Medical Negligence

• Negligence is the failure to take proper care over something
• Medical Negligence: Occurs in healthcare when a professional deviates from accepted standards by either failing to do something right

Actions for Medical Negligence

• When medical negligence is suspected, the affected patient may pursue a legal claim to seek compensation
• Establishing Duty of Care: When a cardiologist agrees to examine, diagnose, and treat a patient for a heart condition, a duty of care is established
• Proving Breach of Duty: A surgeon leaving a surgical instrument inside a patient after cardiac surgery breaches the standard of care
• Causation: After a surgical instrument remains, an infection develops and leads to septicemia, showing the infection resulted directly from the surgeon's mistake
• Damages: A patient must pay hospital bills in order to treat the infection caused by the surgeon’s mistake
• Harm suffered may include physical injury, emotional distress, additional medical expenses, or loss of income

Types of Medical Negligence

• Gross Negligence: A severe form of negligence is when a healthcare provider’s actions demonstrate a blatant disregard for the patient’s safety, such as performing surgery on the wrong body part or leaving surgical instruments inside a patient
• Comparative Negligence: Involves the court assessing the degree of fault of both the healthcare provider and the patient, potentially reducing the compensation due to the patient’s share of responsibility
• Contributory Negligence: Similar to comparative negligence but more stringent
• A patient undergoes orthopedic surgery to repair a fractured leg and is given discharge instructions to keep the leg elevated and immobilized, not put any weight on the leg for 4 weeks, and return for follow-up visits as scheduled
• However, the patient ignores the instructions and decides to walk without crutches to run errands 2 weeks after surgery, placing full weight on the healing leg and causing surgical screws to shift and the bone to misalign, resulting in pain and requiring a second corrective surgery
• Contributory negligence bars the patient from receiving any compensation if they are found to have any fault in causing their injury
• Vicarious Liability: A legal doctrine holding employers, such as hospitals or clinics, responsible for the negligent actions of their employees
• For instance, if a nurse employed by a hospital administers the wrong medication, the hospital may be held liable for the nurse's negligence

Legal System

• Medical negligence in India is covered under two legal systems:
  • The Indian Penal Code (IPC)
  • The Bharatiya Nyaya Sanhita (BNS) [newly introduced]

Indian Penal Code (IPC) and Medical Negligence

• Section 304A (Causing Death by Negligence): This law applies when someone's careless or reckless actions cause death but are not considered intentional murder
• If a doctor's mistake during treatment leads to a patient's death, they could face up to two years in prison, a fine, or both
• Sections 336, 337, and 338 (Endangering Life or Causing Harm): Used when medical negligence causes injury rather than death
• If a patient is harmed during surgery due to a doctor's careless mistake, these sections might be applied
• Defenses for Medical Practitioners (Sections 80 and 88): These sections protect doctors from being punished if:
  • The incident was an accident or misfortune and there was no criminal intent (Section 80)
  • The act was done in good faith for the patient's benefit with their consent, even if it involved some risk (Section 88)

Paternalism

• Paternalism in healthcare is when a doctor makes decisions for the patient, believing it is for the patient's own good, even if the patient doesn't agree
• In the past, this was common in medicine
• Doctors thought they knew best and would act without always asking the patient
• This was based on beneficence (doing good) and nonmaleficence (not causing harm)
• Over time, patients started to demand control over their own health choices, which led to the rise of autonomy and informed consent
• In the 19th–20th century, society began to question authority, including doctors
• People wanted to be free to make their own choices, not just follow orders
• Not involving patients in decisions became a big ethical issue, denying them their right to choose

Real-Life Court Cases That Changed Medicine

• Mohr v Williams (1905): A doctor operated on both ears when the patient only gave permission for one; the court ruled that doctors can only act within the consent given
• Salgo v Stanford (1957): The term "informed consent" was used for the first time; a patient became paralyzed and the doctor didn't explain the risks, so the patient couldn't make an informed decision
• It's important to involve patients in their own medical choices

