The Incommensurability of the Archaic Perceptions of the Maxim Res Ipsa Loquitur in Medical Negligence Litigation
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The incommensurability of the archaic perceptions of the maxim res ipsa loquitur in medical negligence litigation by CATHERINA ELIZABETH PIENAAR Submitted for the degree of DOCTOR OF PHILOSOPHY IN LAW to the Town Faculty of Law at the Cape University of Cape Town of Promoter: Prof A Price University July 2016 1 The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only. Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University of Cape Town PREFACE The delict of medical negligence is based on the process of identifying fault on the part of a medical professional or medical institution for the harm caused to a patient. The medical professional or hospital is criticised for the alleged substandard care that resulted in injury to the patient. Unfortunately, medical professionals sometimes perceive a claim for compensation based on liability as a personal attack on their character that suggests that they are inefficient or incompetent, whereas it should be seen as a way of correcting a wrong. Furthermore, cases like Michael v Linksfield Park Clinic1contribute to public cynicism about a prejudiced judicial system that seems to favour the medical profession. Michael v Linksfield Park Clinic2embodies this perceived injustice, as it is a case where uncomplicated surgery for the repair of a broken nose in a healthy young man resulted in permanent brain damage. The facts in the causal chain of events were that the anaesthetist, in administering certain anaesthetic solutions, caused a hypertensive crisis that he failed to control. This caused the patient to go into cardiac arrest, which was not adequately managed. The patient suffered a hypoxic incident with insufficient oxygen to the brain and, ultimately, permanent brain damage. The medical professionals failed to explain the medical clinical course of an anaesthetic-induced error to the court and thus the court did not appreciate the medical reality. ‘Medical reality’, in this sense means the true interpretation of the medical facts. Because liability cannot arise before causation has been established, the focus of the thesis is on the medical interpretation of the injury in order to determine factual and legal causation. Perhaps the need to understand such ‘unfairness’ or injustice is the motive behind the legal appeals for the reintroduction of the res ipsa loquitur maxim in medical negligence cases in South Africa. Maybe it is a plea for the introduction of an all-encompassing phrase to confer a reverse onus on the defendant based on the complexity of the science of medicine – or indeed in all complex technical cases. Perhaps it is simply an appeal for greater equality in the doctor-patient relationship thereby advancing patient’s rights. The South African Constitution3 as the supreme law of the country includes a Bill of Rights for a society based on ‘social justice and fundamental human rights’4 with equal rights and equal opportunities to 12001 (3) SA 1188 (SCA). Cf CE Pienaar An analysis of evidence-based medicine in context of medical negligence litigation (unpublished LLM dissertation, University of Pretoria 2011), available at http://upetd.up.ac.za/thesis/available/etd-09212011-130356/unrestricted/dissertation.pdf (accessed 3 February 2012). Pienaar describes the anaesthetic chaos that occurred during the operation in detail. 2Michael (n 1). The plaintiff failed to discharge his onus of proof from the available medical evidence and the court dismissed the plaintiff’s case. See chapter 1 para 3.1 3The Constitution of the Republic of South Africa, 1996 (the Constitution). 4Preamble to the Constitution. 2 all.5 It stipulates that ‘everyone has the right to have access to health care services’ and the right to make decisions over your own body ie the ‘right to bodily integrity’.6 The Constitution places a positive obligation on the state to promote the rights of all South Africans taking into consideration the wrongs of the past, socio- and economic injustices and the right to equality and human dignity; this is referred to as a substantive approach to adapt the common law so that it fulfils the constitutional needs of the country. It should provide more substance to the concept of equality with a purpose to rectify wrongs and eliminate past racial discrimination.7 The Constitutional Court has linked the notion of equality with human dignity. Any violation of a human right affects a person’s dignity and should be interpreted as a form of discrimination.8 This strong constitutional influence resulted in the court leaning towards a wider interpretation of legal principles.9 This is in line with the global movement towards bending the rules of causation in certain cases, motivated by the desire to remedy breach of human dignity and to safeguard