Malpractice

Principlism, a most prominent approach in bioethics, has been criticized for lacking an underlying moral theory. We propose that the four principles of principlism can be related to the four traditional cardinal virtues. These virtues appear prominently in Plato's Republic and in Aristotle's Nicomachean Ethics. We show how this connection can be made. In this way principlism has its own compelling ethical basis.

In his article "How Certain Boundaries and Ethics Diminish Therapeutic Effectiveness", Lazarus asserts that many clinicians are adhering to strict therapeutic boundaries and ethics in a fear-driven effort to avoid unwarranted malpractice claims. Although I agree that maintenance of conventional therapeutic boundaries is apt to minimize malpractice claims in most cases, I believe that is because such boundaries are critical to protect patients' welfare and thereby promote effective treatment. My reasoning, discussed next, revolves around the following premises: 1. For many, (...) if not most, types of patient problems and patient populations, boundaries and the personal meaning of the therapeutic boundaries are an arena in which critical emotional issues are manifested and worked through. 2. Clear, consistent boundaries provide a structure and safety for many patients that is a curative factor in itself. 3. Patients' reactions to alterations in usual therapeutic boundaries are often unpredictable ahead of time (even if requested by the patient) and typically complex, ambivalent, and heavily colored by transferential meaning. 4. Because alterations in therapeutic boundaries typically add a new therapist role or activity that involves potential gratification of personal needs of the therapist, objectivity in evaluating such a change may be compromised by the inherent self-interest. 5. Consistent, clear boundaries need have no impact on therapist warmth and empathy. (shrink)

Una mirada a la historia de la investigación con seres humanos nos revela que la ética (al menos entendida como el ethos de una comunidad) ha estado siempre presente de uno u otro modo. No obstante, también son numerosas las situaciones en las que las pautas morales son sistemáticamente transgredidas.

Determining appropriate legal responses to the conduct of health care workers who endanger patients continues to provoke fierce debate. This is particularly true in the context of criminal law, which offers punishment as an obvious strategy.

'A highly regarded anaesthetist at the height of his abilities has recently faced charges of the manslaughter of a moribund 82-year-old lady who died during the course of an operation for gangrenous bowel'. The language used by McCall Smith and Merry to open their argument for change to New Zealand's manslaughter laws is revealing. Why should it matter that the anaesthetist was 'highly regarded' and 'at the height of his abilities'? Should the criminal law be reserved for lesser mortals who (...) err? Why should the patient's moribund state and age be relevant to criminal liability? Had the anaesthetist hastened her death by stabbing her, would we think that murder charges should not be laid just because she was old and dying? (shrink)

There can be no disputing the proposition that doctors and nurses should be held accountable for their professional activities. In most circumstances this accountability should be achieved through appropriate and effective complaints and disciplinary procedures, but there will be cases where the criminal law should become involved. The criminal law, however, is a serious weapon, and should only be used to punish those whose conduct is truly criminal; it should not be used against those who have merely made a human (...) error. The task of the law should therefore be to identify those situations where a doctor or nurse has behaved in a way which demonstrates a criminally culpable state of mind. In NZ recently the law has failed to do this and has been used as a weapon against those who may be in no sense morally blameworthy. -/- In New Zealand recently the law has failed to do this and has been used as a weapon against those who may be in no sense morally blameworthy. In this respect, NZ has been out of step with other comparable jurisdictions and has demonstrably failed to distinguish between cases where death is caused accidentally (through the making of an ordinary human error) and cases where it is caused criminally (through recklessness or culpable negligence). This is a surprising situation in a jurisdiction which has prided itself on its willingness to adopt a reformist legal agenda. (shrink)

The purpose of this article is to explore both the legal difficulties and policy objections in using public nuisance against conduct which exposes others to the risk of contracting a harmful disease. Drawing on the judicial and legislative responses in Australia, Canada, New Zealand and the United Kingdom, I will identify the important issues of legal principle and public policy which must be addressed when considering the imposition of criminal liability in these circumstances.

