MEDICAL NEGLIGENCE LITIGATION IN MALAYSIA: CURRENT TREND AND PROPOSALS FOR REFORM
By Dr Puteri Nemie bt. Jahn Kassim Associate Professor Ahmad Ibrahim Kulliyyah of Laws International Islamic University Malaysia Tel: 03-61964229 Fax: 03-61964854 Email: puterinemie@hotmail.com / nemie@iiu.edu.my Address: Ahmad Ibrahim Kulliyyah of Laws, International Islamic University Malaysia, PO Box 10, 50728, Kuala Lumpur. 1.0 Introduction
Litigation has never been a haven for neither the doctor nor the patient. Although at present, Malaysia is not experiencing the kind of "malpractice crisis"1 as in the United States2, Australia3 and the United Kingdom4, there is certainly a rise in the number of negligence claims and the size of awards.5 These factors are sufficient to cause alarm for future implications and generate serious thoughts for reform of the present system. Rising number of medical negligence claims is not considered healthy for a country as it leads to a 1 A country is said to be experiencing "malpractice crisis" if the number of malpractice cases has risen dramatically in the last 10 to 15 years in terms of medical malpractice suits by the patients. Other symptoms include dramatic rise in medical malpractice insurance premiums, rise in the amount of courts' awards and settlements whether for economic or non-economic damages and greater availability of punitive damages. 2 Total payments for physicians' malpractice claims in the United States, more than doubled between 1991 to 2003, rising from US$2.12 billion in 1991 to US$4.45 billion in 2003. 3 In 2002, the main insurer for medical practitioners in Australia, United Medical Protection, collapsed under debts of over AUD$ 1 billion. 4 In the year 2001, the cost of claims against the National Health Service as estimated at nearly 4 billion pound sterling. 5 In the year 2000, the amount of compensation paid by the Malaysian government to medico-legal cases was RM219,508 whereas in the year 2001 was RM 430,502, whereas in 2002 was RM951,889. (Source: Medical Practice Division, Ministry of Health Malaysia) 1 reduction in the amount of money available for patient care. A single large award can distort the amount government or private hospitals can use to enhance healthcare. 2.0 The Tort System
Presently, the tort system is used to regulate medical negligence litigation in Malaysia. Generally, this system provides for compensation only when a doctor or any other medical personnel assisting in the treatment of a patient is negligent. The heart of negligence is the element of fault. However, it can be seen that fault is not a satisfactory criterion for liability due to difficulties of adjudicating on it. Litigation demanding proof of fault is notoriously protracted and complex, particularly, where the behaviour being challenged is that of a professional. Fault-based analysis is not and never was designed to cover the more common cause of personal injury namely accident. The rationale for fault-based analysis that a person that causes harm should pay for its consequences is a myth as personal attribution of fault has little relevance to contemporary life. Most professionals and companies are adequately covered by insurance type schemes and not personally made to pay more than the monthly or annual subscription to them. Award of compensation is to put the person back into the situation he or she would have been but for the fault. However, this would again be unlikely since the compensation awarded is inevitably financial. 3.0 Problems with the Tort System
3.1 Adversarial in nature The tort system, being adversarial in nature requires the litigating parties to determine the subject matter of the controversy between them and supply the court with the evidence on 2 which they wish the court to decide. The task of the court is to do justice based on the available evidence and the law. In reality, it sometimes happens that litigation fails to achieve real justice between the opposing parties as a result of inherent weaknesses in the adversarial system and practical disadvantages, which obstruct the proper functioning of such a system. These weaknesses are equally applicable to medical negligence litigation in much the same way as other types of litigation, which include issues of judicial impartiality and competencies, disadvantages of the tactical manoeuvring, partisanship and unreliability of witnesses and the unfairness that can result in such hearings when there is inequality of legal representation. 3.2 The lengthy period in pursuing a claim The tort compensation system has been known to be cost-inefficient. Administrative costs are high due to the nature of the two principal criteria for compensation, namely, case-bycase determinations of fault and lump sum findings of damages under indeterminate guidelines. The main contributor to the costliness of the tort system is the delay involved in the pursuit of a claim. Delay may occur at different stages in the litigation process and for various reasons. In medical negligence cases, delay occurs for instance, before the plaintiff seeks legal advice, while waiting for information from the opposing side, while the parties wait for experts to investigate and produce their report, while the parties seek and exchange documentary evidence and while waiting for the trial date. These delays clearly contribute to the length of time required for the case to be settled. For instance, in the case of Dr Chin Yoon Hiap v Ng Eu Khoon & Ors and other appeals6, litigation was initiated on 6 [1998] 1 MLJ 57. 3 23 December 1981 whereas the judgment was delivered on 7 November 1997. Altogether, the case took about 16 years to conclude. If the time considered was when the cause of action accrued, that is, 7 January 1976, then the duration would be 21 years. Further, in Foo Fio Na v Hospital Assunta & Anor7, the cause of action accrued on 19 July 1982 whereas judgment by the High Court was given on 8 October 19998 whereas the decision of the Court of Appeal9 was given on the 5th of April 2001. An application for leave to appeal to Federal Court against the decision of the Court of Appeal in Dr Soo Fook Mun v Foo Fio Na & Anor10 was made in November 200111 and the Federal Court finally delivered its judgment on the 29th December 2006, after a delay of over four and a half years from when the application for leave to appeal was made. Thus, the total number of years the case took to conclude from the High Court to the Federal Court was 24 years. It can be seen that the entire litigation process for medical negligence case requires an average of about a minimum period of 15 years, from date of injury to the conclusion of the case. 3.3 Effect of a Medical Negligence Claim on the Defendant Doctor Doctors not only fear of losing a lawsuit but the lawsuit itself. If the injured patient files a complaint against the doctor, this already has a detrimental effect on the doctor's reputation and practice even if the matter does not go to trial. This is due to the fact that the publicity which a claim entails is sufficient to cause a loss of reputation which might have
