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 Mater  of  Materiality  


Tortious  Liabilty  &    Infromation  Disculoure  in  English  Medical  Law  

Harrison  F.  Richarz    -­‐  7  December  2009  


 

Introduction    
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Since  McNair  J.  delivered  his  direction  to  the  jury  in  Bolam  v  Friern  Hospital  Management  Committee  an  English  medical  
practitioner’s  legal  duty  of  pretreatment  information  disclosure  has  been  governed  by  some  version  or  interpretation  of  
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the   ‘reasonable   practitioner’   standard   he   laid   forth.     Following   the   inevitable   evolution   effected   by   regular   judicial  
reinterpretation,  this  standard  is  now  taken  to  require  the  disclosure  of  ‘material’  or  ‘serious’  risks  and  a  failure  to  do  so  
constitutes  a  breach  of  duty  capable  of  sustaining  an  action  in  negligence,  if  the  other  requirements  of  that  tort  can  be  
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satisfied.     The   concomitant   changes   to   the   traditional   principle   of   causation   in   cases   dealing   with   risk   disclosure,   and  
reformation   of   the   relevant   professional   practice   guidance   have   given   teeth,   though   certainly   not   venomous   fangs,   to  
patient  autonomy.  As  shall  be  shown,  however,  the  essential  position  of  the  law  has  remained  sustainably  unchanged;  a  
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situation   which   has   allowed   some   commentators   to   contend   that   the   much   ballyhooed   new-­‐found   respect   for   autonomy  
is  little  more  than  a  veneer  on  a  system  which  remains  staunchly  pro-­‐practitioner.  

Sidaway  Sidelines  Patients  


While  the  issue  of  patient  risk  disclosure  was  encountered  in  Bolam  itself  where  McNair  J  found  no  need  to  distinguish  it  
at   law   from   the   standard   of   care   relating   to   therapeutic   measures   and   thus   subject   to   the   same   infamous   test   of   the  
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‘reasonable  practitioner’,  it  would  take  almost  thirty  years  for  the  House  of  Lords  to  fully  engage  with  the  issue  which  it  
did  in  Sidaway.    The  result  of  this  encounter  was  four  distinct  lines  of  judicial  reasoning,  each  approaching  the  issue  from  a  
different  perspective,  though  all  but  Lord  Scarman  ultimately  settled  on  more  or  less  the  same  test,  Bolam’s  ‘reasonable  
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practitioner’,  if  to  somewhat  varying  degrees.    It  was  the  orthodox  Bolam-­‐ite  interpretation  of  Lord  Diplock,  which,  owing  
to  its  selection  as  the  ‘true  ratio’  of   Sidaway  by  the  Court  of  Appeal  was  to  place  a  roadblock  on  the  road  to  a  greater  role  
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for  patient  autonomy  in  UK  law.    

Pearce-­‐ing   Bolam   in   Chester   As   Commonwealth   Law   Comes   Home   to   Roost   000000000000000000000000000  


In   his   speech   dismissing   the   appeal   in   Sidaway,   Lord   Scarman   focused   heavily   on   the   American   case   of   Canterbury   v  
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Spence,   and   the   Canadian   case   Reibl   v   Hughes   to   lay   the   intellectual   foundation   for   his   (rejected)   ‘prudent   patient’  
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test.  Not  long  after,  the  High  Court  of  Australia  would  reject  Bolam  as  the  appropriate  standard  for  risk  disclosure  and  
instead  adopted  a  now  classic  formulation  of  the  ‘prudent  patient  test’:    
‘A  risk  is  material  if,  in  the  circumstances  of  the  particular  case,  a  reasonable  person  in  the  patient's  
position,  if  warned  of  the  risk,  would  be  likely  to  attach  significance  to  it  or  if  the  medical  practitioner  
is  or  should  be  reasonably  aware  that  the  particular  patient,  if  warned  of  the  risk,  would  be  likely  to  
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attach  significance  to  it.’  
 
It   was   this   approach   that   was   to   inspire   Morland   J,   in   Smith   v   Tunbridge   Wells   and   while   unable   to   follow   it   expressly,  
using   the   Bolam   caveat   that   if   medical   law   has   moved   on,   a   practice   contrary   to   the   new   norms   can   be   rejected   as  
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reasonable  by  the  courts,  he  was  able  to  give  some  effect  to  patient  autonomy.    

