We are all for informed consent, aren’t we? Of course we are. It’s a bit like asking if we’re all in favour of an NHS that isn’t crumbling around us, a government that actually delivers on its election promises or a big win on the National Lottery. All I would say is, be careful what you wish for. While informed consent is an excellent goal to aspire to, it’s not as easy to give or receive as it sounds.

Several factors hinder the process. The information exchange involved is often complex. If you haven’t spent five or six years in medical school, you may have trouble understanding key aspects of what you are being told. Another major encumbrance to being properly informed is that assessing the risks and benefits of different proposed treatment options is central to informed consent. The likelihood that your surgical outcome will be satisfactory. The risk of side effects and complications. The possibility that you might even die. These assessments require a knowledge of mathematics and probability theory. In my experience, most people are rubbish at these.

I’ll cover all these issues in detail in my next post. However, before we delve into all that, I want to tell you a story…

‘I swear by Almighty God that the evidence I shall give shall be the truth, the whole truth, and nothing but the truth.’

‘Thank you, Dr McCluskey. You may sit down. Will you please read your witness statement to the court?’

I was the first witness to give evidence after the lunch break. The coroner was smiling, which was most unlike him. Perhaps he’d eaten something that disagreed with him and was suffering from a touch of flatulent dyspepsia.

‘Thank you, Sir.’ I took a sip of water from the plastic cup I had brought to the witness stand and cleared my throat. ‘This statement is based primarily on my examination of the relevant case notes, although I do have some recollection of the events in question. It is an accurate and truthful account of the facts as I understand them.’

I addressed my words to the coroner in the manner the hospital’s solicitor had coached me, but I couldn’t prevent my eyes from straying to the right where Mr Bowden Jr, Miss Lynch and Mr Monkton, KC, were sitting. Mr Bowden Jr, the deceased’s son, was staring at the ceiling. I followed his gaze. There was nothing to see up there. Miss Lynch, Mr Bowden Jr’s solicitor, was busy scribbling in her notebook. Mr Monkton was Mr Bowden Jr’s barrister. His piercing, frightening, steel-grey eyes instantly locked onto mine. I tore them away with difficulty and continued reading my statement.

‘I first met Mr David Bowden at 08:00 on 23 June 2023 in my capacity as his consultant anaesthetist. He had been admitted to hospital that day for a total hip replacement under Mr Sean Monaghan. I conducted a thorough preoperative assessment, from which I concluded that Mr Bowden presented a relatively high perioperative mortality risk. I based this conclusion on several factors, including his age of eighty-four and the following pre-morbid conditions: obesity, Parkinson’s disease, two previous heart attacks, angina and Type 2 diabetes. Using a surgical risk calculator app, I estimated his risk of death within thirty days of surgery to be approximately 5%, or 1 in 20. I discussed this risk with Mr Bowden and asked him if he was certain he wanted to proceed. He was adamant that he did.’

My throat was dry, and the last few words came out as a squeak. I had been fairly successful in focusing my attention either on the coroner or on my notes thus far, but as I reached for my water, I glanced across to my right again. Mr Bowden Jr was staring morosely at his feet, his head in his hands, slowly shaking his head. Miss Lynch was still scribbling furiously. Mr Monkton’s glacial glower was unchanged. I made a mental note to avoid further ocular wanderings.

‘Anaesthesia and surgery proceeded uneventfully,’ I said after lubricating my vocal cords, ‘and Mr Bowden was discharged to the ward after a period of observation in the recovery room. I popped in to see him before leaving for home. He was comfortable, and his observations were satisfactory. I didn’t see him again after that. I was woken up at 11:30 that night by Mr Monaghan phoning to inform me that Mr Bowden had sadly died half an hour earlier after suddenly collapsing with chest pain. We presumed he’d had a heart attack.’

My voice was squeaking again. I took another sip of water before ending my witness statement. ‘I extend my deepest condolences to all Mr Bowden’s family and friends for their loss.