7 8 [1999] 6 MLJ 738. An application for leave to appeal to Federal Court against the decision of the Court of Appeal in Dr Soo Fook Mun v Foo Fio Na & Anor [2001] 2 CLJ 457. The Federal Court delivered its judgment on the 29th December 2006, after a delay of over four and a half years. 9 The judgment can be found in Dr Soo Fook Mun v Foo Fio Na & Anor [2001] 2 CLJ 457. 10 Ibid. 11 This can be found in Foo Fio Na v Dr Soo Fook Mun & Anor [2002] 2 MLJ 129. 4 adverse effects on their practice regardless of whether the doctor wins in court or not. Furthermore, by bringing legal action, the patient assaults the doctor's credibility, insinuating faulty judgment and treatment. Self esteem and status as a successful practitioner may suddenly be jeopardized overnight. In a way, a malpractice suit challenges professional reliability and authority. Such development may not only cause the adoption of defensive medicine but also deter doctors from opting for high-risk specialties. The threat of litigation also subtly changes doctors' relationships with all patients, not just those who initiate claims against them. This is because the threat of malpractice compels the doctor to view his patient as a future adversary in a courtroom proceeding. Even if the negligence claims is settled out of court, there is still an effect on the doctors as settlements out of court leave them with no chance of vindicating themselves. At the end of the day, they still feel that there is a cloud hanging over their head. 3.4 Rise in medical insurance premium rates Frequency of medical malpractice suits and the amount of awards against doctors can lead to sharp increases in the cost of doctor's liability insurance as has occurred in the United States, Australia and the United Kingdom. Significant increases in subscriptions paid by doctors to the medical defence organisations can have an impact on the patients in the form of increased fees. Ultimately, this may raise the cost of medical attention. 3.5 Defensive medicine As the pendulum swung towards the plaintiffs in malpractice suits, many doctors have adopted the practice of "defensive medicine". Thus, the litigation system can be said to 5 have the tendency to develop defensive and confrontational attitudes. In Whitehouse v Jordan12, Lawton J. said that defensive medicine consists of "adopting procedures which are not for the benefit of the patient but safeguards against the possibility of the patient making a claim of negligence."13 Defensive medicine can be considered to be positive as well as negative. Positive defensive medicine involves undertaking extra procedures to eliminate any risk inherent in a treatment. For instance, the doctor may subject the patient to additional tests, which in his professional judgment is clinically unnecessary but necessary to ensure that nothing goes wrong. This procedure is considered to be a waste of time and resources and subjects the patient to unnecessary medical intervention. Negative defensive medicine, on the other hand, deprives the patient of treatments that are beneficial to his health as there are some risks attached to the treatment. For instance, a doctor may refuse to carry out a treatment as the risks inherent in the treatment is rather high and therefore, the risk of malpractice litigation if things go wrong is likely to be high too. 3.6 Accountability Besides their need for compensation, injured victims have also other needs, which the tort system fails to cater. Most medically injured victims are also concerned about obtaining an explanation of why their injury occurred or an apology from the responsible doctor. Furthermore, these victims also place importance on making sure that the mishap does not occur again in the future. A tort action, however, has a limited role as an official and public 12 13 [1980] 1 All ER 650. Ibid., at p. 659. 6 forum in which the defendant's conduct is examined. Moreover, the "real" defendant in a tort action is usually an insurance company any rather than the professional himself. 3.7 Deterrence The current tort system is ineffective as a deterrent against medical incompetence or malpractice. According to Brazier14, the reason for this ineffectiveness is because an action in negligence focuses on a single incident. As a result, a competent surgeon in a high-risk specialty who makes an unlucky error may be penalised whereas a much less competent doctor in a lower risk specialty will continue to practise unchecked by the courts. 15 The adversarial nature of court proceedings also precludes any proper investigation, either of the incident in question or the practice, which has resulted in the error.16 Moreover, the amount of damages paid under the existing system is related to the severity of the consequences and not the degree of negligence. This means that a trivial act that has resulted in serious injury will receive larger compensation. For instance, compensation payment for death is generally lower than that of a long impaired life as the amount is related not only to loss of earnings but also the pain and suffering and costs of care. Thus, it seems unfair that the existing system allows a high degree of deterrence for causing expensive injuries but a low degree of deterrence for causing death. 3.8 Compensation Medical accountability has often been eclipsed by discussion of compensation. The adversarial litigation systems has been said to be unhelpful both to the patients and doctors.
