Professional Documents
Culture Documents
LAW 826
ASSIGNMENT
FACULTY OF LAW
Prepared By:
Nur Azimah Bt. Mohd. Taman
(2015698574)
Prepared For:
En. Sri Rama a/l Subramaniam
23 April 2016
Examine the approach taken by the court with regards to medical expert
opinion in medical negligence cases:
1)
2)
3)
4)
5)
ANSWER
Introduction
Expert opinion is governed under section 45 of Evidence Act 1950. A person is
qualified to testify as an expert if he has special knowledge, skill, experience,
training, or education sufficient to qualify him as an expert on the subject to which his
testimony relates. These types of persons include the registered medical practitioner.
Such special knowledge, skill, experience, training, or education must be shown
before the witness may testify as an expert. The court may consider expert opinion in
determining issues which are beyond its expertise, training or common knowledge. 1
In Leong Wing Kong v PP
1 Omar, H., Marimuthu, S., & Mahali, M. (2015). Law of Evidence In Malaysia (p.
191). Subang Jaya: Sweet & Maxwell.
2 [1994] 2 SLR 54.
However, where the court lacks the expertise to decide on a certain matter, such as
foreign law, science handwriting, and the court will accept opinion evidence. But in
these situations, the opinion evidence are only given as a guide to the judge, hence
it is not conclusive. The judge is free to accept or reject the opinion or to accept an
opinion as against another. In Chou Kooi Pang v PP 3, it was held that expert opinion
is only admissible to furnish the court with scientific information which is likely to be
outside the experience and knowledge of a judge. This implies that the judge still
retains the authority to form his own conclusions. The Court of Appeal of Singapore
went on to say that if on the proven facts, a judge can form him own conclusions,
without help, the opinion of an expert is unnecessary. Therefore, it goes hand in
hand the understanding that evidence of experts can never go beyond an opinion
and can never therefore be of absolute certainty.
Where a duty of care is breached, liability for negligence may arise. Medical
negligence is part of a branch of law called tort and this system provides for
compensation in order to return the claimant to the position they would theoretically
have been if the harm had not occurred. To determine negligence, a three-stage test
must be satisfied. The three-part test establishes that the doctor owed a duty of care
to the patient, the duty of care was breached, and as a direct result of the breach the
patient suffered harm. Medical evidence will be required to assist the court in
deciding the degree of probability of the risk materializing and the seriousness of the
possible injury. In addition, expert evidence may be necessary to assist in the courts
characterization of the risk such as whether the risk is common to all surgery or
specific to a particular operation. The medical evidence provided will be relevant in
determining whether the risk is material however, it will not be determinative.
In examining the approach taken by the courts, the court has to determine whether
the defendant doctor has attained the required standard of care, taking into
consideration of all the relevant important factors in order to balance both parties
interests, the doctors and the patients. While granting a satisfactory solution to the
3 [1998] 3 SLR 593
4 The Trial of a Medical Negligence
Action. http://www.thehollandgroup.ca/naction.pdf. Retrieved 13 April 2016, from
http://www.thehollandgroup.ca/naction.pdf
victimized patient, the courts also have a duty to allow doctors to behave without fear
of litigation.
Bolam v Friern Hospital Management Committee (1957) 2 All ER 118
In 1954, John Hector Bolam, a patient suffering from depression, was voluntarily
admitted to the Friern Hospital to undergo Electroconvulsive Therapy (ECT), a
recognised
legal standards for medical practitioners based on what practices they choose to
adopt. In other words, it allows medical practitioners to determine on their own, the
legal standards required for their practice. Thus, the law here seems unfair as it
provides additional protection for medical practitioners.
In most cases, breach of standard of care is determined according to the standard
of the reasonable man and where theres a breach in the professional duty, that is
determined according to the standard of comparable professional practice. 6 The
court has to determine whether the defendant doctor has attained the required
standard of care, taking into consideration of all the relevant important factors in
order to balance both parties interests, the doctors and the patients. Due to the fact
that the test gives medical practitioners, and not the courts, the power to set their
own standard of care, it seems to have a role in inhibiting the courts power to
choose between competing expert views. Moreover, it prevented judges from having
any right of oversight. They were not allowed to assess the expert evidence
themselves, but instead their only role was to check whether or not it existed.
This case enunciated that there is no breach of standard of care if a responsible
body of similar professionals support the practice that cause the injury, even if the
practice was not the standard of care. It can be seen that the courts have little or no
power to choose between the conflicting practice and is forced to accept the
defendants practice because the defendant can prove that there is a competent
body of professional opinion that supports his practice. The negligence in the
medical profession is determined by fellow medical practitioners, not for the judges
as judges are not expert in medical field. There is no room for evaluation, once the
Court had ascertained that other doctors may have acted in the same way then they
generally accepting an expert opinion without hardly interfere and impose standard
on medical profession. It can be said the Court had adopt a descriptive approach
where the only task available to the judge (or jury) lies in asking whether there is a
body of evidence that might have done as the defendant doctor did. If there is, then
the doctor was obviously acting with ordinary care and thus will not have breached
his duty. 7 Consequently the court has little discretion to decide what the standard of
care as Bolam gives weight to what medical practice is (or what contemporary
practice was) rather than what practice should be.
