Healthcare Law

Question 1

What is the reasonable man test?

Answer 1

The law assumes that “everyone is unreasonable”

Applying equivalency:
A healthcare professional should be reasonably competent when compared to fellow professionals

Question 2

Can a pharmacist be sued by the patient for being called a “crazy Karen”?

Answer 2

• Yes. Defamation - Can you prove this person is crazy? If not it is defamation.
• If it means something that is not true, then it is defamation.

Question 3

Can a pharmacist can be sued for both legal and ethical liabilities?

Answer 3

No. Legal liabilities can be sued or prosecuted (criminal and civil) - Police can prosecute. Ethical liabilities cannot be sued because pharmacist council can only discipline you.

Question 4

A pharmacist stole a carton of glucometers from a retail pharmacy. He sold them at a discounted prices. Which acts has he committed? Criminal, civil or ethical?

Answer 4

• Criminal - Stealing
• Civil - Supposed to be responsible within the organisation
• Ethical - Dishonesty

Question 5

In a medico-legal lawsuit, can patients sue both healthcare professionals and hospital concurrently?

Answer 5

• Practically, people will sue to the hospital because separate court case need to spend more money
• Sue hospital means you can get more money from hospital than suing a person (Practicality)

Question 6

What are torts? What are some examples?

Answer 6

Wrongful acts on individual and corporate levels

Examples:
* Negligence
* Trespassing of lands
* Defamation (e.g. “bitchy caregiver’, “FON patient”)
* Assault, Battery
* Occupier’s Liability
* All occupiers owe duty of care to all users and visitors of their facilities (i.e. safe infrastructure and facilities)

Question 7

How do you determine if something is done out of negligence?

Answer 7

Standard of Care
* Bolam test as supplemented by Bolitho case and confirmed by Gunapathy case

• Bolam - Accepted current practice
• Bolitho - Evidence-based medicine + Logical

Question 8

What is the doctrine of vicarious liability?

Answer 8

An employer is vicariously liable for the torts committed by its employees
* Includes both patient / non-patient care
* Conditions:
(1) Master-servant relationship / employer employee relationship
(2) Within employment (job scope and responsibilities)

An organisation is liable to its non-employees who act as ostensible agents
* E.g. outsourced services (e.g. CSSD, Radiology, delivery services)

Question 9

Are organizations liable in the context of independent contractors? Why?

Answer 9

An organisation is not liable in the context of independent contractor
* Independent contractor = principal has no right of control over the manner how an agent work is to be done

Question 10

What are the 2 sources of law in Singapore’s legal system?

Answer 10

1. Legislations / Statutes
2. Common/Case Law (Decision of Judges)

Question 11

What are the 2 types of law and what are their differences?

Answer 11

Criminal Law
1. Source = Legislation / Statutes
2. Guilty / Not Guilty
3. Burden of Proof = 100% beyond reasonable doubt
4. Guilty = Sentence to fine, caning, jail term, death

Civil Law
1. Source = Contract law / Law of Torts
2. Liable / Not liable
3. Burden of Proof = 51% (Balance of probabilities)
4. Liable = Damages, specific performance, injunction

Question 12

Classification of wrongful acts

Answer 12

• A wrongful act can have both criminal liability and civil liability
• Civil liability can only be proceeded via 1 route: Tort or Contract
• A wrongful act can result in ethical implications that are handled by relevant professional entities (e.g. SPC, SNB, SMC)

Question 13

What are the 6 principles of medical ethics?

Answer 13

(1) Autonomy: Respect for patients’ needs/ desires/ preferences

(2) Beneficence: Contribute to patients’ welfare and well-being

(3) Non-malificence: Do no harm

(4) Justice: Equitable distribution of benefits/burdens

(5) Fidelity: Truthfulness and Confidentiality

(6) Veracity: Honesty

Question 14

Four circumstances where autonomy is absent

Answer 14

• Coercion
• Ignorance
• Immaturity
• Mental incapacity

Question 15

5 legal considerations in autonomy

Answer 15

Mental Capacity Act

Mental Health (Care and Treatment) Act

GiIlick Awareness / Competence

Lasting Power of Attorney

Court-appointed Deputy

Question 16

4 elements of Beneficience

Answer 16

1) One ought not to inflict harm
2) One ought to prevent harm
3) One ought to remove harm
4) One ought to do or promote good

Question 17

What is justice?

Answer 17

“Like cases should be treated alike”

Question 18

What is fidelity? When are there exceptions of fidelity?

