Medical negligence under pressure: obligations of clinicians and healthcare services in the setting of resource limitations.

Healthcare provision takes place in a variety of contexts, with variations of resources available to practitioners and their patients. Effects from the COVID-19 pandemic superimposed on existing system demands have driven increasing concern about resource limitations, particularly in rural and remote settings. This article explores the legal liability of medical practitioners and healthcare services with respect to actions in negligence arising from harm to patients suffered, either partly or wholly, as a result of resource limitations.

[Legal aspects in digital cardiology]. / Rechtliche Aspekte in der digitalen Kardiologie.

Digital assistants have become an indispensable tool in modern cardiology. The associated technological progress offers a significant potential to increase the efficiency of medical processes, enable more precise diagnoses in a shorter time, and thus improve patient care. However, the integration of digital assistants into clinical cardiology also raises new challenges and questions, particularly regarding the handling of legal issues. This review article aims to raise awareness of individual legal issues resulting from the use of digital technologies in cardiology. The focus is on how to deal with various legal challenges that cardiologists face, including issues related to treatment freedom, professional confidentiality and data protection. The integration of digital assistants in cardiology leads to a noticeable improvement in efficiency and quality of patient care, but at the same time, it involves a variety of legal challenges that need to be carefully addressed.

Should obstetric mortality be an inalienable right?

BACKGROUND: Obstetricians often times find themselves in a conflict of right and duty with their patients, when these patients refuse recommended treatment. On the one hand, the obstetrician, aiming to fulfil the duty of care, recommends a treatment in the best interest of the woman. The woman, on the other hand, exercising her right of self-determination and autonomy, declines the recommended treatment. MATERIALS AND METHODS: A search was conducted for literature, articles and case reports on the subject on PubMed/MEDLINE and Google Scholar using the keywords: medical ethics, medical law, obstetric mortality, maternal medicine, foetal medicine, patient autonomy, informed consent, right to life and right to liberty. RESULTS: Opinions have historically differed on whether maternal or foetal rights should be deferred to in situations where pregnant women refuse obstetric interventions. So also have legal decisions on the issue. The general consensus is, however, to respect a woman's refusal of recommended medical treatment, in deference to her right of self-determination and autonomy. The obstetric outcomes in such instances are however, often times, unfavourable. CONCLUSION: The ethics of patient care in the face of conflicting rights deserves renewed examination and discourse.

International Standards and Features of Financing in the Field of Health Care and Provision of Medical Services.

The relevance of this article is due to the fact that international standards in the field of health care and medical services are central to the field of world principles of functioning and development of medical law. The aim of the article is to conduct research on the peculiarities of international standards in the field of health care and medical services, as well as to study the prospects of their implementation in Ukraine. Leading research methods are general and special research methods, including methods of logic, analysis, comparison. The results of this study are to outline recommendations for the use of international standards in the field of health care and medical services in Ukraine and to summarize the legal framework on this issue. The significance of the results is reflected in the fact that this study can serve as a basis for outlining future changes in current legislation of Ukraine on the functioning of the health care system and implementation of world practices in health care. Within the framework of this study, systematized the main international and European documents that reflect the main international standards in the field of health care and medical services and ratified in Ukraine and have a direct impact on the legal framework for this area.

[Medical and legal aspects of the responsibility of medical workers in cases of improper provision of medical care].

The article considers the concept of medical incidents of «improper provision of medical care¼, implying the action or inaction of a medical worker who violates the procedure for providing medical care established by regulatory legal acts and standards. The relevance of the study of issues related to the medical and legal norms of holding medical workers accountable when medical care is of inadequate quality is due to the importance of understanding offenses in the medical field and assessing the responsibility of medical workers, who act as criteria for the presence of problems in the medical field and the impetus for reforming the health system.

Exploring defensive medicine: examples, underlying and contextual factors, and potential strategies - a qualitative study.

BACKGROUND: Medical errors, unsatisfactory outcomes, or treatment complications often prompt patient complaints about healthcare providers. In response, physicians may adopt defensive practices to mitigate objections, avoid complaints, and navigate lengthy trial processes or other potential threats. However, such defensive medicine (DM) practices can carry risks, including potential harm to patients and the imposition of unnecessary costs on both patients and the healthcare system. Moreover, these practices may run counter to accepted ethical standards in medicine. METHODS: This qualitative study involved conducting semi-structured interviews with 43 physicians, among whom 38 were faculty members at medical universities, 42 had administrative experience at various levels of the health system, and 23 had previously served as health system policymakers. On average, the participants had approximately 23.5 years of clinical experience. The selection of participants was based on purposive sampling. Data collection through interviews continued until data saturation was achieved. RESULTS: Based on the findings, DM manifests in both positive and negative forms, illustrated by instances like ordering unnecessary lab tests, imaging, or consultations, reluctance to admit high-risk patients, and avoiding high-risk procedures. The study participants identified a range of underlying and contextual factors contributing to DM, encompassing organizational-managerial, social, personal, and factors inherent to the nature of defensive medical practices. The results also highlight proposed strategies to address and prevent DM, which can be grouped into organizational-managerial, social, and those focused on modifying the medical complaints management system. CONCLUSION: DM is a multifaceted and significant phenomenon that necessitates a comprehensive understanding of its various aspects, including interconnected and complex structures and underlying and contextual factors. While the results of this study offer a solid foundation for informing policy decisions within the healthcare system and include some explanatory policy suggestions, we encourage policymakers to complement the findings of this study with other available evidence to address any potential limitations and to gain a more comprehensive understanding of the policymaking process related to DM.