7 Herring, J., & Wall, J. (2015). Landmark Cases in Medical Law (p. 22). Portland:
Hart Publishing.
The trial judge surmised that even if the view not to intubate was unreasonable and
illogical, she could not substitute her own views for those of the medical experts.
However, the court of final appeal in England, The House of Lords, disagreed with
the reservations of the trial judge to substitute her opinion for those of the medical
experts.
The defendants argued based on Bolam that their decision not to have intubated him
earlier could be confirmed by a reliable and respectable body of opinion. There the
court stated that the court was not bound to find for a defendant doctor simply
because a body of experts testified in his favour. The House of Lords held that there
would have to be a logical basis for the opinion not to intubate. This would involve a
weighing of risk against benefit in order to achieve a defensible conclusion. 8 This
means that a judge will be entitled to choose between 2 bodies of expert opinion and
to reject an opinion which is logically indefensible.
This has been interpreted as being a situation where the court sets the law, not the
profession. However, it was held that the court would hold a practice that was in
conformity with a sound body of expert opinion to be negligent only in a rare case.
On the facts, it was decided that not intubating the child in the particular
circumstances at hand was not a negligent way to take, even though the expert
opinion on the matter was divided. It would appear from this case that the courts
remain unwilling to disregard expert opinion altogether, and if the court is to choose
between two conflicting expert opinions then a reasoned explanation must justify the
decision. The court now has the ultimate responsibility to determine the reasoning of
standard argued by the expert.
Rather, the judge has to be satisfied that the evidence or the reasoning behind it is
so flawed that even though there might be a body of opinion supporting the doctor, it
is not a responsible one. It allows the judge to look at the evidence itself and assess
whether it is logical.
Rogers v Whitaker (1992) 109 ALR 625
8 Weng Kwai, M. (2013). Approach to Medical Negligence Claims by Malaysian
Courts -. MahWengKwai & Associates. Retrieved 15 April 2016, from
http://www.mahwengkwai.com/approach-to-medical-negligence-claims-bymalaysian-courts/
In this case, the respondent, Maree Whitaker, had been almost totally blind in her
right eye for nearly 40 years since suffering a severe injury to the eye at the age of
nine. Despite the injury she had lived a substantially normal life. She consulted the
appellant, Christopher Rogers, an ophthalmic surgeon, who advised her that an
operation on the injured eye would not only improve its appearance but would
probably restore sight to it. Following the surgery, which was conducted with the
required skill and care, the respondent developed a condition known as 'sympathetic
ophthalmia' in her left eye. In the end she lost all sight in her left eye, and as there
had been no restoration of sight in her right eye, she was almost totally blind. She
sued the appellant alleging his failure to warn her of the risk of sympathetic
ophthalmia was negligent. She had not specifically asked whether the operation to
her right eye could affect her left eye but she had incessantly questioned the
appellant as to possible complications. The appellant said in evidence, "sympathetic
ophthalmia was not something that came to my mind to mention to her". Evidence
given at the trial was that the risk of sympathetic ophthalmia was about one in
14,000 and even then not all cases lead to blindness in the affected eye.
The issue is regarding the failure of the surgeon to inform her on the risk. The
opinions of the medical experts were divided, one supporting and one against
informing the risk on patient. The appellant relied on the principle used in Bolam, that
a medical practitioner is not negligent if he acts in accordance with a practice
accepted at the time as proper by his peers, even though other medical practitioners
adopt a different practice. In other words, the standard of care owed to a patient in all
things is determined by medical judgment. The Court drew a clear distinction
between the test to be applied as to whether the operation has been done with the
necessary skill (the Bolam principle applies here) and the duty to warn a patient of
material risks.
The High Court of Australia disapproved the principle stated in Bolam and held that
the surgeon to be negligent in failing to inform the risk. Had the court decided to
follow Bolams case, the court could not evaluate the contradictory medical opinions
and thus a doctor would not have been negligent as long as his practice is in accord
with at least one body of medical opinion.
The court stated in this case that a doctors duty of care for a patient includes a duty
to inform the patient about material risks of a proposed treatment, so that patient
can decide for themselves whether they are prepared to accept those risks by
agreeing to undertake the treatment. The determination whether or not a risk is a
material one does not depend upon the application of medical standards or
practices. This issue does not fall to be determined on the basis of expert testimony
as to whether a particular risk is one of which a patient should or should not be
warned, or expert evidence as to ordinary medical practice in refraining or providing
a warning in such cases.
Expert testimony will, however, be relevant in two ways. First, in order to determine
whether a reasonable patient would be likely to attach significance to a risk of a
particular kind, the court must be apprised of the degree of probability that a
particular risk will materialise and secondly, expert testimony will be relevant in
assessing whether the case falls within the limited category of cases where the duty
to warn is overridden by therapeutic consideration. 9 In this case, the court has the
ultimate responsibility to determine whether a practice conforms to the standard of
reasonable care demanded by law. Drawing upon the evidence presented by the
experts, the court should be the one to set the standard of care and more
importantly, this responsibility could not be delegated to the profession.