14 Brazier, M., "Compensation, Competence and Culpability: The Case for a No-Fault Scheme" (Spring 1988) Journal of Medical Defence Union 8, at p. 9. 15 Ibid. 16 Id. 7 Compensation via negligence is unsatisfactory. In England, the report by the Royal Commission on Civil Liability and Compensation for Personal Injury stated that "[t]he proportion of successful claims for damages in tort is much lower for medical negligence than for all negligence cases..."17 To assess the present system of compensation, there has to be adequate understanding of the legal requisites of a valid claim and the legal processes involved in bringing an action. As compensation depends upon a successful negligence action, the present system leaves many victims uncompensated for injuries. This is due to the fact that the present system is shaped in such a way that only those that are capable of demonstrating medical negligence can gain monetary compensation. The ones that cannot, will walk away empty-handed. Thus, a situation may exist in which there are two individuals with two identical bad results from their medical treatment but who are treated differently in terms of legal remedy. Such result is clearly at odds with common contemporary notions of fairness. The inequity arising from one individual being denied compensation while another with identical injuries obtains recompense has created an impetus for the courts to find ways of compensating medical accidents. 3.9 The Substantive Law The tort system is criticised because the plaintiff bears the burden of proving all components of the medical negligence claim. To prove that the doctor had positively breached a standard of care owed in the circumstances to the patient is peculiarly onerous for the plaintiff due to the existence of the Bolam principle. The fact that the plaintiff has the burden to prove that the defendant had strayed from the recognized standard of care in 17 Royal Commission on Civil Liability and Personal Injury, London : HMSO, Vol. 1, Cmnd. 7054, 1978, at paragraph 1337. 8 the profession imposes upon the plaintiff the burden of establishing first what the professional standard of care is in any given case and then the fact the defendant has departed from it. Generally the only acceptable manner of proof of the standard of care is another doctor's testimony. This often posed an insurmountable obstacle to the victim who routinely has to face the unwillingness of one doctor to provide evidence, which might impose liability on another colleague. What aptly has been dubbed as "conspiracy of silence"18 has effectively prevented numerous medical accidents from prevailing at trial and deterred others from instituting litigation. 4.0 RECENT TREND - The Decline of Judicial Deference to Medical Opinion
Nevertheless, in recent years, the Bolam principle has been subjected to much discussion, not only in the Australian jurisdiction but in its country of origin as well. The problem with the Bolam principle is not with the principle itself, but its interpretation and application by courts. Since it was introduced nearly fifty years ago, the Bolam principle had undergone various phases of recognition19, condemnation20 and re-interpretation.21 For the medical 18 The Supreme Court of California in Salgo v Leland Stanford Jr. Univ. Bd of Trustees 317 P 2d 1093 (1960) commented: "Gradually the courts awoke to the so-called "conspiracy of silence". No matter how lacking in skill or how negligent the medical man might be, it was almost impossible to get other medical men to testify adversely to him in litigation based on his alleged negligence. Not only would the guilty person thereby escape from civil liability from the wrong he had done, but his professional colleagues would take no steps to insure that the same results would not again occur at his hands." 19 The principle has not only been applied to determine the standard of care in cases of medical negligence but to most cases of professional negligence. 20 The principle has been criticised as being over protective of the medical profession and allowing the standard of care of doctors to be a matter of medical judgment. 21 The English courts through cases such as Bolitho v City & Hackney Health Authority [1997] 4 All ER 771 and Penny, Palmer and Cannon v East Kent Health Authority [2000] Lloyd's Law Report (Medical) 41, tried to restore the principle to its proper limits and correct the misinterpretation as what was originally intended by McNair J. in Bolam v Friern Hospital Management Committee [1957] 1 WLR 582. 9 profession, the Bolam principle has been viewed as no more than simple justice that they, like other professionals, to be judged by their own peers. For the patients, the existence of the Bolam principle hinders them from getting justice and the fair trial that they deserve. 4.1 The Bolam principle
It is undeniable that the Bolam principle22 has acted as a gatekeeper to the number of claims against medical practitioners as according to this principle, a doctor is not negligent if he has acted with a practice accepted as proper by a responsible body of medical men skilled in that particular art. It is immaterial that there exists another body of opinion that would not have adopted the approach taken by the doctor in question. As long as there exists a "responsible body of medical opinion" that approves of the actions of the doctor, then the doctor escapes liability. The existence of the Bolam principle had clearly made it difficult for plaintiff to prove that the doctor had positively breached a standard of care owed in the circumstances. This is due to the fact that the Bolam principle has been routinely interpreted by the courts as laying down a principle whereby a court cannot find a defendant negligent as long as there is a common practice or custom that supports the defendant's actions. The "custom test" has been purely descriptive, based on what is
