Herring Jonathan, Fulford Kmw, Dunn Michael, Handa Ashoki
Faculty of Law, Exeter College, University of Oxford, Oxford OX3 1DP, UK.
Collaborating Centre for Values-based Practice in Health and Social Care, St Catherine's College, Oxford, Oxfordshire OX1 3UJ, UK.
Med Law Rev. 2017 Nov 1;25(4):582-603. doi: 10.1093/medlaw/fwx029.
The UK Supreme Court Montgomery judgment marks a decisive shift in the legal test of duty of care in the context of consent to treatment, from the perspective of the clinician (as represented by Bolam rules) to that of the patient. A majority of commentators on Montgomery have focused on the implications of the judgment for disclosure of risk. In this article, we set risk disclosure in context with three further elements of the judgment: benefits, options, and dialogue. These elements, we argue, taken together with risk disclosure, reflect the origins of the Montgomery ruling in a model of consent based on autonomy of patient choice through shared decision-making with their doctor. This model reflects recent developments in both law and medicine and is widely regarded (by the General Medical Council and others) as representing best practice in contemporary person-centred medicine. So understood, we suggest, the shift marked by Montgomery in the basis of duty of care is a shift in underpinning values: it is a shift from the clinician's interpretation about what would be best for patients to the values of (to what is significant or matters from the perspective of) the particular patient concerned in the decision in question. But the values of the particular patient do not thereby become paramount. The Montgomery test of duty of care requires the values of the particular patient to be balanced alongside the values of a reasonable person in the patient's position. We illustrate some of the practical challenges arising from the balance of considerations required by Montgomery with examples from surgical care. These examples show the extent to which Montgomery, in mirroring the realities of clinical decision-making, provides elbowroom for best practice in person-centred clinical care.
英国最高法院在“蒙哥马利案”中的判决标志着在治疗同意方面注意义务法律标准的决定性转变，即从临床医生的视角（以博勒姆规则为代表）转向患者的视角。大多数对“蒙哥马利案”的评论者都聚焦于该判决对风险披露的影响。在本文中，我们将风险披露与该判决的另外三个要素——益处、选择和沟通——放在一起进行考量。我们认为，这些要素与风险披露相结合，反映了“蒙哥马利案”裁决的根源在于一种基于患者自主选择的同意模式，这种模式是通过与医生共同决策来实现的。这种模式反映了法律和医学领域的最新发展，并且（被英国医学总会及其他机构）广泛视为当代以患者为中心的医学的最佳实践。我们认为，如此理解的话，“蒙哥马利案”在注意义务基础上所标志的转变是一种根本价值观的转变：它是从临床医生对什么对患者最有利的解读，转向特定患者在相关决策中（从其角度来看什么是重要的或要紧的）的价值观。但特定患者的价值观并不会因此变得至高无上。“蒙哥马利案”的注意义务标准要求将特定患者的价值观与处于患者位置的理性人的价值观进行平衡。我们通过外科护理中的例子来说明“蒙哥马利案”所要求的这种考量平衡带来的一些实际挑战。这些例子表明，“蒙哥马利案”在反映临床决策现实的程度上，为以患者为中心的临床护理中的最佳实践提供了空间。
