“No need for a new criminal article, and the liability insurance of the physician adopted all over the world”

Iatrogenic crimes come under increasing attention of law enforcement. The Investigative Committee created a Department of conducting examinations in cases of medical errors. On the current topic, which is now actively supplied the theoretical base is protected, has no thesis. And recently the publishing house “unity” was a textbook for law schools “the Investigation of crimes committed by medical workers on imprudence”. The desire of the security forces “to close the gap in the criminal law” with a new article about the medical crimes of Mednovosti talk to the President of the Scientific society of gastroenterologists of Russia, Professor of the Department of outpatient therapy MSMSU them. A. I. Evdokimova, Leonid Lazebnik.

Leonid Lazebnik

Leonid Borisovich that such iatrogenic crime? Whether use of the term “crime” against iatrogenic?

– There are no such crimes. The term “iatros” or “yatros” in Greek means “doctor”, and “genos” – “born”, thus any action of a physician or other health care provider – iatrogenic. According to the International classification of diseases and causes of death 10th revision, which uses the world, “…iatrogenic – any unwanted or adverse effects of preventive, diagnostic and therapeutic interventions or procedures that cause violations of the body, limitation of usual activities, disability, or death; complications of medical interventions developed as a result of both incorrect and correct actions of the doctor.”

Therefore, the physician should be sure that his actions in this particular clinical situation was correct, but a complication has developed as a result of its actions to cure disease, as a result of such changes in the patient’s body, which led to the development of complications. For example – running stage of the underlying disease, when intervention was undertaken with the aim of partial or complete preservation or restoration of the lost functions, the presence of irreversible changes in other organs, sudden failure of the functioning of vital organs, unpredictable complications from injecting drugs.

Experience shows that any intervention, even, sorry, advice to the patient, can lead to the development of undesirable reactions of the patient. No wonder the term “iatrogenic” historically came to us from psychiatrists and psychoneurologists.

One of the clearest examples of iatrogenic – adverse drug reactions. Every drug has a systemic effect, which we call side-effects, because we don’t want them to be, but they are still there. The human body still represents a “black box”. We know that the patient is given, and see what we have to exit, but what is happening inside him, often not knowable. And we can’t predict how a patient will respond to an assigned drug. For example, will give a severe allergic reaction. But this is an article about improper performance of official duties or unintentional infliction of damage to health.

Moreover, there are many situations, for example in Oncology, when we knowingly prescribe medications that suppress the activity of tumor cells, but has the inevitable side effects. Patients who receive potent cytotoxic immunosuppressive therapy, are doomed to adverse systemic effects of drugs – liver damage, baldness, appearance of ulcerative lesions of the digestive system. And, then the patient may complain that the doctor caused damage to his health. But if the doctor will prescribe these medications will be accused of failure to render aid.

It is a vicious circle in which any physician providing medical care or not having it, becomes a potential criminal. Already the fact of receiving a diploma.

A new textbook for future lawyers addresses the need to “criminal law responses iatrogenic crimes”. Thus, inthe criminal code there is no concept of professional crime.

– They’re not needed. The penal code is working in our country for many decades, carefully laid out and include all possible situations (for example, negligence or intentional damage to health). Why do we need to invent a separate “medical” article, which directly aim at the tendentious, accusatory in the investigation? And who is the social customer of the hunt doctors? For sure can’t, but it is obvious that there is a financial interest in this matter. Today offer their services to numerous law firms who professionally are engaged to someone tear, and above this, the competent people very much. Especially if the doctor in advance is perceived by society as a potential criminal.

The country has twice experienced a case of “killers in white gowns”, “doctors-saboteurs” – “rootless cosmopolitans”. I would not like to think that we are now living through the social order, but who could imagine that the modernization of health will manifest themselves as strong aggression to the doctors?

And this may encourage the care provider to the real official crime – the failure to render aid.And such situations are many. Should the physician, for example, on the train to help the new mother if he has no certificate of the obstetrician-gynecologist, and he forgot how to do it? Needs – otherwise it will be failure to render aid. But if during the delivery she developed complications, who is responsible for this? Again the same doctor. Put in such condition and understanding that he urethrane criminal, people try not to approach the patient with the disease, with which he is working.