22 When McNair J. delivered his judgment in Bolam v Friern Hospital Management Committee (supra), little did he know that part of his judgment would become an integral part of the medical litigation revolution. In his judgment, McNair J. formulated a test, that later become known as the Bolam principle or the Bolam test, to determine whether the doctor's act fell below the required standard of care: "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.... in the case of a medical man, negligence means failure to act in accordance with the standards of reasonably competent medical men at the time.... I myself would prefer to put it this way, that he is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. .... Putting it the other way round, a man is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion who would take a contrary view. " 10 customarily done by the medical practitioners, rather than what ought to be done by the medical practitioners. 4.2 Background of the Bolam principle
In order to understand the Bolam principle, a short analysis of several cases occurring before the advent of Bolam need to be illustrated to understand further the reasons for excessive judicial deference to medical opinion. It can be seen that even before the establishment of the Bolam principle, the courts found it difficult to set a standard for the medical profession and majority of them opined that such matter should be left to medical judgments. In Mahon v Osborne23, the Court of Appeal held that the standard of care is to be measured by expert evidence. Lord Justice Goddard stated that: "I would not for a moment attempt to define in vacuo the extent of a surgeon's duty in an operation beyond saying that he must use reasonable care, nor can I imagine anything more disastrous to the community than to leave it to a jury or to a judge, if sitting alone, to lay down what is proper to do in any particular case without the guidance of witnesses who are qualified to speak on the subject.... As it is the task of the surgeon to put swabs in, so it is his task to take them out, and in that task he must use that degree of care which is reasonable in the circumstances and that must depend on the evidence."24 The passage reflects that medicine has always been shrouded with intricacies and technicalities, which may be beyond the comprehension of the judge and jury who have not undergone the rigours of medical training. To reach a just and accurate decision, the matter is best left in the hands of the medical experts who are more capable of analysing
23 24 [1939] 2 KB 14. Ibid., at p. 47. 11 such complex issues. In other words, the question of whether the doctor is in breach of his duty should be judged by his peers. In Roe v Minister for Health25, a passage from the judgment of Denning LJ provides a clue to the philosophy of the Bolam principle. His Lordship said that: "If the anaesthetists had foreseen that the ampoules might get cracked with cracks that could not be detected on inspection, they would no doubt have dyed the phenol a deep blue; and this would expose the contamination. But I do not think that their failure to foresee this was negligence. It is so easy to be wise after the event and to condemn as negligence that which is only a misadventure. We ought always to be on our guard against it, especially in cases against doctors and hospitals. Medical science has conferred great benefits on mankind, but these benefits are attended by considerable risks. Every surgical operation is attended by risks."26 The passage acknowledges that it is not proper to blame the doctor for everything that has gone wrong. Medicine is clearly an inexact science of which its outcome is rarely predictable. It would be a disservice to the community at large if liability were to be imposed on hospitals and doctors for everything that happens to go wrong. Doctors would be led to think more of their own safety than of the good of their patients. Initiative would be stifled and confidence shaken as it would encourage the practice of defensive medicine, which would ultimately not benefit the society as a whole. There must be a proper tool to gauge the standard of care of a doctor in determining his liability. Further in Hunter v Hanley27, Lord President Clyde stated that: "To succeed in an action based on negligence, whether against a doctor or anyone else, it is of course necessary to establish a breach of that duty to take care which the law requires, and the degree of want of care which constitutes negligence must vary
25 26 [1954] 2 QB 66. Ibid., at p. 83. 27 [1955] SLT 213, [1955] SC 200. 12 with circumstances ... But where the conduct of a doctor, or indeed of any professional man, is concerned, the circumstances are not so precise and clear cut as in the normal case. In the realm of diagnosis and treatment there is ample scope for genuine difference of opinion and one man clearly is not negligent merely because his conclusion differs from that of other professional men, nor because he has displayed less skill or knowledge than others would have shown. The true test for establishing negligence in diagnosis and treatment on the part of the doctor is whether he has been proved to be guilty of such failure as no doctor of ordinary skill would be guilty of acting with ordinary care." 28 4.3 Why the excessive judicial deference to medical opinion?