                                                                                                               
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 [1957]  1  WLR  582  
2
 Alasdair  Maclean,  Autonomy,  Informed  Consent  and  Medical  Law  (Cambridge  University  Press,  Cambridge,  2009)  190  
3 nd
 Shaun  Pattinson  Medical  Law  and  Ethics  (2  edition,  Sweet  &  Maxwell  Ltd.  London,  2009)  127  
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 Chester  v  Afshar    [2004]  UKHL  41    
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 Alasdair  Maclean,  Autonomy,  Informed  Consent  and  Medical  Law  (Cambridge  University  Press,  Cambridge,  2009)  191  
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 Bolam  v  Friern  Hospital  Management  Committee  [1957]  WLR  582  at  590  
7 nd
 Emily  Jackson,  Medical  Law:  Text  Cases  and  Materials,  (2  edition,  Oxford  University  Press,  Oxford  2009)    182  
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 ibid    183  
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 464  F  2d772  (DC  Cir  1972)  
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 Reibl  v  Hughes  (1980)  114  D.L.R.  (3d)  1  
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 Sidaway  v  Bethlem  Royal  Hospital  Governors  [1985]  AC  871  
 
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 Rogers  v  Whitaker  (1992)  175  C.L.R.  479  at  490  
13  Smith  v  Tunbridge  Wells  Health  Authority  [1994]  5  Med  LR  334  
A  Mater  of  Materiality  
 
 
Like  Morland  J  before  him,  it  was  not  open  to  Lord  Woolf  to  disregard  the  judgment  of  the  majority  in  Sidaway  for  the   1  
preferred  commonwealth  ‘prudent  patient’  standard  which  placed  a  premium  on  autonomy,  but  as  in  Smith,  the  Master  
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of   the   Rolls,   by   his   own   extrajudicial   admission   acting   upon   academic   insight,   was   able   to   use   both   Bolam   and   Bolitho   to  
restate  the  classic  test  in  a  way  which,  at  least  on  the  surface  gives  the  impression  of  adopting  the  Rogers  v  Whittaker  test,  
in  English  law:      
 
‘In   a   case   where   it   is   being   alleged   that   a   plaintiff   has   been   deprived   of   the   opportunity   to   make   a  
proper  decision  as  to  what  course  he  or  she  should  take  in  relation  to  treatment,  it  seems  to  me  to  be  
the   law,   as   indicated   in   the   cases   to   which   I   have   just   referred,   that   if   there   is   a   significant   risk   which  
would  affect  the  judgment  of  a  reasonable  patient,  then  in  the  normal  course  it  is  the  responsibility  
of   a   doctor   to   inform   the   patient   of   that   significant   risk,   if   the   information   is   needed   so   that   the  
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patient  can  determine  for  him  or  herself  as  to  what  course  he  or  she  should  adopt.’  
 
This   formulation   according   to   Maclean’s   clear   and   logical   analysis   has   the   practitioner   acting   as   a   gatekeeper   in  
determining  the  significance  of  the  risks  to  be  discloses  and  thus  undermines  the  weight  supposedly  accorded  to  patient  
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autonomy.   Fortunately,   for   autonomy,   when   the   question   again   arose   before   the   court   of   appeal   four   years   later   in  
Wyatt   v   Curtis   the   courts   reinforced   the   important   role   of   the   ‘particular   patient’   in   the   decision   making   process   taken  
before  revealing  risks:  
 
‘Lord  Woolf's  formulation  refines  Lord  Bridge's  test  by  recognising  that  what  is  substantial  and  what  
is  grave  are  questions  on  which  the  doctor's  and  the  patient's  perception  may  differ,  and  in  relation  
to   which   the   doctor   must   therefore   have   regard   to   what   may   be   the   patient's   perception.   To   the  
doctor,   a   chance   in   a   hundred   that   the   patient's   chickenpox   may   produce   an   abnormality   in   the  
foetus   may   well   be   an   insubstantial   chance,   and   an   abnormality   may   in   any   case   not   be   grave.   To   the  
patient,  a  new  risk  which  (as  I  read  the  judge's  appraisal  of  the  expert  evidence)  doubles,  or  at  least  
enhances,  the  background  risk  of  a  potentially  catastrophic  abnormality  may  well  be  both  substantial  
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and  grave,  or  at  least  sufficiently  real  for  her  to  want  to  make  an  informed  decision  about  it.’  
 