I was in such a situation, however, is quite long. While driving, I saw a group of people scurrying about lying on the road men who fought in convulsions.Was chtou it was the aspiration with a piece of kebab. I didn’t have at hand anything suitable, and I went for a risky, in fact, prohibited the reception of the wound with one hand with a handkerchief and pushed him in the jaw, and the second hand tried to pick up this piece of kebab. I knew that one wrong move and I’ll push a foreign object in the windpipe, and the man will die. Fortunately, all ended well. But rate this my act, if fate decreed otherwise.

It could be qualified as a crime by negligence: “the doctor his actions killed a man, why do have got do to help?”

– What is the General “inadvertently”? In the UK it means an act committed by carelessness or negligence. But, for example, the patient died during surgery. Is that causing death by negligence, as it is now interpreted in many articles? And if the doctor deliberately went to a high degree of risk in the hope of saving the patient, but was unable to save him. What’s negligence? And will he go next in a difficult operation?

There is a more correct concept of “improper performance of official duties.” But to make it proper, every action a doctor should be spelled out and approved in the pertinent instructions. And in the agreement that the doctor signed with the employer, needs to be spelled out step by step, every manipulation, every drug that he can prescribe the patients with indications contraindications. A deviation from such instructions can be called the improper execution. Everything else is interpreted.

And can we talk about iatrogenic as a result of medical errors? For example, when prescribing medication off-label.

– There is no causal relationship. The medical error had a clear definition, which I first heard as a student from the head. Department of forensic medicine of the First medical school Professor Gromov is a honest mistake the doctor. In every profession there is, first, risks second, unsuccessful results, due to unforeseen circumstances. But the crime here. And, by the way, please tell us in our country who are criminally responsible for bugs in other branches of the social sphere, or there is a special criminal charges for professions?

As for the medications off-label is not a mistake, there is no bona fide error, the doctor deliberately goes to the use of the drug is not on the testimony– a violation that has already be treated as a crime. And then everything will depend on the consequences, a competent lawyer will always find the desired article in the existing criminal or administrative code. And even if the patient recovers, he may file a lawsuit and will be right.Clearly, if the doctor does it with the best of intentions, perhaps, he learned information in foreign scientific articles and it is absolutely certain it is right. But then you have to raise the question of the appointment of the drug for non-RF reasons, I believe that a reasonable specialist will not go for it.

And please give a better example of a medical error.

– Please, practical life example, I cite in my lectures. A patient who suffers from atrial fibrillation, taking drugs from arrhythmia, high blood pressure and prevention of thrombosis, and he needed drugs from pain in the joints. In patients receiving these drugs, he developed gastric bleeding. The time of treatment to the doctor the bleeding stopped, clinics are almost there. What to do? First, it is necessary to examine, find the source of bleeding. And to calculate the risk of the examination – can he do gastro and colonoscopy or not. On the basis of indicators of the level of hemoglobin and presence of blood in stool you need to calculate, how many he lost blood. And then we should make a decision. He has atrial fibrillation, there remains a risk of thrombosis, so we must continue to take anticoagulants. But he lost blood, then he should take, and drugs from blood loss, and drugs that prevent the possibility of risk of re-bleeding.

Literate thinking (and have the time on it) the doctor will see recommendations, the appropriate scale will calculate the stratification of the risks… And can still make mistakes.The patient either will develop thrombosis, thromboembolism branches of the pulmonary artery due to the fact that the blood is not enough liquid, or develop bleeding if the blood is too liquid. In our profession there is a principle: the art of diagnosis and healing is an art of balancing probabilities. The more experience a doctor, so the balance is better, but it constantly need to update and restore, i.e. to learn. In this example we need to teach physicians to use a particular scale of risks, reflecting international experience into account the likelihood of complications.

In every particular situation should be held absolutely clear stratification of risk. Today there are a number of different international scales for different situations. This is the result of long hours of great work large groups of doctors, both foreign and Russian. But this should be taught to all the doctors, especially doctors in the field of “high professional risk.” But still, you need to understand that any scale gives a mechanical response, e.g., “the risk of adverse outcome is high…” or “the risk of an adverse outcome is so many points…” will tell you what events to hold, what drugs to prescribe, but the final decision still must be made by a doctor!

And I urge my colleagues – taking a responsible decision, be careful and attentive, no initiative, all actions only in accordance with professional recommendations (better than national, though they are available in different professional communities, but little different from each other, because in General correspond to international). And, most importantly, all your actions and thoughts must be recorded in the document history. Older doctors remember the truth which we were taught at the departments of the third year, when we first came to the clinic – “We write history not for himself but for the Prosecutor”.

