A doctor must discuss all reasonable alternative treatment
options with the patient, according to the Supreme Court in
Montgomery v Lanarkshire Health Board. So what must
be discussed, and if the doctor fails to offer a reasonable
alternative will the patient automatically succeed? The
recent decision in Britten v Tayside Health Board
demonstrates how the courts address those
Mr Britten suffered from bipolar disorder for which he took
lithium. In January 2001 he was diagnosed with acute anterior
uveitis in the left eye. He was successfully treated with
steroid eye drops. The anterior uveitis reoccurred in
February 2003 and in January 2005. He was again treated with
steroid eye drops.
At a review appointment on 26 January 2005 Mr Britten's
vision had significantly worsened. He was diagnosed with
pan-uveitis in the left eye, a serious condition which could result
in permanent loss of vision. Steroid eye drops were no longer
One alternative was oral steroids. Unfortunately this
carried a risk of psychosis. This risk was discussed with Mr
Britten. He accepted the risks and agreed to the
Another alternative was a steroid injection. That carried
a lower risk of an adverse psychiatric event. Mr Britten was
not told that steroid injections were an option.
Unfortunately Mr Britten became delusional and suffered a
relapse of his bipolar disorder. He was admitted to hospital,
where he was an in-patient for eight weeks.
Mr Britten alleged his treating doctors breached their duty of
care by failing to advise of all the alternative treatment
options. Sheriff Collins QC found that there had been a
breach of duty. However, Mr Britten failed on causation: had
he been told of the options, he would still have opted for
treatment by oral steroids.
The sheriff considered the importance of treatment options in
the light of Montgomery. The Supreme Court had held
that a doctor has a duty to make the patient aware of "all
reasonable alternative or variant treatments". How
should the doctor approach that discussion?
The sheriff's view was that the discussion is to be a
"dynamic and interactive" process. A patient's
initial position of wanting the most efficacious treatment may
change upon hearing of the alternatives and their risks and
benefits. A doctor should not accept the response of
"you decide, doctor" unless that response is made clearly
It is the doctor's job to explain the alternatives
"whether the patient wants to hear them or not". It
might be that a patient maintains their initial view. But
they still need to hear the alternatives.
Twenty months on from the decision in Montgomery, its
effects are yet to be fully worked through. Even where a
patient is reluctant to hear of alternative treatments they still
need to be told – but their reluctance might then be a basis
for them failing on causation.
After studying bioengineering and completing a PhD in the San Francisco Bay Area and a two-year postdoctoral research fellowship in London, Mark has spent the past four years analysing global health policy.
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