Medical Negligence - Medical Negligence Judgments

Medical Negligence- Necessary Protection Or Licence To Kill

Medical profession is one of the oldest professions of the world and is the most humanitarian one. Inherent In the concept of any profession is a code of conduct, containing the basic ethics that underline the moral values that govern professional practice and is aimed at upholding its dignity. Medical Ethics underpins the values at the heart of the practitioner-client relationship. Medical negligence and malpractices by doctors were the grey areas in health care where legal issues operated.

Characteristics of Humane physician

# Encompassing integrity, respect & compassion.
# Availability
# Expression of sincere concern.
# Willingness to take time to take all aspects of the patients' illness.
# Attitude of being non judgmental with patient who have different lifestyle, attitude and value.
# Alert to their reaction to such a situation which evoke strong negative emotional response.
# Consciously monitor and control their behavior so that patient's best interest remains the principle motivation of their action.

Essential Components of Medical Negligence

On basis of various judicial pronouncements essentials of 'Medical Negligence' as are discernible, in brief and in so far as it is relatable to the medical profession, are as under:
(i) The Doctor must owe a duty of care to the patient;
(ii) The Doctor must have made a breach of that duty; and
(iii) The patient must have suffered damages due to the said breach.

The Supreme Court in the case of Minu B. Mehta vs. B.R. Nayar [1] has held that the right to receive compensation can only be against a person who is bound to compensate due to his failure to perform a legal obligation. In many cases doctors have been held liable for negligent acts, such as removal of a wrong eye or a kidney, based on pecuniary interest or where minimum facilities were available.

Absence of any of these requirements can result into endanger to the patients life. On April 9, 1985, the General Assembly of the United Nations adopted the guidelines to provide framework for Governments, particularly those of developing countries. The legitimate needs which the guidelines are intended to meet include the protection of consumers from hazards to their health and safety and availability of effective consumer redress were first set up in 1986. The Supreme Court's judgement in the Indian Medical Association, v. V.P. Shanta and ors.[2] has brought them within its purview. There are three tiers of disputes redressal forum. At the lowest level are the District Consumer Disputes Redressal Forum), which entertain compensation claims up to Rs.20 Lakh. At the next level are the State Consumer Disputes Redressal Forums (one in each state), where compensation claims between Rs.20 Lakh and Rs. l Crore are made. At the National Forum, claim of over Rs. 1 Crore are lodged. Those dissatisfied with the judgment of the lower forum can appeal to a higher forum. The final court of appeal is the Supreme Court.

What is an accepted medical practice?

It is also called as scientific medical practice. It is a practice which is mentioned in standard text books or various issues of leading medical journals or recognized by responsible body of medical profession.

In cases of medical negligence the outcome of the treatment is of secondary importance, but the method adopted is of primary and much greater importance.
In case if doctor fails to follow one of the accepted methods & instead departs from the conventional course of treatment, the burden of proof lies upon the doctor to show that whether he had taken all proper care into account before deciding the depart & he had informed the patient and taken his consent or not.
There may be one or more perfectly proper standards, and if he conformed to one of these proper standards, he will not be considered negligent. In case of State of Haryana v. Santra,[3] the court has decided that in absence of gross mismanagement, liability of gross negligence will not be succeeded.

Any reasonable man entering into a profession which requires a particular level of learning to be called a professional of that branch, impliedly assures the person dealing with him that the skill which he professes to possess shall be exercised and exercised with reasonable degree of care and caution. He does not assure his client of the result. A lawyer does not tell his client that the client shall win the case in all circumstances. A physician would not assure the patient of full recovery in every case. A surgeon cannot and does not guarantee that the result of surgery would invariably be beneficial, much less to the extent of 100% for the person operated on. The only assurance which such a professional can give or can be understood to have given by implication is that he is possessed, of the requisite skill in that branch of profession which he is practicing and while undertaking the performance of the task entrusted to him he would be exercising his skill with reasonable competence. This is what the entire person approaching the professional can expect. Judged by this standard, a Professional may be held liable for negligence on one of two findings either he was not possessed of the requisite skill which he professed to have possessed, or, he did not exercise, with reasonable competence in the given case, the skill which he did possess. The standard to be applied for judging. whether the person charged has been negligent or not, would be that of an ordinary competent person exercising ordinary skill in that profession. In Bolam v. Friern Hospital Management Committee [4] the following words:

'Where you get a situation which involves the use of some special skill or competence, then the test as to whether there has been negligence or not is not the test of the man on the top of a Clapham omnibus, because he has not got this special skill. The test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill. It is well established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art.';

