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Medical Malpractice
Masaryk University, Faculty of Medicine, Spring 2014
Francisca Azevedo – 346684
azevedofrancisca@yahoo.com
Public health – VLVZ9X1c
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Introduction
Medical malpractice is defined as “professional negligence by a health care professional or
provider in which treatment provided was substandard, and caused harm, injury or death to a
patient“. [1]
This notion is very ancient, dating back to the Babylonians‘ code of Hammurabi that had 282
rules of which rule 218 that stated “ If a physician make a large incision with the operating
knife, and kill him, or open a tumour with the operating knife, and cut out the eye, his hands
shall be cut off [2].”
In the centuries that followed, there were periods where this notion was forgotten only to be
brought back in the 19th century as we all know it.
In medical malpractice, two kinds of concepts can be drawn, “lege artis” and “non lege artis”.
The term “lege artis” is applied to doctors that keep up with the law of the art, meaning they
adhere to certain standardized protocols while “non lege artis” is when doctors don’t follow
these standards. While “lege artis” poses no problems in situations in which the patient agrees
with the physician through the signing of a consent form, it can lead to problems when the
patient does not. Several examples of this kind of situation can be given but the best and most
common ones relay upon end of life care such as in the situation where a patient is not able to
swallow and the doctor recommends the usage of a feeding tube and the patient refuses,
putting so the doctor in a dilemma about whether he should adhere to the “lege artis” concept
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or respect the will of the patient. Other such ethical topics can be emphasized such as the
application of this principle towards euthanasia [3].
Some ethnical populations can also cause concern such as that of the Jehovah’s witnesses.
Patients with these beliefs are strongly against receiving any kind of blood product, from
platelets to whole blood but they will accept fluid replacement therapies as long as they do not
contain blood [4]. Whilst they will be against receiving the “primary components” of blood
(red blood cells, white blood cells, platelets and plasma), the acceptance of fractions of these
is up to each individual patient. Patients can thus choose if they want to receive albumin,
globulins, interferons, interleukins, haemoglobin and other such components of blood (Annex
1 [5]). Jehovah’s witnesses being against allogenous transfusions in all cases, they might
consider autologous transfusion in a situation where the blood will not be separated from the
patients’ circulation at any time but they will always refuse preoperative blood auto donation.
In these patients, it is performed a so called “bloodless surgery” so that there is no use of
blood transfusions during these procedures. [6] Some other procedures such as dialysis, heartlung
equipment, intraoperative blood salvage without storage or therapeutic apheresis are
dependent on a personal decision from the Jehovah’s witness (Annex 2) [7]. In the case of this
particular religious conviction, doctors are generally protected from malpractice suits since
the faithful population tends to take some legal steps in order to protect themselves [4].
A very important medical subject in which this concept is proving impossible to implement is
in research and clinical trials in which the use of standardized procedures goes against its
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basic principle, that of discovery and novelty [3]. Whilst the violation of the “lege artis”
concept might still be a reason to accuse a doctor of wrong doing, it might be exculpated in
situations such as that reported in which doctors failed to make the right diagnosis due to the
lack of time of hospital practitioners derived from their attempt to do things as fast as possible
as a means to maximize profit [3, 8].
In France, we distinguish three types of courts in which doctors can be tried: criminal,
administrative and civil.
Civil court is responsible for assessing several kinds of medical errors such as the doctor
misinforming the patient, no signing of consent forms, lack of respect of the doctor towards
the patient, breach of professional secrecy or technical mistakes like misdiagnosis, wrongful
choice of treatments or performance to undertake. The plaintiff can make a claim both on
moral and physical integrity grounds and he will be the prosecutor while the defendant will be
the doctor. Judges will call to the stand medical experts that will not only explain the correct
procedure in that situation but also try, if possible to justify the doctor’s attitudes. If some
wrong doing is ascertained then the plaintiff will receive a monetary sum [9].
Administrative court is responsible to assess not a physicians’ responsibility but a hospital
one in situations such as bad management or organisation of the healthcare staff, defects in
the architecture and safety of hospital that can lead to a patient’s escape or fall. Unlike in civil
court, in administrative court the patient does not have to present any evidence and it is the
hospital’s responsibility to pay the plaintiff [10].
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Criminal court can condemn doctors that have been proven to have false diplomas, committed
violence voluntarily, involuntary man slaughter, euthanasia, human sterilisation without
therapeutic ends, illegal abortions, breach in medical secrecy, experimental procedures
without human consent and for not assisting a dying person. Since these situations are quite
hard to prove, most commonly doctors do not suffer any consequences unless there is absolute
certainty [11].
In the United States, medical malpractice is considered a civil offense in which negligence
occurred. To prove this alleged malpractice, four elements must be verified and proved by the
plaintiff: The supposed physician was treating this specific patient, the physician broke the
rules relating to the standard of care, the plaintiff was injured due to the doctors errors,
deserving so a compensation [12].