Answer 18

Confidentiality:
* Must be maintained at all times

Exceptions to Patient Confidentiality:
* When a patient consents
* To other healthcare staff caring for patients
* Statutory duty by Dr (Infectious Diseases Act)
* Disclosure under court order
* Discovery of documents in court proceedings
* Public interest (e.g. injuries indicative of child/elderly abuse, rape, crimes)

Question 19

What is veracity?

Answer 19

A relationship based on mutual trust and honesty

Question 20

3 Aspects of Medical Negligence

Answer 20

1. Wrong Diagnosis
2. Wrong Treatment
3. Inadequate information disclosure

Question 21

3 Ways that people can be deemed medically negligent

Answer 21

1. Did not do properly (Failure to exercise reasonable care)
2. Did not do what was supposed to be done (Omission to do something that a reasonable healthcare professional would do)
3. Did what was not supposed to be done

Question 22

What is considered negligent misstatement?

Answer 22

If you know that the information was required for the transaction contemplated by the patient

If you know that it would be communicated to the patient

If you know that patient would rely on the information

If patient does rely on the information

Question 23

4 Components needed to prove that an act is considered to be medical negligence

Answer 23

Duty of Care

Breach of Standard of Care

Causation

Foreseeable Damages / Injuries

Question 24

What are 3 principles of duty of care?

Answer 24

Neighbour Principle (Lord Atkin)
- “You must take reasonable care to avoid acts and omissions which can reasonably foresee would likely to injure your neighbour i.e. persons who are so closely and directly affected by your act that you ought reasonably to have them in contemplation…”
- A duty to ensure that one’s acts do not cause foreseeable harm to another (Donoghue V Stevenson)

Vicarious Liability
- Hospital is liable for an employee’s negligence committed during the course of employment

Occupier’s Liability
- Hospital is expected to provide safe premises to everyone on its premises

Question 25

Who do healthcare institutions and staff owe a duty of care to?

Answer 25

1. Patients (Facility, equipment, services)
2. Third party (Not to sustain injuries like mental distress)

Question 26

Pharmacists owe a duty of care to…

Answer 26

Patients
1. In wards / clinics
2. Who purchase Pmeds from retail
3. Who seek advice
4. Who are referred to him by other HCPs
5. In Clinical research / trials

Question 27

The consideration of breach of standard of care is based on

Answer 27

Reasonable Man Test
- A healthcare professional must be reasonably competent when compared to his/her fellow peers
- A reasonable healthcare professional should deliver a reasonable standard of patient care based on evidence-based clinical practices

Question 28

What is the Bolam Test?

Answer 28

The Bolam Test determines whether a HCP is guilty of clinical negligence depending on whether he or she has acted in accordance to accepted current practice (= minimum standard of care)

HCPs are judged against the standards of their peers.

If a responsible body of expert witnesses might make the same mistake in the same scenario, the doctor would not be found guilty of negligence.

Question 29

What is considered the accepted current practice in pharmacy?

Answer 29

SOAP notes
Identifying DRPs to ensure value-based outcomes

Question 30

What is the Bolitho’s case?

Answer 30

Bolitho case = Evidence-based Medicine that is logical (Defensible conclusion based on causality)

Court must be satisfied that exponents of body of professional opinion has a logical basis, and had directed their minds to comparative risks and benefits reaching a defensible conclusion

Opinion of expert must be supported by proven facts and findings, so that the court can judge the strength of that opinion

Question 31

Ways to defend causation of patient injury

Answer 31

Patient’s Defence - Res ipsa loquitor
- The facts speak for themselves
- Patients are not clinically trained and may not be able to explain how the medical negligence leads to the injuries/harm
- The law can help patients in situations where it is unfair or difficult for patients/caregivers to identify the errors or causes of injuries and harm
- If the defendant HCP is unable to give a satisfactory explanation, he/she will be liable for the damages/injuries caused to patient

HCP’s Defence
(1) Contributory Negligence - If patient contributed to his/her injury/harm through own negligence in addition to HCP’s negligence, his damages will be reduced
(2) Volenti Non Fit Injuria - Consent to the risk (informed consent)

Question 32

What is needed for a good defence against negligence?

Answer 32

Good documentation to show that
- Patient rights are not violated
- Patient responsibility also played a role

Question 33

3 Consequences of the non-adherence to the Bolam Test

Answer 33

1. Defensive medicine - Choosing treatment which is most legally safe even if they think such treatment may not be strictly warranted
2. More medical litigation - Increased premiums and overall healthcare costs
3. Affect doctor-patient relationships