Re: Montgomery and its impact on current medical practice – good or bad?

Abstract

The article by George Buttigieg is thought provoking. 1 Undoubtedly, Montgomery has made a big impact on the medical fraternity regarding disclosure during consenting. 2 A more detailed discussion is needed of pros and cons of the procedure concerned, covering every 'material risk', which may affect the patient's postoperative life; also the mention of 'any reasonable alternative or variant treatments'. 3 As members of a surgical team from a tertiary centre, we wonder how this translates into consenting for laparoscopic cholecystectomy (LC). LC is one of the most commonly performed operations in General Surgery, for symptomatic gallstone disease. Robust evidence supports offering LC to all eligible patients with acutely inflamed gallbladder as the gold standard treatment in their index admission; proven to be clinically effective on one hand, and financially beneficial for health authorities, on the other. 4 While consenting for LC, following the cue from Montgomery, we now routinely mention all the rare peri-operative risks like cardiac complications and mortality (incidence of each of which is less than 0.1%), along with other commonly quoted complications for this operation. We then explain management of the rare complications and also the related sequelae. 5,6 However, in doing so, the obvious worry is to overburden the patient with substantial clinical information within a very short span of time. An overwhelmed, apprehensive person is prone to make unreasonable and harmful decisions, which under normal relaxed circumstances they may not have made. Sometimes they fail to make any decision at all like Buttigieg's 'sweet old lady' (Buttigieg, 1 p. 3). This invalidates the entire consent. It is therefore of paramount importance to recognise this limit while disclosing information, given that preventing harm to patients is an important ethical and moral obligation for every clinician. 7 This reminds us of Lord Templeton's view in Sidaway, where he stated:

Increasing trend of virtual clinics in the NHS

“…Needless to say, breakdown of communication while doing this is not only ethically inappropriate but may lead to future litigation. 2…”