Medical malpractice: Evolution of a standard of care
Medical malpractice is not a modern invention. Some historians trace malpractice to the Code of Hammurabi (2030 BC), through Roman law,4 into English common law.5 It was sufficiently established by 1765 that the classic legal treatise of the century referred to medical malpractice.6,7 Although medical malpractice existed for a long time, actual malpractice cases were relatively rare before the last half of the 20th century.8
Defensive medicine born out of necessity. The number of malpractice cases increased substantially—described as a “geometric increase”—after 1960, with a 300% rise between 1965 and 1970.7,9 This “malpractice maelstrom of the 70s”7 resulted in dramatic increases in malpractice insurance costs and invited the practice of defensive medicine—medically unnecessary or unjustified tests and services.10Although there is controversy about what is defensive medicine and what is reasonably cautious medicine, the practice may account for 3% of total health care spending.11 Mello and others have estimated that there may be a $55 billion annual cost related to the medical malpractice system.12
Several malpractice crises and waves of malpractice or tort reform ensued,13 beginning in the 1970s and extending into the 2000s.11 Malpractice law is primarily a matter of state law, so reform essentially has been at the state level—as we will see in the second part in this series.
Defining a standard of care
Medical malpractice is the application of standard legal principles to medical practice. Those principles generally are torts (intentional torts and negligence), and sometimes contracts.14 Eventually, medical malpractice came to focus primarily on negligence. The legal purposes of imposing negligence liability are compensation (to repay the plaintiff the costs of the harm caused by the defendant) and deterrence (to discourage careless conduct that can harm others.)
Negligence is essentially carelessness that falls below the acceptable standard of care. Negligence may arise, for example, from15:
- doing something (giving a drug to a patient with a known allergy to it)
- not doing something (failing to test for a possible tumor, as in the second case above)
- not giving appropriate informed consent
- failing to conduct an adequate examination
- abandoning a patient
- failing to refer a patient to a specialist (or conduct a consultation).
(In recent years, law reforms directed specifically at medical malpractice have somewhat separated medical malpractice from other tort law.)
In malpractice cases, the core question is whether the provider did (or did not) do something that a reasonably careful physician would have done. It is axiomatic that not all bad outcomes are negligent. Indeed, not all mistakes are negligent—only the mistakes that were unreasonable given all of the circumstances. In the first case above, for example, given all of the facts that preceded it, the delay of the physician for 4.5 hours after the fetal distress started was, as seen by the jury, not just a mistake but an unreasonable mistake. Hence, it was negligent. In the second case, the failure to investigate the pain and swelling in the surgical site for 2 years (or failure to refer the patient to another physician) was seen by the jury as an unreasonable mistake—one that would not have been made by a reasonably careful practitioner.
Continue to: The big verdict...