The conundrums of the reasonable patient standard in English medical law.

BACKGROUND: In its 2015 decision in Montgomery v. Lanarkshire Health Board, the Supreme Court of the United Kingdom overruled the long-standing, paternalistic prudent doctor standard of care in favour of a new reasonable patient standard which obligates doctors to make their patients aware of all material risks of the recommended treatment and of any reasonable alternative treatment. This landmark judgment has been of interest to the rest of the common law world. A judicial trend of invoking Montgomery to impose more stringent requirements on doctors is discernible in subsequent decisions since then. MAIN BODY: In this narrative review, without questioning the idea that properly informed patients should play a more active role in procedures affecting their own health in furtherance of their autonomy, safety, and consumer rights, we identify and analyse, with the aid of realistic clinical thought experiments, three practical conundrums that the Montgomery standard may inflict on the daily work of doctors, unfairly exposing them to arbitrary legal risks. CONCLUSIONS: These conundrums pertain to the ascertainment of the risks that must be disclosed to the patient under the test of 'materiality'; the legal uncertainty as to the scope of the exceptions; and the actual ability of doctors to cope with the pressures of time. These conundrums offer ripe opportunities to rethink the proper role of judicially developed medical law in modern health care practice.

Reply to reaction on 'Organ donation after euthanasia starting at home in a patient with multiple system atrophy - case report'.

We would like to respond to the comment we received from our colleagues on our case report about organ donation after euthanasia starting at home. We reply to their statements on medical and legal aspects, and provide more information on our view of informed consent.

Organ transplantation in Nepal: Ethical, legal, and practical issues.

In Nepal, live donor organ transplantation is only 14 years old with the first successful kidney transplant made in 2008 and a successful liver and bone marrow transplant made in 2016. However, transplantation of cadaveric cornea dates back to 1998. There are still no cases of animal-to-human organ transplantation in Nepal. There are stringent laws to regulate human body organ transplantation in Nepal which are amended from time to time. However, there is a racket of human traffickers who lure rural people from this low-income country into the illegal organ trade. Furthermore, there is a substantial lack of awareness of organ donation among the general public. This article focuses on the stipulations of ethical, legal, and practical issues of obtaining organs procured from living and brain-dead donors that support the process of transplantation in Nepal. In addition, the article also explores the legal and practical issues of organ trafficking and organ donation awareness in Nepal on the basis of factual data and findings from other studies.

#WeAreNotWaiting DIY artificial pancreas systems and challenges for the law.

Commercial hybrid closed-loop systems are becoming more readily available, yet the number of DIY artificial pancreas system (DIY APS) users continues to rise. These DIY systems have not gone through the usual regulatory approvals processes, and, thus, present a number of legal difficulties for a number of actors, including clinicians, parents who build DIY APS for their children, and users themselves. These issues have so far received insufficient attention. Due to the complex constellation of actors involved in both development of DIY APSs and in its deployment, it is not currently clear who, and to what extent, different parties might (successfully) be held liable if something goes wrong. Despite this uncertainty, unless and until clearer guidance is issued by relevant bodies, or a case appears before the courts which clarifies the situation, existing legal principles apply. In this article, we examine some of these to shed light on how the law would likely be applied if harm were to result from the use of a DIY APS.

Reforming DoLS: liberty protection safeguards.

From April 2022, current Deprivation of Liberty Safeguards (DoLS) will be replaced by Liberty Protection Safeguards (LPS). This review article outlines key information about these changes for patients, carers and healthcare professionals, for whom a deprivation of liberty may be relevant.Deprivation of liberty occurs within healthcare settings when someone's freedoms are limited in order to meet their care needs and lack capacity to consent to these arrangements. DoLS, enacted in 2009, ensured that patients deprived of liberties in care settings have similar rights to patients held under the Mental Health Act 1983. However, DoLS have been extensively criticised and considered unfit for purpose, therefore are being replaced by LPS.LPS intend to provide a more robust protection to a wider group of vulnerable people. This includes changes to patient age, transferability between a wider range of care settings, a reduced number of assessments for authorisation and less frequent reauthorisations.