Statement delivered, I put my notes down, the first part of my ordeal over. The easy bit, I reminded myself.

‘Thank you, Dr McCluskey,’ said the coroner. ‘That was most helpful. I believe Mr Monkton has a few questions he wishes to put to you.’

Mr Monkton rose slowly and deliberately from his chair. There was no avoiding those eyes now. ‘Dr McCluskey, we heard earlier from Mr Bowden Jr that his father would never have gambled his life away had he truly understood the risks of proceeding with surgery.’ Mr Monkton paused and looked thoughtful. ‘He didn’t know what he was consenting to, ergo his consent was invalid. That’s the simple truth, isn’t it?’

The temptation to stare directly back at Mr Monkton while I answered him was almost overwhelming, but I resisted and directed my reply to the coroner. ‘No. In my opinion, it is not true, Sir.’

‘No? Not true? Really?’ Mr Monkton’s eyebrows rose in astonishment. Quickly regaining his composure, he followed up with, ‘Did you know the deceased better than his own son?’

‘Of course not,’ I responded, ‘but it was clear to me that Mr Bowden fully understood the risks and was keen to go ahead with his hip replacement. I even remember him saying he’d rather be dead than carry on with the constant, unbearable pain. He reckoned a 1 in 20 risk of death was good odds in the circumstances.’

‘Do you? Do you indeed?’ No longer merely astonished, a now dumbfounded Mr Monkton asked, ‘Do you think a 1 in 20 risk of death is good odds?’

‘It depends on your point of view,’ I replied.

A now utterly flabbergasted Mr Monkton took a restorative gulp of water from his plastic cup before continuing, ‘Would you care to explain what you mean?’

What did I mean? I studied the ceiling, hoping for inspiration. ‘Well,’ I said slowly, ‘if you were to tell me on good authority that I had a 1 in 20 risk of a lightning bolt striking me dead in the hospital car park tomorrow, I would say those are poor odds. If I were sure of your prediction, I’d stay safely tucked up in bed all day. On the other hand, if you were selling twenty raffle tickets at £10 each for a £1 million jackpot prize, I would say those 1 in 20 odds are good. Very good, actually. I’d risk a tenner, for sure. The odds are the same in each case, but whether you perceive them as poor or good depends on the outcome. Mr Bowden thought that risking his life, which he said was miserable, on odds of 1 in 20 was well worth the 19 in 20 odds that his operation would go well and his quality of life would be transformed for the better.’

Mr Monkton attempted a smile, which looked more like a painful grimace, before giving it up as a bad job. ‘Dr McCluskey, we are not here to talk about being struck by lightning or winning £1 million lotteries. We are here to find out why and how Mr Bowden died and whether or not he understood the gravity of the risk he was taking in going ahead with surgery.’

No suitable retort came to mind, so I kept my mouth shut.

‘Have you ever bought double glazing, Dr McCluskey?’

‘I’m sorry?’ I said, baffled.

‘I was just wondering if you had ever purchased double glazing. If you had, you would know that after signing a contract, you have a statutory cooling-off period to cancel without penalty should you change your mind.’

‘Er, yes. I did know that.’

‘Do you not think, then, that if a customer has two weeks to change his or her mind when spending a few quid on windows, you should afford a patient the same right when their very life is at stake?’

I agreed with Mr Monkton on that one. I was about to explain that I didn’t make the rules whereby patients in the UK aren’t usually consented by their anaesthetist, even for major surgery, until the day of their operation when Mr Monkton interjected. ‘I put it to you that the 5% risk of death you calculated for Mr Bowden was so high, that his hip operation was so inherently risky, that the onus was on you as the professional to take charge, step in and postpone surgery until he had had the opportunity to reflect and take counsel with close friends and family. After all, this was not life-saving surgery, was it? It was a lifestyle choice. Do you not agree?’

