Steroid-induced osteonecrosis in inflammatory bowel disease: Canadian legal status

Abstract

The challenges of treating inflammatory bowel disease (IBD) with steroids has not only serious medical implications but also the potential for legal ramifications. There are a number of possible side-effects with steroid use, including the risk of avascular necrosis, or osteonecrosis (ON).

If the clinician treats an IBD patient with steroids and is sued, the legal principles of standard of care and informed consent are triggered. These common law principles form the basis of medical negligence actions against physicians and affect physicians sued in common law jurisdiction such as Canada, United States and Commonwealth countries. Allegations of medical negligence are predicated on assumptions that physicians in prescribing steroids for IBD may have breached the standard of care in relation to dosage, both in time and amount prescribed, and in failure to refer the patient for surgery in a timely fashion. Lack of informed consent is almost always an issue.

At least lO lawsuits in Canada relating to steroid use in IBD have occurred since 1990 and the risk of legal actions against gastroenterologists in Canada has more than doubled since the 1980s. A recent (1999) Canadian court judgement against a gastroenterologist alleging an inappropriate prescribing of steroids for IBD that resulted in ON, provided a change in the stance of the courts. Emphasis was placed on standard of care, informed-consent status, timing of referral for surgery, and analysis employed by the court resulted in a favourable finding for the defendant gastroenterologist. This case provides a contrast to earlier judgements in favour of patients. In spite of the favourable finding for the gastroenterologist the court still concluded, based on evidence of orthopaedic surgeons and gastroenterologists, that a direct link existed between steroid use in treatment of IBD and development of ON.