Background: The knowledge of scientific dishonesty is scarce and heterogeneous. Therefore this study investigates the experiences with and the attitudes towards various forms of scientific dishonesty among PhD-students at the medical faculties of all Norwegian universities.MethodAnonymous questionnaire distributed to all post graduate students attending introductory PhD-courses at all medical faculties in Norway in 2010/2011. Descriptive statistics. Results: 189 of 262 questionnaires were returned (72.1%). 65% of the respondents had not, during the last year, heard or read about researchers who committed (...) scientific dishonesty. One respondent had experienced pressure to fabricate and to falsify data, and one had experienced pressure to plagiarize data. On average 60% of the respondents were uncertain whether their department had a written policy concerning scientific conduct. About 11% of the respondents had experienced unethical pressure concerning the order of authors during the last 12 months. 10% did not find it inappropriate to report experimental data without having conducted the experiment and 38% did not find it inappropriate to try a variety of different methods of analysis to find a statistically significant result. 13% agreed that it is acceptable to selectively omit contradictory results to expedite publication and 10% found it acceptable to falsify or fabricate data to expedite publication, if they were confident of their findings. 79% agreed that they would be willing to report misconduct to a responsible official. Conclusion: Although there is less scientific dishonesty reported in Norway than in other countries, dishonesty is not unknown to doctoral students. Some forms of scientific misconduct are considered to be acceptable by a significant minority. There was little awareness of relevant policies for scientific conduct, but a high level of willingness to report misconduct. (shrink)

Most experts would agree that the current medical malpractice system in the United States does not work effectively either to compensate victims fairly or prevent injuries caused by medical errors. Policy responses to a series of medical malpractice crises have not resulted in effective reform and have not altered the fundamental incentives of the stakeholders. In Medical Malpractice, economist Frank Sloan and lawyer Lindsey Chepke examine the U.S. medical malpractice process from legal, medical, economic, and insurance perspectives, analyze past efforts (...) at reform, and offer realistic, achievable policy recommendations. They review the considerable empirical evidence in a balanced fashion and assess objectively what works in the current system and what does not. Sloan and Chepke argue that the complexity of medical malpractice stems largely from the interaction of the four discrete markets that determine outcomes--legal, medical malpractice insurance, medical care, and government activity. After describing what the evidence shows about the functioning of medical malpractice, types of defensive medicine, and the effects of past reforms, they examine such topics as scheduling damages as an alternative to flat caps, jury behavior, health courts, incentives to prevent medical errors, insurance regulation, reinsurance, no-fault insurance, and suggestions for future reforms. Medical Malpractice is the most comprehensive treatment of malpractice available, integrating findings from several different areas of research and describing them accessibly in nontechnical language. It will be an essential reference for anyone interested in medical malpractice.Frank A. Sloan is J. Alexander McMahon Professor of Health Policy and Management and Professor of Economics at Duke University. He is the coauthor of The Price of Smoking and author or editor of many other books on health economics. Lindsey M. Chepke, an attorney, is a Research Associate at the Center for Health Policy at Duke University. (shrink)

At first glance, the first informed consent case to be decided by the High Court of Australia appears to be little more than a clear and simple description of the substantive law accepted in most American jurisdictions - although that is no small accomplishment in and of itself. In Rogers v. Whitaker, the highest court in Australia succinctly and persuasively rejected informed consent as a species of battery law, accepted it as a form, of ordinary professional negligence law, and adopted (...) the “American” patient-oriented standard for measuring the breach of a healthcare professional's duty to her or his patients. On second look, however, the opinion is an even more significant one because it reveals that the law of informed consent is now based on principles broad enough to create a duty on the part of healthcare providers to offer adequate health education to all of their patients. In Implicitly recognizing the physician's duty to educate her or his patients, the High Court's judgment is consistent with a view increasingly held In the medical and ethical communities that teaching patients about how to maintain their health is just as much a part of the doctor's function as diagnosing and treating disease. It may have taken 2,500 years for medicine to progress from, the Hippocratic notion that physicians should apply treatment to patients who are kept in blissful Ignorance of their condition and Its remedy, but there Is little doubt that medicine finally has entered a post-Hippocratic era. (shrink)

This essay examines the so-called phenomenon of defensive medicine and the problematic aspects of attempting to maintain the safest legal position possible. While physicians face genuine litigation threats they frequently overestimate legal peril. Many defensive practices are benign, but others alter patient care and increase costs in ways that are ethically suspect. Physicians should learn to evaluate realistically the legal risks of their profession and weigh the emotional, physical, and financial costs to the patient before employing a defensive measure.

