Science and Law: Canterbury v. Spence: What are the boundaries of informed consent?

February 5, 2015

Science and Law

gavel


Today we’ll be discussing another interesting case regarding informed consent for patients. This raises issues regarding the boundary between physician and patient responsibilities regarding medical care and informing patients of risks. This case took place at the D.C. Circuit Court level, meaning that the case was one step from the United States Supreme Court.

Case Background

  • Canterbury, a 19-year-old typist met with Dr. Spence complaining of persistent back pain.
  • Dr. Spence recommended a laminectomy, a procedure where a small portion of the vertebrae covering the spinal canal, creating space and relieving pressure.
  • A laminectomy, like all procedures comes with a small chance of some major risks:
    • Nerve root damage – 1 in 1,000 chance
      • This problem, as well as the next, are both extremely unlikely, since the surgery is generally a minimally invasive one, not reaching areas that could be damaged
    • Bowel/bladder incontinence – 1 in 10,000 chance
    • Cerebrospinal fluid leak – 1-3 in 100 chance
      • Requires around 24 hours to heal
    • Infections – around 1 in 100 chance
      • Usually taken care of quickly with antibiotics
    • Bleeding – minimal chance
      • There are no major blood vessels in the area of the surgery.
    • Postoperative instability of the operated level of the spine – 5-10 in 100 chance
      • The spinal stability should be fine in most cases if the pars interarticularis, a structure in the spine that helps maintain stability, is left alone.
  • At the time Spence recommended the procedure, Canterbury did not raise any objections, and Canterbury’s mother signed a consent form afterward.
  • The operation went without apparent difficulty, but problems began during post-operation recovery. Hospital staff failed to assist him in voiding (using the bathroom), and he fell out of his bed in the process.
  • Canterbury began to develop signs of partial paralysis several hours later, only partially improved by an additional operation.
  • At the time of the trial Canterbury still required crutches to walk, and suffered from urinal incontinence and bowel paralysis, and wore a penile clamp.
  • Canterbury claimed that his condition has made him unable to hold a job, since he must be able to remain seated and be located near a bathroom.

What issues are being debated?

  • Did Dr. Spence fail in his duty to inform his patient of necessary risks?
  • Should Dr. Spence be held responsible for a negative outcome due to negligence by hospital staff?
  • How should have Dr. Spence have spoken to his patient? Was this a risk he could or should have anticipated?

How was the law interpreted and applied in this case?

  • Canterbury claimed that Dr. Spence was negligent in the way he performed the surgery, and the court agreed that a jury would need to consider whether or not the doctor failed in this duty.
  • The judge also ruled that the informed consent issue required that the lawsuit go to trial.

Further analysis

This case helps reveal the complications that both patients and physicians face, and often cannot anticipate. Most likely, if the hospital had provided a side-rail and a staff member to help the patient, this lawsuit would never have arisen. The partial paralysis signs only surfaced after the fall, suggesting that the physician did his job properly, and that blame should be with the hospital. Should the doctor be held responsible for disclosing risks made reality due to others’ negligence?

While giving testimony, the court established that laminectomies patients may have problems with paralysis after surgery in up to 1% of cases (slightly larger than the current number thanks to advances in medical science). What should be a threshold for requiring disclosure? A 1% chance is very small, but if hundreds of these operations are done over time, there will inevitably be cases of paralysis. If the chance is too small, it may end up causing unnecessary anxiety for patients, and maybe cause them to decline a virtually harmless and beneficial procedure. This question and others presented here have been plaguing physicians and lawyers alike for decades, and as medical science continues to progress, so will the questions we must ask ourselves when creating legal frameworks for practicing medicine.

See: Bioethics and Public Health Law by Orentlicher, Bobinski, and Hall

More on laminectomies: http://www.spine-health.com/treatment/back-surgery/laminectomy-and-spinal-stenosis-risks-and-complications

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About jslachman381

I'm a Yale graduate who majored in History of Science, Medicine, and Public Health.

View all posts by jslachman381

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One Comment on “Science and Law: Canterbury v. Spence: What are the boundaries of informed consent?”

  1. DH Says:

    Sounds like a nursing error as apparently they did not follow all fall risk precautions for this patient and this resulted in the patient falling out of bed. That’s a huge problem in hospitals. Aside from that, informed consent forms contain the phrase “including but not limited to” with regards to potential adverse effects resulting from procedures in order to cover the physician and hospital in these situations. I don’t think informed consent was violated here but that’s just my uninformed knee-jerk opinion.

    http://www.skeptictaproom.wordpress.com

    Like

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