Medical and Dental Practitioners’ Disciplinary Tribunal V Okonkwo (2001)

CASE TITLE: Medical and Dental Practitioners’ Disciplinary Tribunal V Okonkwo (2001)

CITATION: (2001) 7 NWLR (Pt. 711) 206.

COURT: Supreme Court of Nigeria.

JURISDICTION: Nigeria. 

JUDGES:

• Salihu Modibbo Alfa Belgore, J.S.C. (Presided)
• Sylvester Umaru Onu, J.S.C
• Okay Achike, J.S.C
• Samson Odemwingie Uwaifo, J.S.C
• Emmanuel Olayinka Ayoola, J.S.C (Read the Leading Judgment)

DATE OF JUDGMENT: FRIDAY, 2ND MARCH, 2001.

PARTIES INVOLVED:

• APPELLANTS: Medical and Dental Practitioners Disciplinary Tribunal
• DEFENDANTS: Dr. John Emewulu Nicholas Okonkwo

FACTS OF THE CASE:

Mrs. Martha Okorie, a 29 year old woman (the patient), delivered at a maternity clinic on the 29th of July, 1991. Shortly after delivery, she complained of difficulty walking and severe pain in her pubic area. She was admitted as a patient at the Kenayo Specialist Hospital, for a period of 9 days. 

After several tests, the hospital diagnosis reported a serious ailment and thereafter a blood transfusion was recommended. However, the patient and her husband Mr. Loveday Okorie vehemently refused granting consent to the blood transfusion, citing their religious beliefs as members of Jehovah Witness as the basis for their refusal. Following their refusal, the patient was discharged from the hospital by Dr. Okafor with a written document acknowledging their decision, despite warning them of the possible risk of death.

On the same day she was discharged- Mr. Okorie took his wife to Jeno hospital. Upon arrival, he presented to Dr. Okonkwo, who was attending to the patient, a signed card from Mrs. Okorie titled Medical Directive/Release prohibiting any blood transfusion and specifying alternative treatments such as non-blood expanders, including Dextran, saline, Ringer’s solution, and hetastarch.

On that same day, Mr. Okorie signed a separate document title Release from Liability, refusing blood transfusion for his wife due to religious beliefs and accepting all resulting medical consequences. The respondent proceeded to treat the patient without any blood transfusion and the patient subsequently died 5 days later.

Following the death of the patient, a complaint was lodged against the respondent at the medical and dental practitioners’ disciplinary tribunal by the patient’s mother and uncle. The respondent was charged on a two count complaint by the tribunal in 1993. The charges alleged negligence in attending to the patient and acting contrary to the Hippocratic Oath, which amounted to infamous conduct punishable under section 16 of the Medical and Dental Practitioners’ Act. 

ISSUES RAISED:

The central issue raised in this appeal was whether a medical practitioner was guilty of infamous conduct when, in reference to the patient’s religious objection to a blood transfusion, he failed to adopt such treatment to save the patient’s life or terminate his medical contract or transfer the patient to another health facility.

ARGUMENT OF THE PARTIES:

• Appellant: The appellant tribunal, who had previously charged and tried the defendant for medical negligence and infamous conduct, appealed the judgment of the court of appeal. Their core argument was that the defendant, Dr. Okonkwo, failed to administer a potentially life-saving blood transfusion not solely because of the patient’s objection, but also due to his own religious reservations as a member of the Jehovah witness sect. They relied heavily on Rules 5, 9 and 10 of Rules Professional Conduct (RPC) in the Medical Profession, insisting that instead of continuing to treat the patient under such disadvantageous conditions, he ought to have terminated his medical contract, or better still,  transferred the patient to a ‘larger facility’ where necessary life saving measures could have been taken. 
• Defendant: The defendant, however, argued that his failure to administer the blood transfusion to the patient in the course of her treatment, was in no way influenced by his personal religious beliefs as a Jehovah Witness, but rather stemmed out of his professional duty to respect his patient’s right to autonomy and informed decision making. 

JUDGEMENT: 

The appeal as dismissed unanimously, with all issues settled in favor of the defendant. In the leading judgment, Ayoola, J.S.C stated that there was no doubt that the tribunal had arrived at a wrong conclusion by its misplaced emphasis on the respondent’s belief rather than on the patient’s belief an actions. The tribunal had also ignored the respondent’s evidence that notwithstanding his beliefs he had transfused blood to consenting patients before, demonstrating that his conduct was not influence by religion but by professional ethics.

