and uncertainties of different treatments, and to allow patients to make decisions that will affect their health and well-being on proper information. The significance of the risks and uncertainties, including the possibility of alternative treatment, being sensitive to the characteristics of the patient.
- evidence is not to be selectively disclosed; even ‘emerging but recent and incomplete material’ should be shared with the patient (or her surrogate decision-maker).
- treatment choices should be respected, even if the doctor disagrees with the course chosen.
Paternalism is dead. Notice that the old Bolam principle no longer applies in the domain of disclosure and valid consent. A doctor cannot defend his actions by showing that another doctor would have done the same thing. Ignorance could however defend you; pretend you never heard of Marik’s Chest report and you couldn’t be blamed for failing to disclose its existence. But ethically and legally that would be dishonest.