This  further  broadening  of  Lord  Woolf’s  conflation  has  been  adopted  and  further  adapted  by  the  courts.  Cranston  J  in  
the  recent  case  of  Birch  v  UCL  Hospital  NHS  Trust  held  that:    
‘If   patients   must   be   informed   of   significant   risks   it   is   necessary   to   spell   out   what,   in   practice,   that  
encompasses.   …   Was   it   necessary   for   the   defendant   to   go   further   and   to   inform   Mrs.   Birch   of  
comparative   risk,   how   this   risk   compared   with   that   associated   with   other   imaging   procedures,   in  
particular  MRI?  No  authority  was  cited  to  this  effect  but  in  my  judgment  there  will  be  circumstances  
where  consistently  with  Lord  Woolf  MR's  statement  of  the  law  in  Pearce  v  United  Bristol  Healthcare  
NHS   Trust   the   duty   to   inform   a   patient   of   the   significant   risks   will   not   be   discharged   unless   she   is  
made  aware  that  fewer,  or  no  risks,  are  associated  with  another  procedure.  In  other  words,  unless  
the  patient  is  informed  of  the  comparative  risks  of  different  procedures  she  will  not  be  in  a  position  
to  give  her  fully  informed  consent  to  one  procedure  rather  than  another.  …  
There  was  disagreement  between  Dr.  McConachie  and  Dr.  Molyneux  as  to  whether,  on  the  facts  of  
Mrs.   Birch's   case   she   should   have   been   informed   of   these   matters.   In   the   light   of   Mr.   Kitchen's  
important   evidence,   I   am   convinced   that   in   Mrs.   Birch's   case   no   reasonable,   prudent   medical  
practitioner  would  have  failed  to  discuss  the  respective  modalities  and  risks  with  her  along  the  lines  
outlined.  In  their  absence  she  was  denied  the  opportunity  to  make  an  informed  choice.  Even  if  I  am  
wrong  on  this,  the  failure  to  discuss  with  Mrs.  Birch  these  matters  could  not  be  described  in  law  as  
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reasonable,  responsible  or  logical.    
An   English   medical   practioner’s   duty   therefore   encompasses   not   only   the   disclosure   of   material   risks   of   the   proposed  

                                                                                                               
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 Lord  Woolf  MR,  ‘Are  the  Courts  Excessively  deferential  to  the  Medical  Procession?’  (2001)  9  Medical  Law  Review  1,10,  
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 Pearce  v  United  Bristol  Healthcare  NHS  Trust    [1999]  P.I.Q.R.  P53  at  59  
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   Alasdair  Maclean,  Autonomy,  Informed  Consent  and  Medical  Law  (Cambridge  University  Press,  Cambridge,  2009)  175  
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 Sarah  Wyatt  v  Dr  Anne  Curtis,  Central  Nottinghamshire  Health  Authority  [2003]  EWCA  Civ  1779  para  16  
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 Janet  Birch  v  University  College  London  Hospital  NHS  Foundation  Trust    [2008]  EWHC  2237  (QB)  para  74    and  79  
A  Mater  of  Materiality  
 
treatment  but  also  to  disclose  alternatives  as  well,  surely  a  bold  step  in  strengthening  the  position  of  patient   autonomy  
within  the  law.   2  
It  remained  for  the  courts  to  give  forceful  effect  to  this  right,  and  to  do  this,  once  again  an  antipodean  approach,  this  time  
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taken   from   Chappel   v   Hart   would   be   adopted   by   the   English   courts.   In   Chester   v   Afshar,   despite   the   powerful   and  
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logically   reason   dissents   of   the   two   most   senior   and   influential   Law   Lords   (surely   a   sign   that   the   decision   of   the   majority  
was  intellectually  and  legal  tenuous)  the  majority  twisted  the  principles  of  causation  to  provided  a  remedy  for  a  ‘breach  of  
autonomy’.  Autonomy  being  felt  to  be  a  suitably  serious  right  deserving  of  greater  and  more  effective  legal  protection,  a  
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laudable,  goal  although,  one  which  their  Lordships  felt  could  apparently  only  be  achieved  through  perverting  causation.    
It  is  submitted  that  while  on  the  basis  of  logic  and  established  English  law  wrongly  decided,  this  bold  judgment  has  done  
much  to  strengthen  not  only  the  actual  protections  afforded  autonomy,  but  the  perceived  ones  as  well.    