Paternalism in Medicine: A Doctor's Perspective

• Doctors may want to protect the patient from harm
• Doctors feel their expertise gives them the right to decide
• Doctors believe the patient can't understand the situation fully
• This comes from the ethical principles of beneficence (do good) and nonmaleficence (do no harm)
• Still, ignoring patient autonomy can lead to ethical problems
• Specific situations where paternalism is still used:
  • Emergencies (when the patient is unconscious)
  • Public health issues (like outbreaks where individual choice may risk others)
  • Therapeutic privilege (when telling a patient might emotionally harm them)
  • Patient waivers (when the patient chooses not to know)
  • Incompetence (if the patient isn't mentally able to decide)

Categories of Paternalistic Approaches

• Hard Paternalism: The doctor overrides the patient's decision, even if the patient is fully informed and capable of making their own choice, such as forcing a mentally capable patient to take medication against their will
• Soft Paternalism: The doctor makes decisions because the patient is not fully informed or not capable (e.g., unconscious, confused), such as giving treatment to an unconscious accident victim without consent
• Pure Paternalism: The action affects only the person being protected, such as a doctor withholding dangerous medication from a patient to protect them
• Impure Paternalism: The action affects others as well as the person being protected, such as restricting the sale of antibiotics to prevent resistance

Justifiable Paternalism

• A doctor's decision to act against a patient's wishes is ethically acceptable when it prevents serious harm and the patient is not fully capable of making a sound decision
• This is justifiable if the patient lacks understanding, the risk to the patient is very serious or life-threatening, and the doctor has tried to inform and involve the patient as much as possible
• An example is a diabetic patient refusing insulin because of a false belief and the doctor gives treatment anyway to save the patient's life

Models of Doctor-Patient Relationship

• Paternalistic Model: The doctor makes most of the decisions, the patient plays a passive role, and is suitable in emergencies or when the patient can't decide, such as treating an unconscious patient in an emergency room
• Informative Model: The doctor provides all the facts, but the patient makes the decisions, which focuses on information-sharing; an example is when a doctor explains all cancer treatment options, and the patient picks the one they prefer
• Interpretive Model: The doctor helps the patient understand their own values and choices, work together to find the best option, and gives advice, but the decision is shared; an example is a doctor helping a patient choose a treatment based on the patient's lifestyle, beliefs, and goals
• Deliberative Model: The doctor and patient discuss what's best not just medically, but ethically and personally; the doctor helps the patient form values and preferences, and together they decide; an example is a doctor discussing the long-term effects of treatment on a patient's family life and values

Autonomy of the Patient

• Autonomy: A person has the right to make their own decisions about their body and health; in healthcare, this means patients have the right to choose or refuse treatment after being properly informed
• The patient must be given all the necessary information in a way they can understand
• The patient must be able to make a free choice without being forced
• Respecting autonomy is a way of respecting the person as an individual
• If a patient refuses chemotherapy, even if it could save their life, doctors must respect that choice (after making sure the patient understands the risks)

Core Elements of Autonomy

• Informed Consent: Patients must receive clear, comprehensive, and relevant information about their diagnosis, treatment options, risks, and benefits; the explanation should be in a language and manner the patient can understand
• Voluntary Decision-Making: The patient's choice must be made freely, without coercion, manipulation, or undue influence from doctors, family members, or institutions
• Decision-Making Capacity: Patients must have the mental and emotional ability to understand the information and make a reasoned choice; in cases where the patient lacks this ability, alternative legal or ethical frameworks are followed

Significance of Autonomy in Healthcare

• Respect for Individuals: Recognizing that every person has their own beliefs, values, and goals for treatment
• Legal & Ethical Requirement: Many countries, including India, have legal mandates to obtain informed consent
• Improved Patient Satisfaction: Patients are more likely to follow treatment plans they helped choose
• Trust in Healthcare: Promotes transparency and strengthens the patient-doctor relationship