4.3.1 Reluctance in making findings of negligence against members of any honourable profession Generally, standards of behaviour within all professions were high. The reluctance was not confined to medical profession as they were understandably not comfortable in secondguessing the conduct and opinions of respected professionals practising in their field of expertise. 4.3.2 Difficulties in setting the standard, breach of duty to be judged by his peers. Judges have difficulties in dealing with cases shrouded with intricacies and technicalities, which may be beyond the comprehension of the judge who has not undergone the rigours of medical training. Medicine being an inexact science may at times produce outcomes that are not predictable. To reach a just and accurate decision, the matter is best left in the hands of the medical experts who are more capable of analysing such complex issues. Thus, the question of whether the doctor is in breach of his duty is to be judged by his peers. 28 [1955] SLT 213, at p. 217. 13 4.3.3 Presumption of beneficence From the time when the Hippocratic Oath was formulated, doctors are generally regarded as having a positive duty to do good, which includes active promotion of good, kindness and charity to help others further their legitimate interests by preventing or removing possible harms. The practice of medicine for quite some time gave rise to little controversy as the medical profession has been trusted to do what's best for their patients. 4.4 Reinterpretation of the Bolam principle: Bolitho v City & Hackney Health Authority
After much dissatisfaction on how the Bolam principle has developed in medical negligence litigation29, the principle was put under rigorous scrutiny in the case of Bolitho v City & Hackney Health Authority30. Lord Browne-Wilkinson delivering judgment in the House of Lords in Bolitho held that the court is not bound to hold that a defendant doctor escapes liability for negligent treatment or diagnosis just because he leads evidence from a number of medical experts who are genuinely of opinion that the defendant's treatment and diagnosis accorded with sound medical practice. His Lordship held that the word "responsible" used by McNair J. in Bolam "show[s] that the court has to be satisfied that the exponents of the body of opinion relied on can demonstrate that such opinion has a logical basis."31 This means that merely by showing that the defendant's action was supported by expert medical opinion will not automatically exculpate him. The expert medical opinion in question has to have a sufficient logical basis. Lord Browne-Wilkinson
29 The judgment of Sachs LJ in the case of Hucks v Cole [1993] 4 Med LR 393 was very influential in bringing about the change in attitude by the English judiciary of delegating the determination of doctor's liability to the medical profession. Hucks adopted a pragmatic approach to this issue and held that it was appropriate for the judge to reject medical expert evidence if it does not really stand up to analysis. 30 [1997] 4 All ER 771. 31 Ibid. at p. 778. 14 then went on to explain that before a judge can accept a body of opinion as being "responsible", the judge will have to be satisfied that "...in forming their views, the experts have directed their minds to the question of comparative risks and benefits and have reached a defensible conclusion on the matter."32 Thus, a "responsible" view presupposes that the experts in forming their opinions have weighed the relative risks and benefits. His Lordship further held that "if it can be demonstrated that the expert medical opinion is not capable of withstanding logical analysis, the judge is entitled to hold that the body of opinion is not responsible."33 Thus, this would mean that even though there exists a body of professional opinion sanctioning the defendant's conduct, the defendant can still be held negligent if it cannot be demonstrated to the judge's satisfaction that the opinion relied on is reasonable or responsible. 4.5 Burying Bolam Down Under
The Australian judiciary has been quite determined in ensuring that expert evidence is subjected to close judicial scrutiny as stated by King C.J in of F v R34 when he said that: "...professions may adopt unreasonable practices.... The court has an obligation to scrutinise professional practices to ensure that they accord with the standard of reasonableness imposed by the law.... The ultimate question, however, is not whether the defendant's conduct accords with the practices of his profession or some part of it, but whether it conforms to the standard of care demanded by the law. That is a question for the court and the duty of deciding it cannot be delegated to any profession or group in the community."35 This view was approved by the High Court of Australia in Rogers v Whitaker36, where it was accepted that the question of how much information to be departed by a doctor cannot
32 33 Id. Id. at p. 779. 34 (1982) 33 SASR 189. (S.C. of South Australia). 35 Ibid., at p. 194. 36 [1993] 4 Med LR 79, [1992] 175 CLR 479. 15 be determined by "any profession or group in the community"37 but it should be determined upon consideration of complex factors, namely, "the nature of the matter to be disclosed; the nature of the treatment; the desire of the patient for information; the temperament and health of the patient; and the general surrounding circumstances."38 Thus, the High Court felt that opinions of medical witnesses should not be decisive at this point. One consequence of the application of the Bolam principle to a case involving the provision of advice and information is that, "even if a patient asks a direct question about the possible risks or complications, the making of that inquiry would be logically be of little or no significance; medical opinion determines whether the risk should or should not be disclosed and the express desire of a particular patient for information or advice does not alter that opinion or the legal significance of that opinion."39 Thus, if the medical profession has already determined what risks should or should not be disclosed to the patient, it would be futile for the patient to ask questions about them. Clearly, the Bolam principle pays insufficient regard to questioning by the patient. The High Court further opined that the provision of information merely involves communication skills, which are not exclusive to medical practitioners and therefore, can be judged by non-medical people. The rationale behind the Bolam principle that expert matters can only be judged by expert opinion cannot be used to justify its application to determine doctor's duty of disclosure. In such context, the Bolam principle serves only to endorse poor communication between doctor and patient and to deprive patients of their ability to make meaningful choices about their treatment. In exceptional cases where the patient seems "unusually nervous, disturbed or volatile"40, then the doctor would be exercising clinical judgment in deciding whether to