Professional  Guidance:    A  Yellow  Card  for  Paternalism  or  Just  Back-­‐Door  Bolam  Bolstering  Autonomy?  
There  are  three  important  reasons  to  consider  the  role  and  effect  of  the  professional  guidance  provided  by  the  General  
Medical  Council  (CMG)  and  the  Royal  College  of  Surgeons  (RCS).  Firstly,  because  it  is  to  this  guidance  which  practitioners  
will   turn   to   direct   their   behavior   towards   patients.   Secondly,   because   of   the   deference   shown   by   the   courts   to   such  
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guidance   in   the   leading   case   of   W   v   Egdel   and   thirdly,   because   as   Miola   points   out,   they   must   surely   represent   a  
respected  and  responsible  body  of  opinion,  which  Bolam  (still  the  test)  requires  the  reasonable  doctor  to  follow  to  avoid  
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liability  in  negligence.  Section  7  of  the  most  recent  CMC  guidance,  which  is  essentially  reproduced   verbatim  in  its  RCS  
counterpart,   describes   a   cooperative   decision   making   process,   where   patients   are   engaged,   their   questions,   actively  
sought  and  answered  (Lord  Diplock  no  doubt  would  posthumously  smile  at  that  physicians  must  now  willingly  submit  to  
cross-­‐examination).        
 
The  guidance  tells  medical  practitioners  that  how  much  information  they  share  with  patients  will  vary,  depending  on  the  
patient’s  individual  circumstances  and  that  they  must  tailor  their  discussions  with  patients  according  to  a  patient’s,  needs,  
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wishes   and   priorities   and   that   they   must   reveal   significant   risks   and   alternative   treatments.   Physicians   and   surgeons  
must,  if  an  investigation  or  treatment  might  result  in  an  adverse  outcome,  even  if  such  eventualities  are  highly  unlikely,  
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inform  patients  of  this  risk.  Additionally  patients  must  be  told  about  less  serious  complications  if  they  occur  frequently.  
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All  pertinent  information  must,  according  to  the  guidance  be  presented  to  patients  in  a  ‘a  balanced  way’.  

Therapeutic  Trump  Card?  


In  both  Sidaway  and  Chester,  their  Lordships  found  there  existed  an  exception,  where  in  the  opinion  of  the  ‘reasonable  
practitioner’  it  would  be  in  the  patients  best  interests  to  withhold  information  from  them,  that  such  a  failure  to  disclose  
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would  not  constitute  a  breach  of  duty.  This  paternalistic  element  of  the  law,  has  not  been  challenge  before  the  courts,  
and  were  such  a  challenge  to  arise,  it  seems  unlikely  to  succeed,  as  this  exception  is  founded      on  the  ‘best  interests’  of  the  
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patient’,  a  supposedly  clinical  judgment.    It  therefore  remains  an  important  but  severely  limited  exception  to  the  normal  
rules  governing  of  risk  disclosure  to  patients.    

A  Role  for  Human  Rights?  


As   yet   in   the   reported   cases   there   has   been   little   to   no   consideration   of   the   effects   or   potential   impact   of   the   Human  
Rights   Act,   the   newly   enacted   EU   Charter   of   Fundamental   Rights   or   the   non   ratified,   but   surely   significant,   European  
Convention  on  Human  Rights  and  Biomedicine,  relating  to  the  risk  disclosure  duties  of  medical  practitioners.    Optimists,  no  
doubt,  would  take  this  as  a  sign  that  recent  judicial  and  regulatory  guidance  are  such  that  a  patient’s  fundamental  rights  
are   adequately   protected   by   the   repackaged   ‘responsible   practitioner’   standard   without   resorting   to   the   legal  
sledgehammer  of  administrative  law.    
 
                                                                                                               
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 Chappel  v  Hart  (1998)  195  CLR  232  
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 Chester  v  Afshar    [2004]  UKHL  41    
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 ibid.  per  Lord  Bingham  at  para  8-­‐9  and  Lord  Hoffmann  at  31-­‐34  
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 ibid.  per  Lord  Steyn  at  para  23,  25  &  25,  Lord  Hope  at  81-­‐88,  and  Lord  Walker  at  97-­‐101.  
23
 W  v  Egdell  [1990]  Ch.  359  
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 José  Miola,  ‘On  the  Materiality  of  Risk  –  Paper  Tigers  and  Panaceas”  (2009)  17  Medical  Law  Review  76-­‐108    
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 General  Medical  Counsel,  Guidance  for  Doctors,  Consent:  Patients  and  Doctors  Making  Decisions  Together  (General  Medical  Counsel,  London  2008)  s  7  
26
 ibid.  s  8  
27
 ibid.  s  9  
28
 Sheila  McLean,  Autonomy,  Consent  and  the  Law  (Routledge-­‐Cavendish,  London  2010[sic])  77  
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 ibid  86-­‐87  
A  Mater  of  Materiality  
 