The classical statement of law in Bolam's case has been widely accepted as decisive of the standard of care required both of professional men generally and medical practitioners in particular. It has been invariably cited with approval before Courts in India and applied to as touchstone to test the pleas of medical negligence. In tort, it is enough for the defendant to show that the standard of care and the skill attained was that of the ordinary competent medical practitioner exercising an ordinary degree of professional skill. The fact that a defendant charged with negligence acted in accord with the general and approved practice is enough to clear him of the charge. Two things are pertinent to be noted. Firstly, the standard of care, when assessing the practice as adopted, is judged in the light of knowledge available at the time (of the incident), and not at the date of trial. Secondly, when the charge of negligence arises out of failure to use some particular equipment, the charge would fail if the equipment was not generally available at that point of time on which it is suggested as should have been used.
In Syad Akbar v. State of Karnataka [5]. The Supreme Court has dealt with and pointed out with reasons the distinction between negligence in civil law and in criminal law. Their Lordships have opined that there is a marked difference as to the effect of evidence, viz. the proof, in civil and criminal proceedings. In civil proceedings, a mere preponderance of probability is sufficient, and the defendant is not necessarily entitled to the benefit of every reasonable doubt; but in criminal proceedings, the persuasion of guilt must amount to such a moral certainty as convinces the mind of the Court, as a reasonable man, beyond all reasonable doubt. Where negligence is an essential ingredient of the offence, the negligence to be established by the prosecution must be culpable or gross and not the negligence merely based upon an error of judgment.

Res ipsa loquitur

The doctrine of res ipsa loquitur means, that the accident speaks for itself or tells its own story. The normal rule is, that it is for the plaintiff to prove negligence, but, in some cases, considerable hardship is caused to the plaintiff, as the true cause of the accident is not known to him, but is solely within the knowledge of the defendant who caused it. The plaintiff can prove the accident but cannot prove how it happened (so as) to establish negligence on the part of the defendant.
For the applicability of the principle should fulfill three essential conditions;
(i) The opposite party must have been in control of things;
(ii) Common knowledge/accepted norms suggesting that the injury/damage/loss, in itself cannot occur without negligence; and
(iii) The cause of incident/injury must be unknown or unascertainable.

Some of the common instances, where this principle can be invoked, are operation on a wrong patient or a wrong part of the body, transfusion of improper blood, leaving some foreign material in the body, performing an abortion or any other operation or surgery which is prohibited in law, etc.

Medical Professionals in Criminal Law

The criminal law has invariably placed the medical professionals on a pedestal different from ordinary mortals. The Indian Penal Code Act 1860, Section 88 in the Chapter on General Exceptions provides exemption for acts not intended to cause death, done by consent in good faith for person's benefit. Section 92 provides for exemption for acts done in good faith for the benefit of a person without his consent though the acts cause harm to a. person and that person has not consented to suffer such harm. There are four exceptions listed in the Section, which is not necessary in this context to deal with. Section 93 saves from criminality certain communications made in good faith.

The following statement of law on criminal negligence by reference to surgeons, doctors etc. and unskillful treatment contained in Roscoe's Law of Evidence (Fifteenth 'Edition) is classic:

'Where a person, acting as a medical man & c whether licensed or unlicensed, is so negligent in his treatment of a patient that death results, it is manslaughter if the negligence was so great as to ;, amount to a crime, and whether or not there was such a degree of negligence is a question in each case for the jury. 'In explaining to juries the test which they should apply to determine whether the negligence in the particular case amounted or did not amount to a crime, judges have used many epithets, such as 'culpable,' 'criminal', 'gross', 'wicked', 'clear', 'complete.' But whatever epithet be used and whether an epithet be used or not, in order to establish criminal liability the facts must be such that, in the opinion of the, jury, the negligence of the accused went beyond a mere matter of compensatiol' between r subjects and showed such disregard for the life and safety of others as to amount to a crime against the State and conduct deserving punishment.';

In Kurban Hussein Mohamedalli Rangawalla v. State of Maharashtra [6] dealing with Section 304A of IPC,
'To impose criminal liability under Section 304-A, Indian Penal Code, it is necessary that the death should have been the direct result of a rash and negligent act of the accused, and that act must be the proximate and efficient cause without the intervention of another's negligence. It must be the causa causans; it is not enough that it may have been the causa sine qua non.';

The same view has been reiterated in Kishan Chand & Anr. v. The State of Haryana [7]

In Juggankhan v. The State of Madhya Pradesh [8] the accused, a registered Homoeopath, administered 24 drops of stramonium and a leaf of dhatura to the patient suffering from guinea worm. The accused had no knowledge of the effect of such substance being administered and yet he did so. In this background, the inference of the accused being guilty of rash and negligent act was drawn against him.

So, the principle which emerges is that a doctor who administers medicine known to or used in a particular branch of medical profession impliedly declares that he has knowledge of that branch of science and if he does not, in fact, possess that knowledge, he is prima facie acting with rashness or negligence.
Dr. Laxman Balkrishna Joshi v. Dr. Trimbak Bapu Godbole and Anr. [9] The Court held that a person who holds himself out ready to give medical advice and treatment impliedly undertakes that he is possessed of skill and knowledge for that purpose. Such a person when consulted by a patient owes him certain duties, viz., a duty of care in deciding whether to undertake the case, a duty of care in deciding what treatment to be given or a duty of care in the administration of that treatment. A breach of any of those duties gives a right of action for negligence to the patient.