37 38 (1982) 33 SASR 189, at p. 194. Ibid., at pp. 192 - 193. 39 [1992] 175 CLR 479, at pp. 486 - 487. 40 Ibid., at p. 490. 16 disclose or not. In such a case, the doctor does not need special skill to be able to disclose the risks but rather, communicating skill that will enable the patient to apprehend his situation. Whatever information the patient is given must be given in such a way that the information can be digested rationally. The High Court concluded that, with regard to negligence, the scope of a doctor's duty of disclosure is: "to warn a patient of a material risk inherent in the proposed treatment; a risk is material if, in the circumstances of a particular case, a reasonable person in the patient's position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that a particular patient, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it. This is subject to therapeutic privilege."41 The decision in Rogers emphasised that patients are entitled to make their own decisions about medical procedures and to be given sufficient information to make an informed choice. The High Court cautioned that the phrase "informed consent" commonly used by the American counterparts is "apt to mislead as it suggests a test of validity of the patient's consent.... [and] consent is relevant to actions framed in trespass, not in negligence." 42 The court further found that the expression "the right of self determination" is also unsuitable "to cases where the issue is whether a person has agreed to the general surgical procedure or treatment, but is of little assistance in the balancing process that is involved in the determination of whether there has been a breach of duty."43 In determining what information is "material" for a given patient, the needs of each patient must be taken into account. The doctor must consider all that he or she knows about the patient, in order to decide, in the light of those circumstances, what risks the patient would be likely to
41 [1992] 175 CLR, at p. 490. Ibid. Id. 42 43 17 consider significant. The High Court adopted the views of King C.J. in F v R44, and concurred that the question of how much information to be departed by a doctor cannot be determined by "any profession or group in the community"45 but it should be determined upon consideration of complex factors, namely, "the nature of the matter to be disclosed; the nature of the treatment; the desire of the patient for information; the temperament and health of the patient; and the general surrounding circumstances."46 Thus, the High Court felt that opinions of medical witnesses should not be decisive at this point. In other words, it was for the courts, having regard to the "paramount consideration" that a person is entitled to make decisions about his own life, to set the appropriate standard of care. This point is considered the most significant aspect of the case as this means that the determination of the standard of care is a matter for judicial, not professional opinion. Rogers had only buried the Bolam principle in the realm of doctor's disclosure of risks. However, the decision of Australian High Court in Naxakis v Western General Hospital47 rejected the the Bolam principle in all aspects of medical treatment including duty to treat and diagnose. In Naxakis, Kirby J. and McHugh J. opined that it was left to the jury to accept expert opinion of a fellow medical practitioner. Expert opinion of fellow practitioner should not be determinative on the issue of whether or not the defendant is negligent as such evidence may stem "from professional courtesy or collegial sympathy" 48 for the defendant. Kirby J. reiterated the principle decided in Rogers v Whitaker where the court pointed out that the standard of care owed by persons possessing special skills is not
44 45 (1983) 33 SASR 189. Ibid., at p. 194. 46 Id., at pp. 192 - 193. 47 (1999) 73 ALJR 782. 48 Ibid., at p. 797. 18 determined "solely or even primarily by reference to the practice followed or supported by a responsible body of opinion in the relevant profession or trade." 49 Instead, evidence of acceptable medical practice will only serve as a useful guide for the courts in adjudicating on the appropriate standard of care. 4.6 Departing from Bolam's progeny, Sidaway: The case of Chester v Afshar
The case of Sidaway v Board Governors of Bethlem Royal Hospital and the Maudsley Hospital50 has been known to be a staunch follower of the Bolam principle emphasising judicial deference to medical opinion. Sidaway rejected the "North American doctrine of informed consent"51, which is the "the prudent patient" test adopted in Rogers. Accordingly, "the law imposes the duty of care; but the standard of care is a matter of medical judgment."52 However, the ruling by the House of Lords in Chester v Afshar
53 marked a departure from the strict line followed by Sidaway in applying the Bolam principle to information disclosure. The case of Chester v Afshar involved complex issues of causation in finding the causal link between the breach of duty and the damage caused. As the operation was conducted with care and skill, the damage that resulted from the operation was not due to any breach of duty on the part of the doctor in handling the operation. Instead, the claim was made on the basis that the doctor had breach his duty in failing to warn the patient of the risks, which if properly warned, would have caused her to 49 50 Id., at p. 798, citing Rogers (1992) 175 CLR 479, at p. 487. [1985] 1 AC 871 ; [1985] 2 WLR 480, [1985] 1 All ER 643. 51 Informed consent took a major turnabout in the United States with the introduction of the reasonable prudent patient test in Canterbury v Spence 464 F. 2d 772 (D.C.Cir. 1972). This test was instrumental in shaping the decision of Rogers v Whitaker.
