This post is part of the Bumper Guide to Interview Preparation for UK Med Schools by Josh from MedPrepUK
For aspiring doctors looking to practice in the UK, mastering clinical skills is just the beginning. Equally crucial is your understanding and application of the principles and values outlined in the General Medical Council’s “Good Medical Practice” guidelines. These foundational standards are essential for ensuring both the safety and trust of your patients. To deepen your comprehension and demonstrate how these guidelines translate into real-world scenarios, we present a series of cases that affected GMC guidelines. By engaging with these case studies, you’ll be better equipped to navigate the intricacies of medical ethics and professional conduct, setting you on the path to becoming a successful and principled doctor in the UK.
Risk
In the case of Chester v Afshar [2004], Ms Carole Chester experienced partial paralysis following surgery to treat lumbar disc protrusion, a condition for which Dr Afshar failed to inform her of a foreseeable (1–2%) yet unavoidable risk. The House of Lords ruled that although Dr Afshar’s failure to warn Ms Chester did not directly cause her injury, it constituted negligence. Lord Bingham emphasised that surgeons have a duty to generally inform patients about serious potential risks of procedures, with the caveat that in exceptional circumstances, it might be in the patient’s best interest not to be informed. This ruling underscores a departure from medical paternalism, affirming the patient’s right to know about small but significant risks of serious injury from surgery. The judgement deemed that patients must be made aware of any significant potential adverse outcomes of proposed treatments, marking a pivotal stance on the importance of informed consent in medical practice.
Refusal of Treatment
In the landmark case of Re C (Adult, refusal of treatment) [1994], the court affirmed the right of a competent adult to refuse medical treatment, highlighting that mental illness does not inherently undermine a patient’s capacity to make informed decisions about their care. C, who was diagnosed with paranoid schizophrenia and detained in Broadmoor secure hospital, developed gangrene in his leg. Despite doctors recommending amputation as a life-saving measure, C refused the procedure. The court supported C’s autonomy, emphasising that having a mental illness does not automatically disqualify someone from making medical treatment decisions. The ruling established that patients with the capacity to understand, believe, retain, and weigh necessary information have the right to refuse treatment, regardless of how irrational such decisions might seem to healthcare providers or the potential risk to the patient’s health or life.
In the case of Re MB (Adult, medical treatment) [1997], which concerned the capacity to refuse treatment, MB, who was in need of a caesarean section, initially withdrew her consent due to a severe phobia of needles, leading to a state of panic. This prompted the hospital to seek and obtain a judicial declaration allowing them to proceed with the caesarean section, a decision MB appealed. However, she later consented to the induction of anaesthesia, and the procedure was successfully carried out. The Court of Appeal supported the initial judgement, finding that MB’s capacity to refuse treatment was compromised at the time due to her acute fear and panic, which impaired her ability to understand the information about her condition and the recommended treatment. This case reaffirmed the principles established in the Re C judgement regarding the assessment of a patient’s capacity, emphasising that capacity can be influenced by various factors such as pain, fear, confusion, or the effects of medication and that it must be evaluated with respect to the specific time and decision at hand.
In the case of Re B (Adult, refusal of medical treatment) [2002], the court addressed the right of a patient with capacity to refuse life-prolonging treatment. B, a 43-year-old woman who had become tetraplegic, expressed her desire to not be sustained by artificial ventilation any longer. Despite her clear wishes, the medical professionals responsible for her care were hesitant to comply. B, whose mental capacity remained unaffected by her condition, successfully sought a legal declaration affirming that the hospital’s refusal to honour her request constituted unlawful action. This case underscored the principle that a competent patient possesses the unequivocal right to decline medical treatment, and that such a decision must be respected by healthcare providers, even if the refusal of treatment leads to the patient’s death.
In St George’s Healthcare NHS Trust v S; R v Collins and others, ex parte S [1998], the court examined the rights of a competent pregnant woman to refuse medical treatment, even when such refusal could potentially harm her or her unborn child, and the applicability of the Mental Health Act 1983. S, who was diagnosed with preeclampsia, a condition necessitating hospital admission and induction of labour, chose to refuse treatment, objecting to medical intervention during pregnancy. Despite her competence and absence of a serious mental illness, S was detained under the Mental Health Act for assessment. A court subsequently authorised treatment without her consent, leading to the delivery of her baby via caesarean section. The Appeal Court later found that S’s autonomy had been unjustly infringed upon, ruling her detention unlawful as it was based not on her mental health but on the medical necessity to address her preeclampsia. It was determined that the judicial approval for the caesarean section had been granted based on misleading and incomplete information. This case reaffirmed the principle that a competent pregnant woman has the right to decline medical treatment, highlighting that it is unlawful to detain patients and administer compulsory treatment for physical conditions under the Mental Health Act.
