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VeRBosity
Journal of the Veterans' Review Board
�Selected Decisions of the
Administrative Appeals Tribunal
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Hypertension - inability to obtain appropriate clinical management
Re M Crowe and Repatriation Commission
Gerber and Kennedy
Q1997/776
5 March 1999
[Full Text]
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Mrs Crowe applied to the Tribunal for review of a decision that the death of her husband was not war-caused. The late veteran served in the Army in Australia from 1942 to 1944 and died in 1968 as a result of a cerebral haemorrhage. Mrs Crowe's evidence was that her husband suffered from chest pains during war service and afterwards which he attributed to indigestion and had used Quickeze for relief. The veteran had a heart attack and was admitted to hospital in 1960. He suffered his first cerebrovascular accident in 1964 and a second and fatal cerebrovascular accident in 1968.
Medical evidence
Dr R Goodwin, specialist physician, gave evidence in support of Mrs Crowe's application. Dr Goodwin was of the opinion that the late veteran had borderline hypertension (140/90) during war service which led to ischaemic heart disease. He was of the view that although the veteran had been treated during service according to the medical standards of the time, he did not receive the appropriate treatment as measured by today's standards. He accepted that no effective medication for the treatment of hypertension was available in 1942-44.
Dr J Douglas, specialist physician, gave evidence for the Repatriation Commission. He did not accept that ischaemic heart disease could have caused chest pain throughout the period since the veteran's war service without resulting in an earlier heart attack. Both doctors told the Tribunal that a patient today with borderline hypertension of 140/90 would not necessarily be treated with medication.
Statements of Principles
The Tribunal considered the application in terms of the Statement of Principles relating to the primary cause of death, cerebrovascular accident (formerly No 24 of 1998). One of the factors that must as a minimum exist for a cerebrovascular accident to be connected with a person's service is that the person was suffering from hypertension before the clinical onset of the cerebrovascular accident. In this case, it was agreed by both parties that a blood pressure of 140/90 did indicate hypertension as defined in the SoP. The SoP relating to hypertension includes as a factor related to service:
"5(x) inability to obtain appropriate clinical management for hypertension."
Submissions
Mrs Crowe's counsel submitted that the late veteran's hypertension was due to an "inability to obtain appropriate clinical management" during war service. It was submitted that an inability to obtain appropriate treatment in the 1940's should be judged according to the current state of medical knowledge.
Tribunal's conclusions
The Tribunal rejected the submission by Mrs Crowe's counsel. The Tribunal said:
"We are unable to accede to so anachronistic an interpretation of 5(x), applying modern medical practice and/or knowledge as though it existed in 1942, it being conceded that the veteran was treated according to accepted medical practice at the time, that management would be regarded as inappropriate by the standards of today. The Tribunal finds it impossible to accept that the term 'appropriate clinical management' should not relate to what is considered appropriate at the point in time that the clinical management is being applied. We could not accept for example that a person whose life might have been saved in 1940 if heart transplantation had then been available could be said to have received 'inappropriate treatment' in 1940 because he or she did not receive a heart transplant. In short, if one were to adopt such a basis for inappropriate management, then one would have to say almost every person being treated today is receiving inappropriate treatment because they are being denied future developments.
In any event, even if one were to regard treatment in 1942-1944 as being inappropriate based on today's knowledge, that inappropriateness was in no way related to his service - it was the standard generally applicable to service personnel and the civilian population alike. For good measure, since we find on the evidence indicated that there had been no aggravation of his hypertension during his period in the service, the veteran's hypertension could not be regarded as service related.
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In the result, we have concluded that only contemporary medical standards, technology and knowledge can be considered when applying the test of 'inability to obtain appropriate clinical management' of any medical condition. It follows that the existence in the 1990's of medical knowledge regarding the diagnosis and treatment of hypertension and its subsequent effects has no application when considering whether there was an inability to obtain appropriate clinical management in the 1940's. Applying the mischief rule, we find that the inability to obtain appropriate clinical management must be solely due to the exigencies of service in the armed forces. It follows that the late veteran did not suffer any inability to obtain appropriate clinical management solely by reason of serving as a member of the Armed Forces between 1942 and 1944. He was regularly examined by doctors whilst he was a member of the armed forces and there is nothing to indicate that his clinical management within the service was anything other than what was appropriate at the time."
Formal decision
The Tribunal affirmed the decision that the veteran's death was not war-caused.
[Ed: In some other cases, the Tribunal has applied current medical standards in determining the meaning of "appropriate clinical management" - e.g. Re Wellington (2 February 1999) and Re Lucas (12 March 1999) which are both on appeal to the Federal Court on this point]