The era of altruism in medicine ends, public medicine is fastly becoming digital. “Dixi, etanimamlevati” (“the reprimand, and relieved my soul”) – modern hurrying a doctor who works not with man, but with a digital indicator of its physiological state.

Medicine of the XXI century is the management of functional systems, including remote. And these numbers, including the risk indicators, should be included in the medical history and communicated to and the patient, and those interested in his life (but which he indicated in writing their consent for release of information). Probably modern the art of medicine is not only to provide high-quality patient care, but also in order not to incur the wrath of loved ones, sick people are increasingly seeking the assistance of lawyers or investigators.

How else can you insure against medical errors?

– First, the physician must have relevant qualifications – the document that spelled out the kind of assistance it can provide. Second, it needs to be established in this regard. Third, perhaps in the employment contract with the employer must be present when the decision is made alone, and in any Council. Another question – if that is impossible, no one with whom to consult? I believe that in the field need to address issues of telecommunications with the Central healthcare institutions. The responsibility must be collective. And again I urge colleagues – beware of situations where you have to go it alone to make a difficult decision. A consultation, collective thinking is not only a collective responsibility but also a great guarantee against Commission of mistakes.

I was recently at the European Congress of internal medicine. So, in Europe about the same situation: there, too, with doctors looking to obtain more money for the alleged error. And there medical community now proposes a new, and long-known concept – “Not I, but We” (“I and we”).

And in this respect documents regulating the actions of the doctor of any specialty, are developed by professional communities on the initiative of the Ministry of health and Nameplate “Professional standards in the specialty…”. Most of these are already officially approved by all approving state authorities and posted on the Ministry’s website.

Let’s go back to the initiatives of the Investigative Committee. In particular, it createdthe head of the Department of forensic scienceDepartment of forensic investigations, who will conduct the examinations on Affairs about medical errors.

– The investigative Committee creates examination divisions, which will operate from his point of view, professionals. It is their right. But first, the teams should have medical education and be accredited, have extensive experience in the field of health care in the occupation for which they are going to carry out investigative actions, and, preferably, a license for this activity. And then, what conclusions will be to give people who administered the Investigative Committee, the independent or those who need the most the UK or other authorities, insisting on the fact that the doctor is subject to criminal liability. Moreover, currently, there is no guarantee that the courts involve experts are experts in specific medical fields.

No one claims law Investigation Committee, it may initiate any number of criminal cases against doctors, but the right expert evaluation in a conflict situation should be delegated to the national professional associations.About the quality of professional assistance can be judged only by professionals. The guy who opened a criminal case has the right to transfer the materials for consideration in multiple professional communities, and then choose a middle ground. But communities formal law should be granted the right to establish expert groups with the relevant statutes, regulations and funding (to the unfortunate doctor, who is so persecuted, do not have to pay the experts for this job). Now, according to my information, this question is actively working Society of Russian doctors and the national medical chamber. Yavas and assure that our professional honor would not allow to allocate the experts of those people, the integrity of which we doubt.

But if the physician admitted error is obvious for professionals, and albeit unwittingly, but the damage was made to the patient.

– Imagine the situation, a small town, the hospital which employs two surgeons. Each of them had a post-op complication, against every criminal case, and they both dismissed. Or on the court, they received a suspended sentence and prohibition to conduct professional activities. Who is going to operate in this city?

No one takes responsibility nor experts, nor from the doctor, if he really caused damage to the health of the patient. We know about the trials of foreign doctors to arrogate to itself the right to commit murder patients, whom they regarded as incurable. They are criminals. But in doubtful situations, the professional community must appreciate the depth of medical errors, identify the cause (often, and not in the doctor business, and the organization of medical-diagnostic process!), perhaps to force the doctor to learn more, to continue such mistakes are not allowed. Before exactly what previously worked the medical control Commission. But if it’s the crime of intentional injury, the fate of this man, the court will decide.

But if you look at the situation from the perspective of the patient, is he not entitled to compensation?

And it requires no new criminal charges, and the insurance of medical responsibility, are widely developed throughout the world.We started talking about this back in the 90-ies, when the country appeared medical insurance. The doctor should not be ignorant, a boor, lazy. But it can be somewhere to hurry, something rusty and make mistakes, from which no one is guaranteed. And then the insurance organization with the professional community will have to figure out what this error is, how it is random and whether it was allowed. And address issues of fair compensation.