physical and bodily integrity.10 South Africa currently has a compromised health system. A finding of fault in medical negligence cases is directed at an individual health professional or institution and such claims rarely highlight organisational errors or badly managed systems. However, statistical evidence11that shows an increase in medical negligence litigation in the last five years may well indicate systemic failures. South Africa is fighting crime, corruption and systemic failures. Although it seems inadequate to promote human dignity to the homeless in South Africa where people are starving, it should remain our constitutional vision and goal to strive for and promote human dignity as a human value worthy of protection. It is certainly 5Preamble to the Constitution. 6Section 27(1)(a)and section 12(2) of the Constitution respectively. 7City Council of Pretoria v Walker 1998 (3) BCLR 257 (CC). The court held that it is the duty of the municipality to eliminate all disparities in the community. The aim is substantive equality and not formal equality so the previously disadvantaged community was treated with a ‘softer hand’. 8Oppelt v Head: Health, Department of Health Provincial Administration: Western Cape [2015] ZACC 33.The human worth (dignity) refers to a situation where all human beings are treated equally for purposes of section 9(2) of the Constitution and in respect whereof they may not be unfairly discriminated against in terms of section (3). See chapter 2 para 7. 9Oppelt (n 8). The majority ruled in favour of the plaintiff based on inadequate policy and system structures. 10Chester v Afshar (2004) All ER (HL) 24, where the English court developed the English common law on causation to protect patient rights and the ‘right of autonomy and dignity can and ought to be vindicated by a narrow and modest departure from traditional causation principles’. 11See article written by Prof M Pepper (University of Pretoria, Department Immunology) http://www.news24.com/Archives/City-Press/Doctors-lose-patience-as-suites-spike-20150429 (accessed 14 March 2013). The author describes a case in point, the death of Rita Nel (45) of Carolina, Mpumalanga. On 2 April she was admitted to the Steve Biko Academic Hospital in Pretoria with a lung condition, and had to undergo a diagnostic CT scan. However, the scanner was broken and, because the Gauteng health department had failed to pay their suppliers, the latter refused to repair the machine. For three weeks, Nel lay untreated in the hospital, waiting in vain for the scan. She died untreated on 23 April. Cf Bulletin of the World Health Organization: Bridging the gap in South Africa, http://www.who.int/bulletin/volumes/88/11/10-021110/en/ 3 worthy of being developed by means of the substantive constitutional approach for a better South Africa.12One sees activists, like the group Know Your Constitution, 13campaigning for the Constitution to be made available to the people in all South African languages. From this, it is natural to see the public developing a growing interest in, for example, patients’ rights and awareness regarding the expected standard of health care delivery. Because the function of the Bill of Rights is to enable rights to be vindicated and to provide remedies when duties have been breached, it is not surprising to find claims based on the fallacy that any medical accident or ‘any medical injury’ or negative medical outcome is or should be seen as a breach of a legal duty by a medical professional. The global increase in litigation in the field of medical negligence is perhaps as a result of a heightened general awareness of patients’ rights. However, from a medical perspective, the increase in litigation may be based on unrealistic expectations from the public regarding treatment options and surgical outcomes. An additional cause for the increase in litigation may be the consequence of the rapid development in the field of technical-medicine (such as laparoscopic surgery) and its higher risk of injury.14 It is in this technical field where the incidence of injury decreases with the experience of the surgeon and where the unaware jurist might be tempted to make use of the res ipsa loquitur maxim. Another silent, yet fundamental, cause of the increased number of court cases is the shift in focus of managed health care systems to cutting costs rather than delivering effective health care. This has a marked influence on medical insurance systems. Such a notional shift in managed health care is cause for concern in respect of the expected standard of care, as cost- reducing principles increase the risk of compromising the golden standard of care delivery in health care. One can only be astounded at the lack of ethical considerations and the failure of integrity and respect for human life exhibited in Sibisi NO v Maitin, 15where a larger-than- normal baby was born with severe shoulder paralysis.