In Re T (Adult) [1992], the Court of Appeal dealt with the impact of coercion and pressure on patient consent, focusing on the case of T, a 20-year-old pregnant woman who was involved in a car accident and subsequently developed complications necessitating blood transfusions. Initially, T did not express any opposition to the transfusions upon admission. However, after spending time with her mother, a practicing Jehovah’s Witness, she opted to refuse the treatment. The court found that T’s decision was heavily influenced by her mother’s pressure and that her capacity to make an informed decision was further compromised by the medication she was receiving. Consequently, the court ruled in favour of proceeding with the blood transfusions. This case highlights the principle that a patient’s consent may be considered invalid if it results from coercion or undue influence by others.
Requests for Treatment
In the case of Mr Leslie Burke v GMC [2005], the Court of Appeal addressed a series of significant issues surrounding end-of-life decision-making. Leslie Burke, a 45-year-old individual with a degenerative brain condition, expressed concern over the possibility that artificial nutrition might be withdrawn against his wishes at a stage when he would be unable to communicate. The General Medical Council (GMC) countered, suggesting that adhering to Mr. Burke’s request could potentially compel doctors to sustain life support indefinitely, even in circumstances where Mr. Burke would no longer be conscious or considered alive in a functional sense. A critical outcome of this case was the Court of Appeal’s clarification that doctors are not legally or ethically obligated to comply with a patient’s request for treatment if they judge the requested treatment not to be in the patient’s best interests. This ruling underscored the complex balance between patient autonomy and medical discretion in the context of end-of-life care.
Children and Young People
In the landmark case of Gillick v West Norfolk and Wisbech AHA [1986], the House of Lords addressed the contentious issue of whether young people under the age of 16 could consent to contraceptive advice and treatment without the need for parental consent or knowledge under certain conditions. Mrs. Gillick contested the legality of Department of Health guidelines permitting doctors to offer contraceptive services to girls under 16 in specific scenarios. The House of Lords determined that a doctor is justified in providing contraceptive advice and treatment to a minor if the young person demonstrates sufficient maturity and intelligence to grasp the nature and consequences of the treatment, is unlikely to inform her parents or consent to the doctor doing so, is probable to engage in sexual activity with or without contraceptive care, and if her physical or mental health could deteriorate without the advice or treatment. Furthermore, the treatment or advice must align with the best interests of the young person.
This ruling not only applied to contraceptive advice and treatment but was later expanded in the case of Axon, R (on the application of) v Secretary of State for Health [2006] to encompass decisions regarding care for sexually transmitted infections and abortion. The decision established the principle of ‘Gillick competence’, referring to the capacity of individuals under 16 to make informed decisions about their medical treatment, setting a significant precedent in medical law concerning the autonomy and rights of young people.
Euthanasia
The case of Lillian Boynes in 1992 brings to light the profound ethical and legal challenges surrounding euthanasia. Lillian suffered from an exceptionally severe case of rheumatoid arthritis, described by two leading rheumatologists as the worst they had ever encountered, alongside internal bleeding, septicaemia, and vasculitis, leading to deep body abscesses and gangrenous organs. Over 18 years, she was hospitalised 20 times, enduring excruciating pain that made any movement or touch unbearable, resulting in severe emaciation. Despite her suffering, Lillian maintained a cheerful and resilient demeanour, greatly admiring her consultant, Dr. Nigel Cox, who had treated her for 13 years. In her final days, even massive doses of diamorphine failed to alleviate her intense pain. With only a few hours expected to live, Lillian, supported by her sons, expressed a desire to die to Dr. Cox, who had previously promised relief from her suffering without assisting in her death.
Dr. Cox, faced with Lillian’s unbearable condition and her request, administered a lethal dose of potassium chloride, a substance typically used to treat potassium deficiency but capable of stopping the heart at high doses. Lillian passed away within minutes, though it was uncertain whether her death resulted from the injection or her critical condition. The incident was recorded in her medical notes, eventually leading to Dr. Cox’s conviction for manslaughter rather than murder, as the cause of Lillian’s death was ambiguous. He received a suspended sentence and was not barred from practicing medicine by the General Medical Council.
This case underscores the complex dilemmas healthcare professionals face when confronted with patients in extreme suffering and the limitations of palliative care. The reactions of defense witnesses, both eminent rheumatologists, during Dr. Cox’s trial highlighted the distress and moral quandaries faced by medical practitioners in such situations. Dr. Cox’s decision to use potassium chloride, which offers no symptomatic relief and is only effective in stopping the heart, meant he could not argue his actions were intended to alleviate suffering under the principle of double effect. The legal outcome of the case reflects the nuanced and often ambiguous nature of cases involving euthanasia and the ethical, legal, and professional boundaries within which medical practitioners operate.
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