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Privileging the medical norm: liberalism, self-determination and refusal of treatment

Published online by Cambridge University Press:  02 January 2018

John A Harrington
John A Harrington*
Affiliation:
University of Warwick
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Extract

In the last twenty-five years consent has emerged as central to ethical and legal thinking on medical treatment. The meaning of consent and its importance and applicability in the medical context has been tested by scholars and judges in most western jurisdictions. This essay seeks to re-examine the role of consent in medical law in England having regard to a recent series of cases concerning the refusal of treatment. By linking the law, as it has emerged from these decisions, with that developed in the 1980s concerning the doctrine of informed consent it should be possible to draw some conclusions regarding the role of law and the courts in medicine. Throughout we shall be contrasting the supposedly traditional and outdated paternalism of the medical profession with the liberal, pro-autonomy strategies of (mainly) academic commentators.

Type
Research Article
Information
Legal Studies , Volume 16 , Issue 3 , November 1996 , pp. 348 - 367
Copyright
Copyright © Society of Legal Scholars 1996

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References

2. Cf Hippocrates Decorum, in Hippocrates (Mass, Cambridge: Harvard UP, 2nd edn, 1967) quoted in I Kennedy & A Grubb Medical Law: Cases and Materials (London: Butterworths 1989) p 229.

3. A M Can-Saunders & P A Wilson The Professions (London: Frank Cass, 2nd edn, 1964) pp 68–77.

4. T S Szasz The Myth of Mental Illness (New York Harper & Row, 1974) pp 44–45.

5. Cf generally, I Illich Limits to Medicine. Medical Nemesis: The Expropriation of Health (Harmondsworth: Penguin 1976).

6. In the United States the work of Jay Katz has been pathbreaking in this regard. For a recent view, cf J Katz ‘Informed Consent - Must It Remain a Fairytale’, (1994) 10 Journal of Contemporary Health Law and Policy, pp 69-91. For further exposition of the liberal critique of medical law, in varying forms and from a variety of national perspectives, cf I Kennedy & A Grubb Medical Law: Cases with Materials (London: Butterworths 2nd edn, 1994) pp 87–251; S McLean A Patient's Right to Know. Information Disclosure, the Doctor and the Law (Aldershot, Brookfield [Vermont]: Dartmouth 1989); D Giesen International Medical Malpractice Law (J C B Mohr, Martinus Nijhoff Tübingen, Dordrecht, Boston, London 1988) paras 482–601.

7. ‘Fit’ in this connection may be taken to indicate principled consistency as between the interpretation and application of the concept of consent in different areas of substantive (criminal or private) law or ‘horizontal fit’. It may, however, also indicate the consistent specification or derivation of particular rules on consent from constitutional, political and ethical first principles or ‘vertical fit’. For a discussion of ‘fit’ as part of a theory of rights and judicial decision-making, cf R Dworkin Law's Empire (London: Fontana 1986) p 45 passim.

8. Cf S McLean A Patient's Right to Know. Information Disclosure, the Doctor and the Law (Aldershot, Brookfield [Vermont]: Dartmouth, 1989) p 25.

9. Schloendorff v Society of New York Hospital, 211 NY 125, 105 NE 92 (1914) per Cardozo J at 93.

10. Chatterton v Gerson [1981] QB 432, [1980] 3 WLR 1003, [1981] 1 All ER 257 (Bristow J).

11. [1957] 1 WLR 582, [1957] 2 All ER 118 (McNair J).

12. 1955 SC 200, 1955 SLT 213.

13. [1984] 1 WLR 634, [1985] 1 All ER 635 (HL)

14. [1985] AC 871, [1985] 2 WLR 480, [1985] 1 All ER 643 (HL).

15. Sidaway v Bethlem Royal Hospital Governors [1985] AC 871, [1985] 2 WLR 480, [1985] 1 All ER 643 (HL per Lord Scarman at 649h).

16. Sidaway v Bethlem Royal Hospital Governors [1985] AC 871, [19851 2 WLR 480, [1985] 1 All ER 643 (HL per Lord Scarman at 652d-e).

17. This test of disclosure has been adopted by the Australian High Court, in Rogers v Whitaker (1992) 109 ALR 625, (1992) 67 AJLR 47. In the same decision the Court expressly disapproved of the use of the Bolam test in relation to treatment as well as disclosure malpractice.