Indian Medical Association v. V.P. Shantha and Ors. [10] is a three-Judge Bench decision. The principal issue which arose for decision by the Court was whether a medical practitioner renders 'service' and can be proceeded against for 'deficiency in service' before a forum under the Consumer Protection Act, 1986. the court held that professional men should possess a certain minimum degree of competence and that they should exercise reasonable care in the discharge of their duties. In general, a professional man owes to his client a duty in tort as well as in contract to exercise reasonable care in giving advice or performing services.

In Poonam Verma v. Ashwin Patel and Ors [11]a doctor registered as medical practitioner and entitled to practice in Homoeopathy only, prescribed an allopathic medicine to the patient. The patient died. The doctor was held to be negligent and liable to compensate the wife of the deceased, since he trespassed into a prohibited field and prescribed the allopathic medicine to the patient causing the death, his conduct amounted to negligence per se actionable in civil law.

In Achutrao Haribhau Khodwa and Ors. v. State of Maharashtra and Ors.[12] The Court noticed that in the very nature of medical profession, skills differs from doctor to doctor and more than one alternative course of treatment are available, all admissible

In State of Harvana and Ors. v. Smt. Santra,[13] Bolam's test has been approved. This case too refers to liability for compensation under civil law for failure of sterilization operation performed by a surgeon.

Jacob Mathew v. State of Punjab and Anr[14].It was not the case of the complainant that the accused was not a doctor qualified to treat the patient whom he agreed to treat. It is a case of non-availability of oxygen cylinder either because of the hospital having failed to keep available a gas cylinder or because of the gas cylinder being found empty. Then, probably the hospital may be liable in civil law but the accused cannot be proceeded against under Section 304A IPC on the parameters of Bolam's test.

Opinion of Supreme Court in context of Constitution

The judgment of the Supreme Court in Nilbati Behra State of Orissa [15] case holds that in view of the fundamental right to life (Article 21 of the Constitution) [16] the Government cannot claim "sovereign immunity" for liability for the negligence of its employees.

The right to health and health care is protected under Article 21 of the Constitution of India, as a right to life and reach of which can move the Supreme Court on High Court through writ petition. Practice of medicine is capable of rendering great service to the society provided due care, sincerity, efficiency and skill are observed by doctors. When doctors peformed their duties towards the patient negligently in a Government hospital, the servants of the state violated the fundamental right of the patient, guaranteed under Article 21 of the Constitution.

Medical profession has its own ethical parameters and code of conduct. 'Services' of medical establishments are more of purchasable commodities and the 'business' altitude has given an impetus to more and more malpractices and instances of neglect. But the question is, whether, on the whole, branding the entire medical community as a delinquent community would serve any purpose or will it cause damage to the patients. The answer is, no doubt, the later. It is not that measures to check such dereliction are absent. Victims of medical negligence, considering action against an erring doctor, have three options.

a. Compensatory mode - Seek financial compensation before the Consumer Disputes Redressal Forum or before Civil Courts,
b. Punitive/Deterrent mode - Lodge a criminal complaint against the doctor,
c. Corrective/ Deterrent mode - Complaint to the State Medical Council demanding that the doctor's license be revoked.
Jurisdiction of Civil Court was never disputed but its scope was limited for damages only.

Conclusion
In the recent times, professions are developing a tenancy to forget that the self-regulation which Is at the heart of their profession is a privilege and not a right and a profession obtains this privilege In return for an implicit contract with society to provide good competent and accountable service to the public. The self-regulator standards in the profession have shown a decline and this can be attributed to the overwhelming Impact of commercialization of the sector. There are reports against doctors of exploitative medical practices, misuse of diagnostic procedures, brokering deals for sale of human organs, etc. It cannot be denied that black sheep have entered the profession and that the profession has been unable to isolate them effectively. Two basic propositions laid down in law regarding liability for negligence are: firstly, "Breach of Duty" to care and secondly, standard of care, i.e. the practitioner must bring to his task a reasonable degree of skill, knowledge and exercise a reasonable degree of care with caution. Supreme Court has made necessary guidelines for protection in order to secure life and health of individuals.

End-Notes
[1] 1977 (2) SCC 441
[2] AIR 1996 SC 550
[3]2000 (3) SCC 520
[4] [1957] 1 W.L.R. 582, 586
[5] (1980) 1 SCC 30
[6] (1965) 2 SCR 622
[7] (1970) 3 SCC 904
[8] (1965) 1 SCR 14
[9] (1969) 1 SCR 206
[10] (1995) 6 SCC 651
[11](1996) 4 SCC 332
[12](1996) 2 SCC 634
[13] (2000) 5 SCC 182
[14]AIR 2005 SC 3180
[15] AIR 1993 SC 1960
[16] Right to life and personal liberty

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