For a man diagnosed with an enlarged prostate or prostate cancer, choosing the right treatment is not simply about removing the enlargement. It involves decisions about survival, continence, sexual function, recovery time, pain, blood loss and the quality of life after the procedure. Where our public hospitals’ available surgical options are limited to Transurethral Resection of the Prostate and open radical prostatectomy, which have significantly higher rates of complications and undesirable outcomes than newer modalities, an increasingly important question arises: is it okay for a hospitals to continue to perform these older techniques when more modern techniques have proven to have less risk and complications with greater quality of life?
A benign prostatic enlargement is non-cancerous and newer minimally invasive technology has proven to be effective to treat this condition without the need for surgical intervention. One such modality is REZUM therapy and is available within Jamaica’s private healthcare sector.
Prostate cancer treatment has advanced quite significantly from open radical prostatectomy to laparoscopic prostatectomy, robotic assisted prostatectomy and even non-surgical options such as targeted radiotherapy. Modern studies and international guidelines report advantages of these approaches including lower blood loss, reduced transfusion requirements, shorter hospitalization and lower risk of erectile dysfunction. Of these procedures laparoscopic prostatectomy and targeted radiotherapy is currently available in Jamaica.
So now that we are aware that these technologies exist, some of which exist in Jamaica, the question is how their existence should influence public-sector treatment, clinical governance and informed consent. More pointedly: At what point does a health authorities failure to evaluate and adopt safer established alternatives become a clinical-governance and patient-safety issue? The reality faced on our public hospitals by patients and healthcare providers surrounds resource limitations that result in long wait times, cancellations and instability. This is not the environment that fosters growth, innovation, and progress. We have to stabilize our system before we can begin to dream of advancements.
A health authority does not have an unlimited budget. Jamaica cannot reasonably be expected to install every new technology at every public hospital, but resource limitation and failure to review practice are not the same thing. Healthcare institutions should be continually examining surgical complications rate, length of hospitalisation, developments in accepted surgical procedures and whether patients would benefit from referral to centres provided unavailable in the public system or even locally. Therefore, a defensible public healthcare system should be able to demonstrate that is has considered the evidence, audited the results, considered its outcomes with contemporary standards and made a rational decision about whether to maintain, replace, centralise or supplement an existing treatment.
This is where the issue of informed consent comes in. We recently received encouragement from our Minister of Health to approach courts to seek justice where we or our loved ones have suffered from medical negligence in a public institution. I certainly think he is correct. We should. However, I hope we will also be protecting our doctors by guiding them on medicolegally sound practice and one very important practice is informed consent. A seminal and instructive case on this is Octavia Chambers v South East Regional Health Authority and Attorney General of Jamaica [2020] JMSC Civ 102.
Ms. Chambers required treatment at the Spanish Town hospital. She consented to the procedure available at that hospital but not the less risky procedure available at the University Hospital of the West indies. The doctor admitted she did not inform Ms. Chambers about the procedure because it was not available at that hospital and Lawrence-Bewick J rejected that approach stating:
“There is a duty placed on a doctor to provide to the patient all reasonable options for treatment.”
The court concluded that the consent was not proper and therefore any treatment that followed was performed without consent and would amount to assault. Furthermore, the learned judge made it clear that options should not be presented based on a person’s perceived financial status, this is not for the doctor to concern themself with. The duty is to inform the patient fully so that the patient can assess their situation and preference and the risk they want to accept.
This has grave implications on the consent procedure for prostate treatment of patients in public institutions.
Imagine a patient is diagnosed with prostate cancer and he is told:
“You have prostate cancer. We recommend removing the prostate. We will perform an open prostatectomy which is associated with these risks, however if you don’t remove the prostate, it will spread and ultimately cause death. If you would like to have the surgery done, please sign this consent form.”
Surely, this man would choose to do the surgery, however he would not have been properly consented and should any unwanted complications flow from this procedure he would be on good footing to bring a case for assault based on improper or uninformed consent. The same principle applies for the treatment of benign lesions.
Transurethral Resection of the Prostate and open radical prostatectomy are still internationally accepted treatment modalities and certainly continue to be good options for the treatment of enlarged prostate and prostate cancer. However, in the face of the multiplicity of treatment modalities that are available I believe it is essential that the healthcare authorities evaluate the evidence and outcomes and move toward the safest reasonably achievable model of care, while ensuring patients understand and are informed of all reasonable alternatives both here and abroad. So, the final question I will ask is not can we defend these older modalities, we absolutely can, but should we?