Sociodemographic characteristics associated with a higher wish to complain about health care.

OBJECTIVES: Previous research has shown that patients who are older, less educated, or have lower income are less likely to lodge complaints about health care. This variation may reflect less wish to complain or inequitable access to complaint channels or remedies. We aimed to investigate associations between sociodemographic characteristics and health users' wish to complain. STUDY DESIGN: This was a randomized case vignette survey among 6756 Danish men aged 45-70 years (30% response rate). METHODS: Assuming they received the care in vignettes about prostate cancer (prostate-specific antigen) testing, participants rated their wish to complain on a 5-point Likert scale. Information on sociodemographic characteristics was obtained through self-reports and municipality-level information from national registries. RESULTS: Lower education was associated with an increased wish to complain (mean Likert difference 0.44 [95% CI 0.36-0.51]; P < .001). The wish to complain was higher among unemployed men (difference 0.16 [95% CI 0.04-0.28]; P < .011) and those with a chronic illness (difference 0.06 [95% CI 0.02-0.10]; P < .004). Given the same healthcare scenarios, there was no difference in wish to complain among health users who were retired, living rurally, or from lower income groups. CONCLUSIONS: Health users who are less educated, lower income, elderly, or from rural or minority communities appear to be as likely, or more likely, to wish to complain about health care as others. Yet, younger, well-educated, and higher income citizens are overrepresented in actual complaint statistics. The finding suggests persisting inequalities in the suitability or accessibility of complaint processes for some groups of patients.

Developing an innovative medical ethics and law curriculum-constructing a situation-based, interdisciplinary, court-based learning course: a mixed methods study.

BACKGROUND: Traditional lecture-based medical ethics and law courses deliver knowledge but may not improve students' learning motivation. To bridge this theory-to-practice gap and facilitate students' learning effectiveness, we applied situated-learning theory to design an interdisciplinary court-based learning (CBL) component within the curriculum. Our study aimed to investigate students' learning feedbacks and propose a creative course design. METHODS: A total of 135 fourth-year medical students participated in this course. The CBL component included 1 h of introduction, 1 h of court attendance, and 2 h of interdisciplinary discussion with senior physicians, judges, and prosecutors. After the class, we conducted a survey using a mixed-methods approach to gauge students' perceptions of engagement, performance, and satisfaction. RESULTS: A total of 97 questionnaires were received (72% response rate). Over 70% of respondents were satisfied and felt that the class was useful except for role-playing activities (60%). More than 60% reported a better understanding of the practical applications of medical law. Approximately half (54%) reported less anxiety about medical disputes. 73% reported that the lecture provided awareness of potential medical disputes, and most respondents expressed an interest in medical law courses after the court visit (78%). 80% of the respondents were able to display empathy and apply mediation skills. Qualitative analyses showed that students demonstrated new knowledge, including recognizing the significance of the medical profession, distinguishing the importance of physician-patient communication, having confidence in the fairness of the justice system, and being willing to increase their legal knowledge. CONCLUSIONS: CBL curriculum increases students' learning motivation in strengthening medical professionalism and medical law, develops students' empathy for patients and communication skills, as well as builds up students' trust in the justice system. This novel course design can be applied to teach medical ethics and law.

Assisted Deaths Prior to the Voluntary Assisted Dying Act 2017 (Vic): Would Patients Have Met the Eligibility Criteria to Request Voluntary Assisted Dying?

Unlawful assisted dying practices have been reported in Australia for decades. Voluntary assisted dying (VAD) is now lawful in Victoria and Western Australia in limited circumstances and will soon be lawful in a further four Australian States. This article examines nine cases involving unlawful assisted dying practices in Victoria in the 12 months prior to the commencement of the Voluntary Assisted Dying Act 2017 (Vic) in 2019. It explores whether, if that Act had been in operation at the relevant time, these patients would have been eligible to request VAD, having regard to their decision-making capacity and their disease, illness or medical condition. Many of these patients would not have been eligible to request VAD had the legislation been operational, primarily because they lacked decision-making capacity. As VAD is lawful only in a narrow set of circumstances, unlawful assisted deaths may continue to occur in those States where voluntary assisted dying is legal.

The Intersection of Law and Medicine in Full Skin Examination in Screening for Cutaneous Malignancy.

Full skin examination (FSE) is a vital practice in the diagnosis of cutaneous malignancy. Precisely what the FSE entails, however, with respect to concealed site examination (CSE), in particular sensitive sites including the anogenital region, breasts, scalp and oral mucosa, remains poorly elucidated. While the incidence of skin cancer at these sites is low, it carries a poor prognosis. A standardised approach is proposed to FSE with respect to inclusion of CSE to provide: an optimised and uniform approach to patient care, guidance to clinicians performing FSE routinely, and in doing so to protect them medico legally. This article analyses the medico-legal issues pertinent to this issue.