Malpractice insurance rates have created a crisis in American medicine. Rates are rising and reimbursements are not keeping pace. In response, physicians in the states hardest hit by this crisis are feeling compelled to take political action, and the current action of choice seems to be physician strikes. While the malpractice insurance crisis is acknowledged to be severe, does it justify the extreme action of a physician walkout? Should physicians engage in this type of collective action, and what are the (...) costs to patients and the profession when such action is taken? I will offer three related arguments against physician strikes that constitute a prima facie prohibition against such action: first, strikes are intended to cause harm to patients; second, strikes are an affront to the physician-patient relationship; and, third, strikes risk decreasing the public's respect for the medical profession. As with any prima facie obligation, there are justifying conditions that may override the moral prohibition, but I will argue that the current malpractice crisis does not rise to the level of such a justifying condition. While the malpractice crisis demands and justifies a political response on the part of the nation's physicians, strikes and slow-downs are not an ethically justified means to the legitimate end of controlling insurance costs. (shrink)

The objective of this study was to determine the extent of decline in level of access and quality of services reported by healthcare consumers during a media campaign to limit recovery for damages incurred through medical malpractice. Serving as a natural experiment, this campaign involved a widely publicized statewide "malpractice crisis," promoted as causing mass exodus of medical providers from the state. The resulting reduction in services, especially for the most underserved areas and populations, though unproven, had been touted as (...) justification for amending the state constitution. Patient survey responses collected during the crisis indicated relatively high levels of satisfaction with access and quality of care during the publicized crisis . Similar organized malpractice crises examined from previous years suggest that policymakers should demonstrate caution when responding to a perceived crisis, especially when economic benefit for a particular interest group is at stake. Further, a lack of ethics in media through inaccurate reporting and sensationalism may lead to a seductive invitation to like ethical lapses by medical professionals in their attempts to shape policy through artificial crises creation. (shrink)

This essay reviews and defines avoidable medical error, malpractice and complication. The relevant ethical principles pertaining to unanticipated medical outcomes are identified. In light of these principles I critically review the moral culpability of the agents in each circumstance and the resulting obligations to patients, their families, and the health care system in general. While I touch on some legal implications, a full discussion of legal obligations and liability issues is beyond the scope of this paper.

In this paper I argue that doctors who are found guilty of serious professional misconduct should be required to apologize as a condition of their registration. I argue that such a requirement is to be justified on the basis of the need to protect patients, maintain public confidence in the profession, and declare and uphold proper standards of conduct and behaviour. I also answer an objection that might be made to the position I defend. Finally, I consider whether there should (...) be any exceptions to the demand for an apology from doctors who have been found guilty of serious professional misconduct. (shrink)

American medicine has long sought to control the standard of care that physicians are expected to provide to their patients. One effort to insulate the standard of care from external interference, called a “safe harbors” approach, would enable physicians to avoid liability for malpractice if they adhered to medical practice guidelines. The idea is to eliminate the “battle of experts” and reduce defensive medicine by requiring judges and juries to accept guidelines as conclusive evidence of the standard of care. Yet (...) current efforts to improve the guideline development process, including the use of evidence-based guidelines, are unlikely to be able to overcome the shortcomings that led a similar safe harbors initiative to fail in the early 1990s. Moreover, there is no adequate justification for conferring this degree of self-regulatory power on the medical profession. (shrink)

