The importance of an informed consent to chiropractic treatment

There was a very shocking story in the news over the past few days. A retired bank manager, Mr John Lawler, underwent chiropractic treatment for a leg injury with Dr Arleen Scholten at her clinic in York.

Tragically, Mr Lawler suffered irreversible spinal damage during her manipulative therapy session which left him a quadriplegic. This injury sadly led to respiratory depression from which he died within a day of the injury.

It emerged after his death that Mr Lawler had in fact been suffering from an ‘ossified longitudinal ligament’ adjacent to the spinal cord in his neck. This is a rare condition and he could not have known this although it might have been identified had he undergone a pre-treatment x-ray or scan. Dr Scholten was of course unaware of the patient’s unusual anatomy also.

The inquest into Mr Lawler’s death was held last week and the court was told by the investigating pathologist that the ossified longitudinal ligament had fractured during treatment, leading to the rupture of a disc and an injury to the spinal cord. This led to his paralysis and his very sad and sudden death.

It also transpired that “Dr Scholten” had been awarded a “Doctorate of Chiropractic” in her native county of Canada and was not in fact a medically qualified UK doctor.

The inquest was told that Mrs Scholten was incorrectly advertising herself as a ‘Dr’ but she should have referred to herself as ‘Mrs’ and not “Dr.”

The Lawler family said after the Inquest that “’He (Mr Lawler) thought he was being treated by medically qualified doctor when he was not.’

After the neck injury had caused him to cry out, the chiropractor manoeuvred Mr Lawler onto a chair and gave mouth-to-mouth resuscitation until the ambulance service arrived The court heard that had Mr Lawler been immobilized immediately after the fracture he would have survived.

Delivering a narrative verdict, the Coroner ruled that Mr Lawler had “died from the fracture to his neck and resulting spinal cord injury, while undergoing chiropractic treatment, which led to respiratory depression.”

The Coroner also made two recommendations to the General Chiropractic Council (GCC);

1. The coroner requested that the GCC carries out a review of the requirements for pre-treatment imaging,
2. To consider first aid training being made mandatory for chiropractors.

In addition to the coroner’s concerns my view is that this case raises a number of questions with regards to pre-treatment consent in chiropractic treatment.

• Would Mr Lawler have had the treatment at all if he knew that the practitioner was not a medically trained doctor?
• Chiropractors rely heavily on manipulating their patients’ spines – even in cases such as this where the patient’s complaint is a leg injury. The benefits of this therapy are not clear. Was he advised as to the prospects of the treatment working at all or causing him a serious injury?

Several hundred cases have been documented in the medical literature of patients who were seriously and often permanently injured after chiropractic manipulations. The most common serious injury being a vertebral artery dissection – this is a tear in the inner lining of the vertebral artery, which is located toward the back of the neck. It is one of four major arteries that supply blood to the brain. If vigorous neck manipulation is undertaken which causes a tear, blood can then enter the arterial wall and form a blood clot. Pieces of the blood clot can break off and cause a stroke.

But how many chiropractic patients are told of this risk?

A 2005 study of 150 randomly selected chiropractic practitioners in the United Kingdom, showed that ;-

• “25% of chiropractors do not inform patients of physical examination procedures prior to commencement.”
• “Over one-third do not advise patients of alternative available treatments.”
• “Nearly two-thirds of the practitioners report that there are no specific procedures for which they always obtain written consent”
• And “only 23% report always discussing serious risk”.

The leading case on consent to medical treatment is the Supreme Court case of Montgomery v Lanarkshire

At paragraph 87 of its judgment in Montgomery , the Supreme Court stated:

“An adult of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo, and her consent must be obtained before treatment interfering with her bodily integrity is undertaken. The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. (my emphasis) The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.”

As well as pre-operative imaging and first aid training, I would suggest that it is crucial that chiropractic patients are warned of minor and serious risks in writing and also told of the alternative and perhaps less risky treatments that might be available. Manipulation of the neck is clearly not a risk free treatment option.

Finally, words of sympathy and respect must also to go out to Mr Lawler’s family who have been very diligent in seeking justice for their loved one and they have pursued a very dignified and effective campaign to raise awareness of the issues in this very tragic case.