Mapping the Legal Regulation of Voluntary Assisted Dying in Victoria: The Coherence of a New Practice within the Wider Legal System.

This article undertakes the first comprehensive mapping exercise of the legal regulation of voluntary assisted dying (VAD) in Victoria. Despite the detailed nature of the Voluntary Assisted Dying Act 2017 (Vic), this analysis reveals that VAD is also regulated by a diverse array of other law: a further 20 pieces of legislation and 27 broad areas of law. In some instances, this legal regulation beyond the principal VAD legislation is significant for how the VAD system operates in practice. The article then identifies the implications of this mapping exercise for the coherence of the law, focusing in particular on the domains of consistency, comprehensiveness, and completeness. Findings include identifying areas of significant incoherence and the implications of this for law reformers, policymakers, and users of the law, including patients, families, health practitioners, and health service providers.

Medical Error Litigation in Nigeria: A Proposal for Change.

Negligence actions are the most important and dynamic of all torts because they are the principal means of compensating victims of accidents, including medical errors. Unfortunately, victims of medical error in Nigeria have not historically been able to enjoy the relief available through negligence suits. This article explores the Nigerian legal and regulatory framework for addressing medical errors and offers suggestions that could help improve such medical error response.

Fetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study.

OBJECTIVE: To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time. DESIGN: Qualitative study. SETTING: Fetal medicine units in the Republic of Ireland. POPULATION: Ten fetal medicine specialists from five of the six fetal medicine units. METHODS: nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews. MAIN OUTCOME MEASURES: Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA. RESULTS: Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'. CONCLUSIONS: Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service. TWEETABLE ABSTRACT: The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.

Intentional hastening of death through medication: a case series analysis of Victorian deaths prior to the Voluntary Assisted Dying Act 2017.

BACKGROUND: Voluntary assisted dying is lawful in Victoria in limited circumstances and commences in Western Australia in mid-2021. There is evidence that in rare cases, unlawful assisted dying practices occur in Australia. AIMS: To determine whether assisted dying practices occurred in Victoria in the 12 months prior to the commencement of the Voluntary Assisted Dying Act 2017 (Vic) ('VAD Act'), and to examine features of any identified cases. METHODS: Exploratory case series of adult patients in Victoria who died between May 2018 and 18 June 2019 as a result of medication administered with the primary intention of hastening death. Cases were identified from a self-administered survey about medical end-of-life decisions for adult patients, completed by Victorian specialists treating adults at the end of life. We examined reported use of medication with the primary intention of hastening the patient's death; characteristics of assisted dying cases, including doctors' classification of such practices. RESULTS: Nine cases met the inclusion criteria. Death did not occur immediately after providing medication with the intention of hastening death. In eight cases, it was framed as palliative or terminal sedation and/or continuous deep sedation. Most doctors used language that distanced their practices from assisted dying. CONCLUSIONS: Unlawful assisted dying practices seem to have occurred in a small number of deaths in Victoria prior to commencement of the VAD Act. These practices typically occurred within the context of palliative or terminal sedation and may be difficult to distinguish from lawful palliative care practice. Some survey responses possibly reflect ambiguity in doctors' intentions when providing medication.

Junior doctors and fitness to practice procedures in the UK: analysis of factors prompting tribunal referrals and outcomes.

PURPOSE OF THE STUDY: To ascertain factors influencing referral to, and outcomes from medical tribunals for junior doctors with less than 7 years of postgraduate training. STUDY DESIGN: A mixed methods analysis of 49 publicly available determinations from the UK Medical Practitioner Tribunal Service (MPTS) between 2014 and 2020 was undertaken. Data on demographics, training grade, type of case and outcomes from the tribunal were recorded. A qualitative thematic analysis of the determinations was also undertaken, with themes being identified based on frequency and pertinence to the process of determination. RESULTS: The largest group of junior doctors referred to an MPTS tribunal (38%) was those on the foundation programme; in their first 2 years postgraduation. Fifty-three per cent of all junior doctors referred to a tribunal were erased from the medical register. Erasure from the register was significantly associated with male gender, less than 4 years postqualification, non-attendance at the tribunal hearing, lack of legal representation and lack of insight or remorse at the tribunal hearing. Several cases involved dishonesty in relation to academic achievements and workplace-based assessments. CONCLUSION: Consideration should be given as to how best to support the transition in professional identity from student to doctor. Teaching medical professionalism should be a priority in undergraduate and early postgraduate education, with lessons from fitness to practice tribunals shared for educational purposes.