Evading Mr Monkton’s mesmerising gaze while he waited for an answer, I scanned the courtroom. The coroner was watching me with interest. Mr Bowden Jr, too. Miss Lynch had temporarily stopped scribbling, her pen hovering motionless over her notepad. Apart from the court clerk, the only other person in court was a rather bored reporter from the local paper. I rummaged in my inside pocket. ‘Sir, may I present some data from an annualised risk of death table?’

‘By all means,’ answered the coroner with an airy wave of his hand.

I unfolded the typewritten A4 sheet. ‘Sir, the data in this table, published in an evidence-based healthcare journal, represent the average risk of death in the year ahead for people of particular ages. Not people who are terminally ill with cancer or heart disease, and not people undergoing major surgery, either. Just ordinary people minding their own business and going about their daily lives.’

While I gathered my thoughts, I congratulated myself on doing my research.

‘According to these data, the risk of a typical male aged between seventy-five and eighty-four years old dying in the coming year is 1 in 15.’ I paused to let the statistic sink in. ‘Not altogether different from the risk I quoted to Mr Bowden.’

I failed to read Mr Monkton’s expression, but the coroner’s curiosity was piqued. ‘Really, Dr McCluskey. That is most interesting. Ahem, what is my risk of death for the coming year? I’m sixty-four.’

I glanced down. ‘About one in a hundred, Sir.’

‘Good grief,’ he spluttered. ‘As high as that?’

‘I’m afraid so, Sir.’

Mr Monkton didn’t appreciate my use of statistics. ‘That’s all very well,’ he barked, ‘but as you yourself so correctly pointed out, the obverse to a 1 in 20 risk of death is a 95 in 100 chance of survival. A racing certainty, you might say. Nobody reasonably expects a 1 in 20 event to actually happen, do they?’

It sounded like a rhetorical question, so I kept schtum. It was Mr Monkton’s turn to address the coroner directly. ‘Sir, if I randomly shuffle a pack of twenty playing cards and ask you to pick one, you wouldn’t believe it was random chance if I correctly identified your chosen card. You would suspect a trick.’

The coroner was nodding his head. Mr Monkton turned back to face me. ‘And I don’t believe it was random chance that Mr Bowden died. It wasn’t a random event, was it, Dr McCluskey?’

I thought I understood where Mr Monkton was going with this. Initially, he had suggested that a 1 in 20 risk of death was unacceptably high. Then he’d changed tack and maintained it was so low it could be reasonably discounted. Whether 1 in 20 odds were high or low, he was now arguing that Mr Bowden’s death wasn’t merely bad luck. He intended to try to prove that Mr Bowden was clinically mismanaged and that this had led directly to his demise. How should I respond?

‘Sir, according to my logbook of anaesthetic procedures, I have anaesthetised over five hundred patients for hip and knee replacements over the years. Their risk of death within thirty days of surgery has ranged between 0.1% and 20%. Of these, Mr Bowden is the first and only patient to die within thirty days, to my knowledge. I did not attend an inquest for any of the other five hundred plus patients because they didn’t die. If your risk of death is 1 in 20, 1 in 100 or even 1 in 1,000,000, you cannot end up 5% or 1% or 0.0001% dead. Because you can only ever be either 100% dead or 100% alive, it doesn’t matter how high or low your risk of dying is. If it’s not zero, you might die, and if I anaesthetise enough patients – to borrow your phraseology, Mr Monkton – it’s a racing certainty that one of them will die eventually. That’s why we’re here today. It really was just bad luck.’

The take-home message

Okay, so my short story won’t be shortlisted for the Booker Prize any time soon, but I hope you enjoyed reading it. More importantly, I hope it encouraged you to think a little about risks (chances) presented as odds or percentages. Rare events really do happen by random chance, as any EuroMillions lottery jackpot winner will happily confirm. The chances are that if you die after an operation when the risk quoted to you was “only” 1 in 20, it was just a case of wrong person, wrong place, wrong time. On average, another nineteen similar patients are thoroughly enjoying life with their new hip and knee joints!

Don’t worry if you’re a tad confused. All will be made clear in the next post. Fingers crossed.