In the United States it is said that 75 to 99% of practicing doctors will be sued over their
career, [13] being amongst the most commonly threatened specialities, the surgical ones [14].
Jiam et al compiled all the medical claims in the NPDB ( National Practitioner Data Bank)
between 1990 and 2011, finding out the top 10 procedures for which the patients claimed
money in the pretences of either permanent, temporary or emotional injuries. The conclusion
reached was that the most common causes for the plaintiff’s lack of satisfaction were for
improper performance of the physician, improper technique and the inability of the doctor to
detect a complication. An interesting category is the category of „never events“ that also
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figures amongst the top claims and includes errors such as leaving a sponge inside the body
and taking out the wrong organ from the patient [15].
In Italy, not only the number of claims but also the monetary reimbursement for the plaintiff
is increasing yearly. Italy being the country in Europe where more physicians are subject to
criminal action related to medical malpractice. As in the United States, the doctors who have
the highest possibility of being sued are also surgeons. The primary causes of complaint being
deficient follow up, wrong diagnosis and faulty performance of surgeries in patients [16].
Sweden operates according to a „no fault system“ in which insurance adjusters, conversing
with medical experts, have one year to decide whether or not the patient is entitled to receive
any extra amount of money. The doctor is not involved in this process and doesn’t have to
prove he proceeded in the correct way. If the victims are unsatisfied with the decision of the
adjuster, they can appeal to an Independent Patient Claims Panel that is made of judges and
doctors appointed by the government but this rarely happens [17].
Even though doctors have a lot of pressure on them, in most countries in the world they can
rely in Colleges (for instances in England, Portugal and France) or Boards (for instance in the
United States) that will protect them in a first instance. For example, in the United Kingdom,
if there is a suspicion for malpractice, the colleges will inform the individual in question not
only of this problem but also of the possible consequences that might arise from it. The
plaintee will have the right to defend himself and appeal from the College’s decision. In case,
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the College finds the situation too serious to be tried by them, they can report it to the police,
civil or criminal courts [18].
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Discussion
Several countries in Europe and in the United States have different systems each with their
own advantages and disadvantages.
While in the Mediterranean countries ( Portugal, Spain and Italy) and in the United States,
physicians are tried in court houses, subjected to criminal penalties and very severe money
compensations; in Scandinavian countries such as Denmark, Sweden and Finland, physicians
are not tried in any way, being the victims compensated directly by insurance adjusters
causing much less burden both to the doctors and economically to their countries but not
reprehending the doctor in any way for any possible grave mistake he might have committed.
In United States, due to the very frequent claims, doctors are practicing more and more a so
called „defensive medicine“, ordering excessive diagnostic tests and performing additional
therapeutic interventions that might harm the patient to a bigger extent, not to mention putting
a strain in the health care costs. Furthermore, this system is causing also a psychological toll
on doctors leading them to either change speciality (to a speciality with lower risk of getting
sued) or quitting their profession entirely [19].
A new approach towards avoiding malpractice suits in the United States, is disclosing medical
errors to patients. While this promotes transparency, it is bound with legal implications and
can lead to problems with the reputation of the physician [20].
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Whilst the American system can correlate to the Mediterranean system, the numbers of
medical malpractice claims are quite different. For instance in Portugal, there were 184
alleged cases in 2013 [21] while in the United States 76 839 claims were made in 2012 [22].
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Conclusion
While the United States and some other countries have a judicial system that has not only the
ability to punish the doctor and compensate the patient but also the possibility of causing
psychological damages and the creation of a more defensive medicine with time;
Scandinavian countries have an administrative system that is only able to compensate the
patient without reprehending the doctor. An ideal system would be a combination of both.
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Bibliography
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[2] Hammurabi’s Code of Laws. [http://eawc.evansville.edu/anthology/hammurabi.htm]
[3] Kraetschmer K: Is the “Lege Artis” principle obsolete? J Forens Res 2013, 4:3.
[4] Dixon JL, Smalley MG: Jehovah’s Witnesses. The surgical/ethical challenge. JAMA
1981; 246:2471-2472
[5] Annex 2- Jehovah's witnesses' position on blood.
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[6] Jassar et al: Cardiac Surgery in Jehovah’s Witness Patients: Ten-Year Experience.
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[20] Kachalia A, Bates DW: Disclosing medical errors: The view from the USA. The
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[21] Queixas de Negligência Médica quintuplicaram desde 2001.
[http://www.publico.pt/sociedade/noticia/queixas-de-negligencia-medica-quintuplicaram-
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Annex 1- Jehovah's witnesses' position on blood [5].
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Annex 2- Techniques that are considered acceptable by Jehovah's witnesses [7].