The objective of this study was to take a closer look at defense-related expenses for medical malpractice cases over time. We conducted a retrospective review of medical malpractice claims reported to the Physician Insurers Association of America's Data Sharing Project with a closing date between January 1, 1985 and December 31, 2008. On average a medical malpractice claim costs more than $27,000 to defend. Claims that go to trial are much more costly to defend than are those that are dropped, (...) withdrawn, or dismissed. However, since the overwhelming majority of claims are dropped, withdrawn, or dismissed, the total amount spent to defend them surpasses that spent on claims that go to trial. Defense attorney expenses account for the majority of defense-related expenses (74%), while expert witness expenses and other expenses split the remaining 26%. A strong association was also found between the average indemnity payment and the amount it costs to defend individual claims by specialty. Our study found that defense-related expenses for medical malpractice claims are not an insignificant cost. As state and federal governments debate how to repair the malpractice system, addressing the high cost of defending claims should not be ignored. (shrink)

This essay discusses unlimited insurance subrogation (UIS) as a means of improving the deterrence and compensation results of medical malpractice law. Under UIS, health care insureds could assign their entire potential medical malpractice claims to their first-party commercial and government insurers. UIS should improve deterrence by establishing first-party insurers as plaintiffs to confront liability insurers on the defense side, leading to more effective prosecution of meritorious claims and reducing meritless and unnecessary litigation. UIS should improve compensation outcomes by converting litigation (...) cost- and risk- laden “tort insurance” into cheaper and enhanced first-party insurance. UIS also promises dynamic benefits through further reforms by contract between the first-party and liability insurers that would take charge of system. No UIS-related costs are apparent that would outweigh these benefits. (shrink)

Healthcare trends, stressors, and workplace violence -- Patient privacy and exploitation -- Abuse and assault -- Fraud and theft -- Suspicious death and homicide -- Investigations, sanctions, and discipline -- Prevention strategies and the future of healthcare crime.

In this essay, I examine the relationship between lawsuits for medical malpractice and the legal standard of care. I suggest that there is an insidious, dynamic relationship between physicians' reactions to the recent increase in malpractice litigation and an artificial elevation of the legal standard of care. Since, that is, the legal standard for proper medical care is based upon the community standard of care rather than the reasonable person standard, to the extent that overtreatment or “defensive” medicine becomes widespread (...) as a reaction to malpractice litigation, the legal standard becomes elevated as well. Thus, it will increasingly be the case that unless a physician practices defensive medicine, and hence practices unreasonably, she risks being found liable for medical malpractice. (shrink)

This study explored the relation between state medical liability reform measures, hospital malpractice costs, and hospital solvency. It suggests that state malpractice caps are desirable but not essential for improved hospital financial solvency or viability.

We conducted focus groups with 47 potential jurors who were presented with diferent scenarios in a hypothetical malpractice case involving failure to order a PSA test. Better documentation that a patient made an informed decision to decline a PSA test appeared to provide more medical-legal protection for physicians, especially with the use of a decision aid.

Human subject research involving brain imaging is likely to reveal signifcant incidental fndings of abnormal brain morphology. Because of this fact and because of the fduciary relationship between researcher and subject, board-certi-fed or board-eligible radiologists should review the scans to look for any abnormality, the scans should be conducted in accordance with standard medical practice for reviewing the clinical status of the whole brain, and the informed consent process should disclose the possibility that incidental fndings may be revealed and what (...) consequences will follow. In the event such fndings are revealed, qualifed physicians should explain to the subject the signifcance of the fndings and the alternatives available. (shrink)

Medical malpractice is of increasing concern and 60 billion dollars are added annually to healthcare costs. The practice of defensive medicine, decreased availability of doctors, and increased health insurance premiums are all results of medical malpractice. An argument is made from the perspective of Friedrich Nietzsche’s On the Genealogy of Morals that a primal cause of the litigiousness of the public against doctors results from resentment or “ressentiment”. The relationship of promises, responsibility, and guilt between doctors and patients is explored, (...) as well as what may be necessary to reduce the public’s ressentiment. Modern malpractice in the US is covered by Nietzsche’s line of reasoning in On the Genealogy of Morals, although his reasoning is condemned by most Western philosophers. Doctors may be able to better manage their interactions with patients and limit their exposure to litigation by understanding and exploring alternative philosophical and historical origins—or aetiologies—of patient/doctor conflict. (shrink)