18. Sidaway v Bethlem Royal Hospital Governors [1985] AC 871, [1985] 2 WLR 480, [1985] 1 All ER 643 (HL per Lord Diplock at 657i).

19. Sidaway v Bethlem Royal Hospital Governors [1985] AC 871, [1985] 2 WLR 480, [1985] 1 All ER 643 (HL per Lord Templeman at 665c).

20. Sidaway v Bethlem Royal Hospital Governors [1985] AC 871, [1985] 2 WLR 480, [1985] 1 All ER 643 (HL per Lord Bridge at 663c).

21. M Brazier ‘Patient Autonomy and Consent to Treatment: the Role of the Law?’ (1987) 7 LS 169–193.

22. I Kennedy ‘The Patient on the Clapham Omnibus’ in I Kennedy Treat Me Right. Essays in Law und Medical Ethics (Oxford: Clarendon 1988) pp 175-212; For a critique of Sidaway from a continental perspective, cf D Giesen & J Hayes ‘The Patient's Right to Know - A Comparative View’, 21 (1992) Anglo-American LR 101–122.

23. [1988] QB 481, [1987] 3 WLR 649, [1987] 2 All ER 888 (CA).

24. Cf J Keown ‘Burying Bolam: Informed Consent Down Under’ (1994) 53 Cam LJ 16–19.

25. [1985] AC 871, [1985] 2 WLR 480, [1985] 1 All ER 643 (HL per Lord Scarman at 654).

26. United States President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioural Research, Making Health Care Decisions (Washington DC 1982) i 95–99.

27. To quote Lord Scarman in Sidaway again, ‘On both the test and the defence [of therapeutic privilege] medical evidence will of course be of great importance’: [1985] AC 871, [1985] 2 WLR 480, [1985] 1 All ER 643 (HL at 654g).

28. This legislation is discussed in detail in I Kennedy & A Grubb Medical Law Cases with Materials (London: Butterworths, 2nd edn, 1994) pp 625–634.

29. For a contemporary reformulation of the ‘will theory’, cf C Fried Contract as Promise (Havard UP Cambridge (Mass) 1979).

30. T Parsons & R Fox ‘Illness and the Role of the Physician’ in T Parsons On Institutions and Social Evolution-Selected Writings (ed LH Mayhew) (London: University of Chicago Press, 1982) pp 145–156.

31. Cf for example, the studies discussed in M Morgan, M Calnan & N Manning Sociologicial Approaches to Health and Medicine (London and New York: Routledge, 1985) pp 127–156.

32. RC Fox The Sociology of Medicine. A Participant Observer's View (New Jersey: Prentice Hall, 1989) pp 25–26.

33. H Waitzkin & J Stoeckel ‘Information Control and the Micropolitics of Heath Care’, 10 Social Science & Medicine 263–276 (1976) at 265.

34. C West Routine Complications. Troubles with Talk between Doctors and Patients (Indiana Up: Bloomington 1984) esp pp 148–161.

35. [1993] Fam 95, [1992] 3 WLR 782, [1992] 4 All ER 649 (CA per Lord Donaldson MR at 102D).

36. [1993] AC 789, [1993] 2 WLR 316, [1993] 1 All ER 821 (HL per Lord Goff at 864C-D).

37. [1993] Fam 95, [1992] 3 WLR 782, [1992] 4 All ER 649 (CA).

38. [1993] Fam 95, [1992] 3 WLR 782, [1992] 4 All ER 649 (CA).

39. [1994] 1 WLR 290, [1994] 1 All ER 819 (Thorpe J).

40. L Roth, A Meisel & C Lidz ‘Tests of Competency to Consent to Treatment’, (1977) 134 AmJ Psychiatry 279–284.

41. Law Commission, Report No 129: ‘Mental Incapacity’ (London: HMSO 1995) pp 32–42.

42. It might be worth adding that C survived his refusal without any significant deterioration in health: Speech of Mr Mike Hinchliffe (Official Solicitor's Office) to British Medical Association conference ‘Statements, Directives and Dialogue’, London, 5 April 1995.

43. [1993] Fam 123, [1992] 3 WLR 806, [1992] 4 All ER 671 (Sir Stephen Brown P).

44. Re T (Adult: Refusal of Medical Treatment) [1993] Fam 95, [1992] 3 WLR 782, [1992] 4 All ER 649 (CA per Lord Donaldson MR at 102E).