52 53 [1985] 1 All ER 643, at p. 649. [2004] UKHL 41, [2005] 1 AC 134, [2004] 4 All ER 587, [2004] 3 WLR 927. 19 delay the treatment offered until she receives a second or third opinion 54, and she would not have suffered the damage as yet. Relying on Lord Woolf's observations in the case of Pearce v United Bristol Healthcare NHS Trust
55 that "if there is a significant risk which would affect the judgment of a reasonable patient, then in the normal course it is the responsibility of a doctor to inform the patient of that significant risk"56, Lord Steyn held that: "A surgeon owes a legal duty to a patient to warn him or her in general terms of possible serious risks involved in the procedure. The only qualification is that there may be wholly exceptional cases where objectively in the best interests of the patient the surgeon may be excused from giving a warning. This is, however, irrelevant in the present case. In modern law medical paternalism no longer rules and a patient has a prima facie right to be informed by a surgeon of a small, but well established, risk of serious injury as a result of surgery."57 His Lordship went on to further to state that: "...patient's right to an appropriate warning from a surgeon when faced with surgery ought normatively to be regarded as an important right which must be given effective protection whenever possible." The decision in Chester was heavily influenced by the case of Chappel v Hart58, which was a progeny of Rogers v Whitaker. This shows a remarkable departure from the paternalistic and doctor-protective attitudes displayed by the House of Lords in Sidaway. 4.7 The Development of the Bolam principle in Malaysia
The Bolam principle so formulated has been routinely applied by the Malaysian courts to the relevant cases59 in determining the doctor's standard of care. Amongst the earliest case
54 See Puteri Nemie, J.K., Chester v Afshar : Loosening the grip on proving causation for failure to disclose risks in medical treatment [2004] 5 Current Law Journal I - viii. 55 (1998) 48 BMLR 118. 56 Ibid. at p. 124. 57 [2004] 4 All ER 587, at paragraph 16. 58 (1998) 156 ALR 517. 59 E.g.s,. Swamy v Matthews [1967] 1 MLJ 142; Mariah bte Mohamad (Administratix of the estate of Wan Salleh bin Wan Ibrahim, deceased) v Abdullah bin Daud (Dr Lim Kok Eng & Anor, Third Parties) [1990] 1 20 in the Malaysian jurisdiction wherein the Bolam principle was applied is Swamy v Mathews60. There were different opinions presented to the court in this case as to what was supposed to be the proper treatment and the procedure in giving such treatment to the plaintiff. The majority judgment accepted the testimony of the defendant doctor and his explanation that the prescription and the dosage given to the plaintiff, although at variance with the manufacturer's recommendation, was made based on is personal experience. The emphasis in the majority judgment in discounting the contrary evidence is the classic doctor-centric approach. The court did not examine the reasonableness of the treatment. The court found the medical practitioner not negligent because medical practitioners need not have the highest degree of skill. Mr Justice Ismail Khan cited Roe v Minister of Health61 stating: "But we should be doing a disservice to the community at large if we were to impose liability on hospitals and doctors for everything that happens to go wrong. Doctors would be led to think more of their own safety than of the good of their patients. Initiative would be stifled and confidence shaken. A proper sense of proportion requires us to have regard to the conditions in which hospitals and doctors have to work. We must insist on due care for the patient at every point, but we must not condemn as negligence that which is only a misadventure." Further his Lordship stated what was uttered 130 years ago by Tindal J in Hancke v. Hooper62 whereby: "A surgeon does not become an actual insurer; he is only bound to display sufficient skill and knowledge of his profession. If from some accident, or some variation in the frame of a particular individuals, an injury happens, it is not a fault in the medical man ... The plaintiff must show that the injury was attributable to want of skill; you are not to infer it." MLJ 240 ; Inderjeet Singh a/l Piara Singh v Mazlan bin Jasman & Prs [1995] 2 MLJ 646. 60 [1968] 1 MLJ 138. 61 [1954] 2 WLR 915. 62 [1835] 7 C & P 82. 21 The Privy Council had soon after that applied the Bolam principle in Chin Keow v Government of Malaysia63. The trial judge, Ong J., adopted the Bolam test of negligence and found the doctor to be negligent for prescribing a penicillin injection as a routine treatment for the patient and that he did so without asking one single perfunctory question to attempt to discover whether she was sensitive to the drug. Such is not considered as a practice accepted as proper by a responsible body of medical opinion. The Federal Court, however, rejected Ong J.'s finding of negligence but on further appeal, the Privy Council adopted Ong J.'s decision. In Elizabeth Choo v Government of Malaysia64, several medical experts gave conflicting opinions on whether it was proper for the anaesthetist to perform sigmoidoscopic examination under general anaesthesia. One expert had expressed the view that it is better to perform sigmoidoscopy without anaesthesia as the patient could be forewarn the anaesthetist of any pain. The court however, observed that the anaesthetist had previously successfully performed hundreds of sigmoidoscopic examinations under general anaesthesia. This technique is in vogue in his unit since 1956 and the technique had not earned the condemnation of medical opinion generally.65 Thus, applying the Bolam principle to this issue, the court held that the anaesthetist is not negligent as he had followed the general and approved practice in the situation, which he was facing. The technique that he adopted was approved by a responsible body of medical men since 1956. Therefore, it did not matter if there is another body of opinion that would have taken a contrary view. Raja Azlan Shah stated:
