The Montgomery ruling extends patient autonomy

In March 2015 a ruling made by the UK Supreme Court upholding a woman's right to autonomy in childbirth could have a profound impact on obstetric practice in the UK: Montgomery (Appellant) v Lanarkshire Health Board (Respon-dent) (Scotland) [2015] UKSC 11. Nadine Montgomery (NM) was a diabetic of short stature expecting her first baby predicted by ultrasound to weigh >4 kg when labour was induced. NM had expressed anxieties about delivery to her obstetrician on several occasions, but had not specifically inquired about caesarean. The birth was complicated by severe shoulder dystocia and her son later developed cerebral palsy. It was agreed that NM's risk of shoulder dystocia was around 9–10%. Her obstetrician did not warn her of this risk, nor counsel her about the alternative option of a planned caesarean section. The obstetrician stated that although the risk of shoulder dystocia was significant, with correct management there was a very low likelihood of a grave adverse outcome. The obstetrician considered that if all diabetic women were told of the risk of shoulder dystocia they would all choose a caesarean, which would not be in their best interests. Two lower Courts rejected NM's claims, agreeing that many obstetricians would take the same line; to be significant, there must be a substantial risk of grave adverse consequences, and because NM had not asked directly about caesarean section, the obstetrician was under no obligation to discuss this. The Claimant appealed. The Supreme Court unanimously upheld the appeal, affirming that women have a right to information about ‘any material risks’ in order to make an autonomous decision about how to give birth, and that it was inappropriate that disclosure of risk be based on (the doctor's) clinical judgement. The extent of disclosure must instead be determined by whether the patient would attach any relevance to the risk. This explicit recognition of the patient's right to autonomy and informed choice is now set in case law. Medical paternalism is no longer acceptable. This ruling aligns the law with other common law jurisdictions by separating questions of consent from the traditional test for clinical negligence, namely, what a body of responsible medical practitioners would do. This ruling has far-reaching implications for obstetric practice. Obstetricians who do not advise their patient of any material risk are negligent. The ruling explicitly states that doctors should volunteer the pros and cons of caesarean section in ‘any case where either a mother or child is at heightened risk from vaginal delivery’, and that to advise properly, the doctor must engage in dialogue with the patient. The Montgomery ruling is likely to change clinical practice and could lead to a rise in litigation if obstetricians fail to inform patients about all foreseeable risks, however unimportant they may seem to the clinician. Doctors must be guides in providing care, and not leaders expecting obedience to their personal judgement of what is appropriate. When there are options in care, the patient decides, not the doctor. If a caesarean is a reasonable option, women are entitled to choose it. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.