45. Re AC 573 A2d 1235 (1990).

46. M Thomson, ‘After Re S’ (1994) 2 Med L Rev 127-148; K Stem ‘Court-Ordered Caesarian Sections: In Whose Interests?’ (1993) 56 MLR 238–243; cf further, N K Rhoden ‘The Judge in the Deli very Room: The Emergence of Court-Ordered Caesareans’, (1986) 74 California L Rev 1951–2030.

47. [1995] Fam 133, [1995] 1 All ER 683 (CA).

48. [1994] 1 FLR 614, (1994) 2 Med L Rev 93 (CA).

49. [1993] AC 789, [1993] 2 WLR 316, [1993] 1 All ER 821 (HL).

50. This approach was most recently taken in Re VS (Adult: Mental Disorder) (1995) 3 Med L Rev 294 (Douglas Brown J).

51. M Brazier & C Bridge ‘Coercion or Caring: Analysing Adolescent Autonomy’ (1996) 16 LS 84–109 (96).

52. [1992] Fam 11, [1991] 3 WLR 592, [1991] 4 All ER 177(CA).

53. [1993] Fam 64, [1992] 3 WLR 758, [1992] 4 All ER 627(CA).

54. From Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112, [1985] 3 WLR 830, [1985] 3 All ER 402 (HL). As Brazier and Bridge note, however, judicially expressed fear of stigmatization under the Mental Health Act is ‘a self-fulfilling prophecy’: (1996) 16 LS 84-109 at (97).

55. Cf A Grubb Case Note: Riverside Mental Health Trust v Fox (1994) 2 Med L Rev 93 at (98).

56. N 10565/83 7 EHRR 152 at 153 (1984); cf also Herczegfalvy v Austria A 244 (1992) Com Rep.

57. [1995] 1 All ER 677 (FamD per Thorpe J at 682e).

58. Medical writers have indicated a possible correlation between hunger striking and mental disorder. One study concluded that ‘the majority of prisoners refusing food respond to both the observation and counselling within the prison setting’: EP Larkin ‘Food Refusal in Prison’ (1991) 31 Medicine, Science and Law 41–44 at 44. This clearly presents a therapeutic alternative to open contest in the courts.

59. Riverside Mental Health Trust v Fox [1994] 1 FLR 614, (1994) 2 Med L Rev 93 (CA).

60. JA Devereux, DPH Jones & DL Dickenson ‘Can Children Withhold Consent to Treatment?’ (1993) 306 British Medical Journal 1459–1460 (1460). The latter is specifically a discussion of the refusal of treatment by children, but it is submitted that the ‘best interests’ of adult and minor patients are treated as roughly similar.

61. ‘[An ideal type] is not a description of reality but it aims to give unambiguous means of expression to such a description. [It] is formed by the one-sided accentuation of one or more points of view and by the synthesis of a great many diffuse, discrete, more or less present or occasionally absent concrete individual phenomena, which are arranged according to those one-sidedly emphasized viewpoints into a unified analytical construct (Gedankenbild). In its conceptual purity, this mental construct (Gedankenbild) cannot be found empirically anywhere in reality. It is a utopia’: M Weber The Methodology of the Social Sciences (trans EA Shils & HA Finch] (New York: Free Press 1949) p 90 (emphasis in original).

62. For a critical review of these changes, cf D Hughes ‘The Reorganization of the National Health Service: The Rhetoric and the Reality of the Internal Market’ (1991) 54 MLR 88–103.

63. [1992] 2 SCR 226, (1992) 92 DLR (4th) 449 (SCC).

64. [1992] 2 SCR 138. (1992) 93 DLR (4th) 415 (SCC), For further discussion of this case, cf BM Dickens ‘Medical Records - Patient's Right to Receive Copies - Physician's Fiduciary of Disclosure: Mclnerney v MacDonald (1994) 73 Can Bar Rev 234–242.

65. Norberg v Wynrib [1992] 2 SCR 138, (1992) 93 DLR (4th) 415 (SCC per McLachlin J at 486a) emphasis in original.

66. [1992] 2 SCR 138, (1992) 93 DLR (4th) 415 (SCC per McLachlin J at 499c-d).

67. [1992] 2 SCR 138, (1992) 93 DLR (4th) 415 (SCC).

68. [1992] 2 SCR 226, (1992) 92 DLR (4th) 449 (SCC).

69. A Grubb ‘The Doctor as Fiduciary’ (1994) 47 Current Legal Problems 311–340(337).