Conclusions  
As   it   stands   today,   the   standard   of   information   disclosure   broadly   requires   that   to   protect   themselves   from   liability   in   3  
negligence,  is  determined  by  reference  to  hypothetical  ‘reasonable  practitioner’  test,  but  constructed  in  such  a  way  as  to  
approach   the   ‘prudent   patient’,   or   ‘material   risk   standard’   (reasonable   practitioner   has   regard   to   the   prudent   and   or  
particular   patient),   this   duty   however   remains   subject   to   therapeutic   privilege   though   that   derogation   on   behalf   of  
conscious   omission   and   obfuscation   is   recognized   as   capable   of  application   in   only   exceptional   circumstances.     In   contrast  
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to  the  ‘legal  position’,  the  current  professional  guidance  adopts  an  autonomy  bolstering  ‘subjective  standard’  meaning  
that  in  quotidian  practice,  as  opposed  to  court  actions,  patients’  concerns,  needs  and  questions  will  pay  a  significant  role  
in  the  treatment  decision-­‐making  process.  For  the  law  to  move  wholly  towards  the  patient  autonomy  centered  approach  
encapsulated  in  the  ‘material  risk’  or  ‘subjective  standard’  test  for  disclosure,  a  full  reformulation  of  the  current  system,  
without   reference   or   reliance   to   the   Bolam   standard,   incorporating   the   fiduciary   duty   reasoning   of   the   Commonwealth  
law,   and   recognizing   autonomy   as   unique   and   distinct   right   protected   by   the   common   law   is   required.   It   is   submitted   that  
given  the  courts  history  of  very  slow  and  gradual  change  with  regards  to  the  law  of  negligence  and  medical  negligence  in  
particular,   such   a   day   is   not   on   our   doorsteps,   but   lingers   just   beyond   the   horizon:   not   yet   within   sight,   but   ever  
approaching.    
 
Bibliography  
 
Cases  Cited  
Canterbury  v  Spence  464  F  2d772  (DC  Cir  1972)  
Chappel  v  Hart  (1998)  195  CLR  232  
Chester  v  Afshar    [2004]  UKHL  41  
Bolam  v  Friern  Hospital  Management  Committee  [1957]  WLR  582  
Reibl  v  Hughes  (1980)  114  D.L.R.  (3d)  1  
Rogers  v  Whitaker  (1992)  175  C.L.R.  479    
Sidaway  v  Bethlem  Royal  Hospital  Governors  [1985]  AC  871  
Smith  v  Tunbridge  Wells  Health  Authority  [1994]  5  Med  LR  334  
W  v  Egdell  [1990]  Ch.  359  
Sarah  Wyatt  v  Dr  Anne  Curtis,  Central  Nottinghamshire  Health  Authority  [2003]  EWCA  Civ  1779    
 
Works  Cited  
General  Medical  Counsel,  Guidance  for  Doctors,  Consent:  Patients  and  Doctors  Making  Decisions  Together  (General  
Medical  Counsel,  London  2008)  
 
nd
Emily  Jackson,  Medical  Law:  Text  Cases  and  Materials,  (2  edition,  Oxford  University  Press,  Oxford  2009)    
 
Alasdair  Maclean,  Autonomy,  Informed  Consent  and  Medical  Law  (Cambridge  University  Press,  Cambridge,  2009)  
 
Sheila  McLean,  Autonomy,  Consent  and  the  Law  (Routledge-­‐Cavendish,  London  2010[sic])  
 
José  Miola,  ‘On  the  Materiality  of  Risk  –  Paper  Tigers  and  Panaceas’  (2009)  17  Medical  Law  Review  76-­‐108    
 
nd
Shaun  Pattinson,  Medical  Law  and  Ethics  (2  edition,  Sweet  &  Maxwell  Ltd.  London,  2009)  127  
 
Royal  College  of  Surgeons,  Good  Surgical  Practice  (Royal  College  of  Surgeons,  London  2008)  
 
Lord  Woolf  MR,  ‘Are  the  Courts  Excessively  deferential  to  the  Medical  Procession?’  (2001)  9  Medical  Law  Review  1  
                                                                                                               
30 nd
 Emily  Jackson,  Medical  Law:  Text  Cases  and  Materials,  (2  edition,  Oxford  University  Press,  Oxford  2009)  191