Foo Fio Na v Dr. Soo Fook Mun & Anor (2007) 1 MLJ 593
The appellant was a front seat passenger in a car that crashed into a tree on the
night of 11th July 1982. She suffered, inter alia, two dislocated vertebrae as a result of
an accident. At that material time, she can move all her limbs. The first respondent
was the orthopaedic surgeon who treated the appellant and the second respondent
was the hospital in which she was warded. The first respondent performed an
operation on the dislocated vertebrae, which involved the insertion of a loop wire to
stabilise the spinal cord. The appellant became paralysed the day after the
operation. Dr. Mohandas, a neurosurgeon, found that the wire loop was pressuring
the spinal cord and was the cause of the total paralysis. The first respondent, in the
9 Assessing Damages for A Breach of The Duty To Warn: Is The Patient
Compensated For The Loss Of A Chance, Or The Chance Of a Loss?.(2004) (1st
ed., p. 2). Retrieved from http://www.lexscripta.com/pdf/malpractice.pdf
court has to adjudicate on what is the appropriate standard of care after giving
weight to the paramount consideration that a person is entitled to make his own
decisions about his life. The well-known phrase that doctor knows best should now
be followed by the qualifying words if he acts reasonably, logically and gets his facts
right.10 Again, it is for the courts to determine whether the doctor has acted
reasonably despite having acted in accordance with responsible professional
practice.
found the defendants negligent on the three aspects of diagnosis, treatment and
advice. The defendants appealed against the entirety of the judges decision on
liability. The pith of the defendants argument was that the judge had wrongly applied
the Bolam test by relying on his own finding that the nodule was a scar and not a
tumour. 11
The Court of Appeal overturned the High Court decision, commenting on the right of
the High Court judge to make a finding of fact preliminary to the application of the
Bolam test and justified it primarily on the basis that the courts did not possess the
necessary technical expertise to be a competent arbiter of medical standards. The
court also indicated that the Bolam test was confined to cases involving the medical
profession.
12
In determining whether a doctor has breached the duty of care owed to his patient, a
judge will not find him negligent provided there is a respectable body of medical
opinion, logically held, supports his actions. The Court of Appeal considered that the
Bolam test was later supplemented by the House of Lords decision in Bolitho which
stated that the court was not bound to find for a defendant doctor simply because a
body of experts testified in his favour and emphasized that Bolitho was not intended
to dilute the Bolam test by allowing judges to choose between conflicting expert
testimony. Court must be satisfied that the exponents of a body of professional
opinion have a logical basis and had directed their minds to the comparative risks
and benefits in reaching a defensible conclusion. The opinion of expert witnesses
must be founded in logic and good sense.
In the issue of diagnosis, The Court of Appeal then proceeded to consider the facts
in the context of the Bolam and Bolitho test. The crucial question, in the view of the
court, was whether the unanimous view of the defendants expert, that the nodule
was a tumour, was founded on the basis of cogent logic. It was concluded that there
11 Tay Swee Kian, C. (2003). Interpretation of The Bolam Test in the Standard of
Medical Care: Impact of the Gunapathy Case and Beyond. Professional
Negligence, 19(2).
12 Disa, S. (2003). Dr. Khoo James & Anor. v. Gunapathy D/O Muniandy and
Another Appeal: Implication For The Evaluation of Expert Testimony. Singapore
Journal Of Legal Studies, 601-609.
was a respectable body of medical opinion which would have diagnosed the nodule
as a tumour and the defence experts opinion was also found to be internally and
externally consistent. They, therefore, found that the defence experts had satisfied
the threshold of logic. In considering the issue of whether aspects of treatment and
advice to the patient rendered the defendant doctors liable for negligence, it was
held that the decision to radiosurgery treatment and the advice given by them were
not illogical or contrary to the extrinsic evidence available.
As a conclusion, a faithful application of Bolam and Bolitho would mean that the
Court will accept the views of a respected body of experts relied upon that such
opinion has a logical basis. Since the Courts are ill-equipped to adjudicate over
medical issues, it would be unrealistic to expect the court would be able to choose
which version is more meritorious.
CONCLUSION
From the cases discussed above, it can be seen that the courts retain their wide
discretion to not accept the standard presented by the medical profession, although
genuinely held, but to entertain the principle that, if that standard falls short of the
reasonable standard of care expected by the patient, it will be seen as negligent
action. It is for the court to decide whether a physician has in fact been negligent in
the light of the appropriate standard of care demanded by the law.
It appears that the traditional approach of doctors know best has been discarded.
It is not the medical men but the courts who decide whether a doctor was negligent
towards the patient.
However, the courts must evaluate such evidence critically, and ensure that medical
expert witnesses properly understand their role of assisting to establish medical facts
from which the court can draw legal conclusions.
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