Citing Re-Yetter, the learned justice reaffirmed the legal capacity of a competent and mature adult to consent to or refuse treatment – even when it is detrimental to his health. This refusal cannot be overridden because it seems unwise, foolish or ridiculous to others as long as it was made voluntarily by the patient.

Ayoola J.S.C. further clarified that where a medical practitioner despite a patient’s refusal of treatment, proceeds to administer such treatment(s) he acts unlawful fully. This act would amount to an offence of trespass to the patient.

The court also found that the tribunal had misinterpreted the provisions of the rules of professional conduct which they heavily relied on. While the appellants argued these provisions to be mandatory, the court construed it to be permissive, thereby allowing the practitioner’s discretion when dealing with the dilemma of patients’ refusal to treatment.

In light of the above facts, the court confirmed that the defendant acted within the bounds of professional ethics and could not be found guilty of infamous conduct as alleged by the appellant.

RATIO DECIDENDII:

The legal reasoning for which the appeal was dismissed, with judgement in favor in of the defendants can be summarized as follows:

• Patients’ right to autonomy: Patients possess the legal right to make informed decisions regarding their treatment methods and options. These rights are derived from the right to privacy and freedom of thought, conscience and religion guaranteed under sections 34 and 35 of the Constitution of the Federal Republic of Nigeria, 1999 (as amended). These rights can only be derogated or over-weighed for interests of public health and safety as stipulated under section 45 of the constitution. 
• Sufficient efforts by the defendants: The facts of the case showed continuous efforts by both hospitals to persuade the patient to accept the blood transfusion. The argument of the appellant tribunal that the defendant ought to have transferred the patient to a larger facility held no merit, as there was no indication that such a transfer would not have changed the patient’s decision.
• Unclear provision of the RPC: the Rules of Professional Conduct (RPC), on which the appellant heavily relied, did not contain any clear provision addressing a medical practitioners’ duty when a patient refuses informed consent. The two options contained in the act- to either terminate the medical contract or transfer the patient to another facility- were permissive and did not constitute a legal obligation on the part of the medical practitioner.
• Conduct of the Defendant: The defendant’s refusal to administer a blood transfusion was not influenced by his personal religious beliefs, but stemmed from his professional obligation to respect the patient’s autonomy and informed refusal. Additionally, the hospital and its staff were relieved of liability by virtue of the written documents signed by the patient’s husband, acknowledging their decision and accepting all resultant risks.
• Liability of medical practitioners: Making a medical practitioner a ‘scapegoat’ of the voluntary decisions and unfortunate outcome of the decision of his patient would amount to grave injustice. This highlights the fact that a doctor cannot make choices on behalf of a competent patient, nor can he be held liable for the adverse outcomes of such decisions. 

CONCLUSION:

The case of Medical and Dental Practitioners Disciplinary Tribunal v Okonkwo (2001)  stands as a landmark decision, that highlights  the delicate balance between a patient’s right to autonomy and informed decision making (including the right to refuse treatment)  and the professional liability of medical practitioners.

By vindicating the defendant, Dr. Okonkwo, and dismissing the appeal, the Supreme Court affirmed the timeless principle of ‘justice being seen to be done‘ first established in R v Sussex Justices, Ex parte McCarthy.

Although not expressly stated, it can be inferred from this judgement that patients who exercises their right to autonomy and refusal of treatment (or certain treatment options) assume full responsibility for the consequences of such decisions- whether they are favourable or not. Medical practitioners cannot and should not be dragged down the lane of liability for unfavorable outcomes of a patient’s informed refusal, under the guise of medical negligence or whatever nomenclature the charge is brought under.

The reasoning in the instant case has been frequently referenced, relied on and adopted n subsequent cases having the same material facts or issues, in line with the doctrine of stare decisis, for instance the case of Esubunor v Faweya. It continues to serve as a guiding authority on the intersection of patients’ autonomy, religious freedom and medical ethics in Nigeria.

Reference(S):

1 (1973) 62 Pa D & 2d 619

2 (1923) All ER Rep 233

3 (2019) 7 NWLR (Pt.167) 316