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Montgomery and shared decision-making: implications for good psychiatric practice

  • Gwen Adshead (a1), David Crepaz-Keay (a2), Mayura Deshpande (a3), K.W.M (Bill) Fulford (a4) and Veryan Richards (a5)...

Summary

The 2015 Supreme Court judgment in Montgomery v Lanarkshire Health Board [2015] UKSC 11 established that consent to medical treatment requires shared decision-making based on dialogue between the clinician and patient. In this editorial, we examine what Montgomery means for standards of good psychiatric practice, and argue that it represents an opportunity for delivering best practice in psychiatric care.

Declaration of interest

None.

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Copyright

Corresponding author

Correspondence: Gwen Adshead, Hampshire Pathfinder Service, Southern Health NHS Foundation Trust, Ravenswood House, Mayles Lane, Fareham, Hampshire PO17 5NA, UK. Email: g.adshead@nhs.net

References

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1Montgomery v Lanarkshire Health Board [2015] UKSC 11.
2Bolam v Friern Hospital Management Committee [1957] 1 WLR 582, 587.
3General Medical Council. Consent: Patients and Doctors Making Decisions Together. General Medical Council, 2008.
4Herring, J, Fulford, KWM, Dunn, D, Handa, A. Elbow room for best practice? Montgomery, patients’ values, and balanced decision-making in person-centred care. Med Law Rev 2017; 25(4): 582603.
5Karthik, M, Kulhara, P, Chakrabarti, S. Attitude towards second-generation antipsychotics among patients with schizophrenia and their relatives. Hum Psychopharmacol Clin Exp 2013; 28: 457–65.
6Gao, K, Fang, F, Wang, Z, Calabrese, JR. Subjective v. objective weight gain during acute treatment with second-generation antipsychotics in schizophrenia and bipolar disorder. J Clin Psychopharmacol 2016; 36(6): 637–42.
7Lee, A. ‘Bolam’ to ‘Montgomery’ is result of evolutionary change of medical practice towards ‘patient-centred care. Postgrad Med J 2017; 93(1095): 4650.
8Slovic, P, Peters, E, Finucane, ML, MacGregor, DG. Affect, risk, and decision making. Health Psychol 2005; 24(Suppl 4): S3540.
9Katsakou, C, Bowers, L, Amos, T, Morriss, R, Rose, D, Wykes, T, et al. Coercion and treatment satisfaction among involuntary patients. Psychiatr Serv 2010; 61(3): 286–92.
10Heywood, R. R.I.P. Sidaway: patient-oriented disclosure–a standard worth waiting for? Montgomery v Lanarkshire Health Board [2015] UKSC 11. Med Law Rev 2015; 23: 455–66.
11Person-centred Training and Curriculum Scoping Group. Person-Centred Care: Implications for Training in Psychiatry. Royal College of Psychiatrists, 2018.
12Values-based Child and Adolescent Mental Health System Commission. What Really Matters in Children and Young People's Mental Health. Royal College of Psychiatrists and on behalf of Young Minds and the Children and Young People's Mental Health Commission, Values-Based Child and Adolescent Mental Health System Coalition, 2016.
13Richards, V, Lloyd, K. Core Values for Psychiatrists: Report CR204. Royal College of Psychiatrists, 2017.

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Montgomery and shared decision-making: implications for good psychiatric practice

  • Gwen Adshead (a1), David Crepaz-Keay (a2), Mayura Deshpande (a3), K.W.M (Bill) Fulford (a4) and Veryan Richards (a5)...

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Montgomery and shared decision-making: implications for good psychiatric practice

  • Gwen Adshead (a1), David Crepaz-Keay (a2), Mayura Deshpande (a3), K.W.M (Bill) Fulford (a4) and Veryan Richards (a5)...
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eLetters

Montgomery and changes to the process of consent: debate required

John Watts, Child and Adolescent Psychiatrist, South London and Maudsley NHS Foundation Trust
18 December 2018

The doctrine of precedence is a feature of common law jurisdictions such as that in England and Wales, Scotland and other areas of the UK. It allows for judgments made in courts of law to be followed by other courts, unless they are replaced by different decisions in a higher court. In a similar fashion, rulings in courts tend to be taken by professions and incorporated into practice. The case discussed by Adshead et al refers to a judgment in the UK’s highest court, where a decision about information required to achieve appropriate consent for the delivery of a pregnancy was heard. 1. Adshead et al argue that the judgment should be followed when, for example, medication is discussed with patients by psychiatrists .

In order for a lower court to follow a previous judgement, the subsequent case must be similar in nature or fact, so that precedence can be applied. Therefore it follows that if a court judgment is to be applied to clinical practice, then the case it concerns should be similar to the patient being seen. As a Child and Adolescent psychiatrist, I am interested in the application of the Judgement to patients under 18, and whether Montgomery is similar enough to be applied to the process of consenting minors to take psychotropic medication? The legal case concerned a ‘clearly highly intelligent’ diabetic mother. 2. Is this the case for a significant number of CAMHS patients? Does the procedure of a caesarean section or an instrumental delivery of a baby resemble closely enough aspects of treatment using psychotropic medication?

Clearly, informed consent needs to involve the presentation of appropriate information to enable patients to make a choice, and that information presented needs to be adequate and tailored to the individual concerned. Making a patient aware of material risks of treatment or procedures is a laudable aim, but knowing every patient’s life, aspirations and interests in sufficient detail in which to form a definitive view of what risks to include may be unachievable in normal clinical practice. I fear that, in order to avoid criticism and censure, clinicians may take an approach that presents all risk information without filter or context. Some might describe this as defensive medicine.

I make these points, not to imply they represent my opinion or point of view, but rather to stimulate debate and argument, so that we, as a profession, are not necessarily bound by decisions that are made in situations that cannot be properly applied to the patient in front of us. Accusations of pedantry and missing the point could be levelled at such arguments, but the law is precise, and so should those following the law. This is such a very important topic that could have ramifications throughout the psychiatric (and medical) world. I note that Adshead et al recommend the College’s Professional Practice and Ethics Committee update Good Psychiatric Practice to incorporate the Montgomery ruling. I say that we, as a membership and profession, need to have a debate first, before agreeing what becomes our college’s guidance for consent, as this will be the guidance to which our practice is measured against.

1. Adshead G, Crepaz-Keay D, Deshpande M, Fulford KWM, Richards V. Montgomery and shared decision-making: implications for good psychiatric practice.

2. Montgomery v Lanarkshire Health Board [2015] UKSC 11
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Conflict of interest: I was a member of the Professional Practice and Ethics Committee from 2012 to 2016

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