63 64 [1967] 2 MLJ 45. [1970] 2 MLJ 171. 65 Ibid. at p. 172. 22 "The anaesthetist had done hundreds of endoscopic examinations including sigmoisdoscopy...and had encountered no trouble except this particular mishap... .There is evidence that the greatest care is required to ensure free passage when the instrument is introduced in the rectum and the procedure required a high degree of concentration. The anaesthetist said he exercised all care and caution he possessed at the time...at no time did he lift his sight from the mirror.... The principle of law is well established that a practitioner cannot be held negligent if he treads the well-worn path; he cannot be held negligent if he follows what is the general and approved practice in the situation with which he is faced."66 The judicial decision in Elizabeth Choo was further approved in Kow Nan Seng v Nagamah & Ors 67. There were conflicting opinions on whether a complete plaster cast or a plaster slab is to be used. Again, applying the Bolam principle the court held that there may be differences of opinion as to the types of plaster casts to be applied in the treatment but this does not mean that choosing a type of plaster cast is in itself negligence. To be negligent, the doctor must have departed from the reasonable standard of care and skill of an ordinary competent doctor. In Liew Sin Kiong v Dr Sharon M Paulraj68, Ian Chin J. applied Sidaway, which endorses the Bolam principle69 and found the defendant not liable as the plaintiff had failed to prove that the defendant had not acted in accordance with the standards of a competent ophthalmologist. The learned judge said that although the consent form did not state that the defendant had informed the plaintiff of the risk of infection, it did not mean that the risk was not explained. Further, the court held that if a doctor was of the view that a patient was in need of an operation then such benefit outweighed a remote risk as the doctor should be allowed the "therapeutic privilege" in deciding whether or not to disclose the
66 67 Id. at p. 173. [1982] 1 MLJ 128. 68 [1996] 2 AMR 1403. 69 Ibid., at pp. 1418 - 1419. 23 risk. However, it should be noted that even though Ian Chin J. did not follow the principles established in Rogers v Whitaker, he commented that: "[t]he issue here is not what risks are material for disclosure and therefore it does not call for my decision as to whether to follow Sidaway or Rogers regarding deferring to medical expert evidence."70 Further, in Chelliah a/l Manickam & Anor v Kerajaan Malaysia71, the High Court held that the defendant was vicariously liable for the acts of the doctors at Penang General Hospital. The doctors involved had wrongly diagnosed an acute perforated appendicitis. The treatment for pancreatitis and appendicitis are different, namely in the case of acute appendicitis the treatment is surgical intervention whereas for acute pancreatitis is conservative treatment. Jeffrey Tan JC stated that: "Doctors and members of other professions and callings must, therefore, exercise the standard of skill which is usual in their profession or calling, and it is no defence that they acted to the best of their skill if that falls below the required standard....The obligation to exercise that skill is based on the ground that a reasonable man who owes a duty of care would exercise the care of a skilled man in doing the operation in those circumstances."72 In Chin Yoon Hiap, Dr v Ng Eu Khoon & 2 Ors73, Abdul Malik Ahmad JCA referred to Maynard v. West Midlands Regional Health Authority
74 and held that it had to be recognised that differences of opinion and practice existed in the medical profession and that there was seldom any one answer exclusive of all others to problems of professional judgment. Although the court might prefer one body of opinion to the other, that was not a basis for a conclusion that there had been negligence on the part of the defendant doctor. On a similar note, PS Gill J. in Dr KS Sivanathan v The Government of Malaysia
70 71 75 held Id., at p. 1420. (1997) 2 AMR 1856. 72 Ibid., at p. 1859. 73 [1997] 4 AMR 4204. 74 [1985] 1 All ER 635. 75 [2001] 1 MLJ 25. 24 that it is not sufficient to establish negligence for the plaintiff to show that there was a body of competent professional opinion that considered the decision was wrong. As there were differences of opinion by the expert witnesses as to the correct type of fixation that should have been done, there is a body of professional opinion, equally competent, that supported the decision as having been reasonable in the circumstances. In Payremalu Veerappan v Dr Amarjeet Kaur & Ors76, VT Singham JC, referring to the judgment by his Lordship S. Krishnan Unni in M Shoba v. Dr. Mrs Rajakumari Unnithan & Others77 said that: "A doctor is never presumed to be infallible. He is also not obliged to achieve triumph in every clinical case that he treats. Doctor cannot be held negligent simply because something goes wrong. Doctor can be found guilty only if he falls short of standard of reasonable skilful medical practice. The true test, therefore, to hold a medical practitioner guilty of negligence is to have a positive finding of such failure on his part as no doctor of ordinary skill would be guilty of acting with r