FEATURE such comprehensive information could and should be imparted. Two 1972 cases in the USA, Canterbury vs. Spence [7] and Cobbs vs. Grant [8], shifted the paradigm of the inquiry from doctor to patient by creating a ‘lay’ or ‘patient’ standard. According to this standard, allegations of failure to disclose are to be judged according to jury assessments of what a reasonable patient in the plaintiff’s position would expect to be informed of prior to making a decision about treatment. Judge Robinson said, “It is the prerogative of the patient, not the physician, to determine for himself the direction in which his interests seem to lie [7].” The Canterbury and Cobbs decisions have exerted their influence beyond the United States. Appellate courts in Australia [12], Malaysia [13], New Zealand [14], Ireland [15], Germany [16] and Canada [17] have now embraced the patient standard. Singapore [18] remains one of the last legal bastions that subscribes to the Bolam test, rejecting the patient standard in lieu of a professional one. Brazil (where the authors practice) adheres to a patient standard with regards to risk disclosure in informed consent [19]. In the landmark case of Rogers vs. Whitaker (1992), the question to be decided by the Australian High Court was whether an ophthalmic surgeon should have warned his patient of the one in 14,000 probability of a complication, sympathetic ophthalmia and subsequent risk of blindness, arising from a proposed surgery [10]. The defendant, Dr Christopher Rogers, was sued for a negligent failure to warn of the risks. Many medical experts were called to testify in court on whether the surgeon ought to have warned the patient of the risk involved, and opinions were divided. If the Australian High Court had utilised the Bolam test, the surgeon would not have been found guilty for the failure to disclose. The High Court disapproved the principle stated in Bolam and affirmed that a finding of medical negligence may be made even though the conduct of the doctor was in accordance with practice accepted at the time as proper by a responsible body of medical opinion. In Montgomery vs. Lanarkshire Health Board in 2015, a gynaecologist was successfully sued and found guilty of negligence for failing to disclose to the plaintiff the small risk (0.1%) of shoulder dystocia with subsequent hypoxia and brain damage in perusing normal vaginal delivery in diabetic mothers [11]. The gynaecologist stated that she did not disclose this risk to the patient as her clinical experience showed that the risk was a very small one and that, by disclosing such information, all mothers would opt for caesarean section. It was her opinion that “it is not in the maternal interests of women to have caeserean sections.” These landmark cases should force all aesthetic surgeons to be even more hypervigilant in disclosing risks, complications and possible long-term financial implications. For example, how many doctors inform their prospective clientele that the risk of injecting soft tissue fillers in the facial region may result in irreversible blindness via central retinal artery occlusion [20]? A recent survey conducted by The Consulting Room UK states that few practitioners (less than 75%) inform their prospective patients of this rare but real risk [21]. Risks and complications In the authors’ own practice, it is standard operating protocol to first determine what the patients’ expectations are and weigh that in with what can be done to improve the condition. It is vital that the surgeon focuses on the aesthetic desire of the patient and not what the surgeon wants or thinks is best. Nonetheless, if what the patient requests could lead to potential adverse trade offs (for example, very large breast implants may give rise to chest wall deformities, back pain and glandular tissue atrophy) then the patient needs to pmfa news | OCTOBER/NOVEMBER 2016 | VOL 4 NO 1 | www.pmfanews.com 15