This article was authored by Pranay Jalan and Madhav Aggarwal from GNLU, Gandhinagar.
The laws applied by the current resolution forum in the evolving sphere of medical science fails to take into consideration the rights and obligations of both the physician and the patient that extend beyond an action in tort. A mediation process, which is not governed by the operation of specific laws provides for a progressive framework that can help the parties reach at a resolution. In developed countries, even with the application of modern standards in litigation, mediation is seen as an alternative to litigation in order to cut down costs and address the concerns of the parties effectively. However, in India the absence of modern standards needs to be brought into light.
This paper seeks to subjectively examine the shortcomings of the litigation system in addressing medical malpractice disputes in order to establish the need for Mediation. Litigating healthcare disputes overlooks the established ethical considerations which could otherwise be respected by promoting a bilateral dialogue between the parties. The consequences of replacing the existing standards with modern axioms have also been examined which calls for a forum to address the concerns that might arise in adopting them. Mediation, is evaluated as a tool to circumvent the hindrances posed in litigating disputes in the existing system. Thus, mediation shall be seen as a primary attempt to ensure patient safety by internalizing standards and therefore providing a platform to settle disputes at interpersonal level.
Medical litigation has been on the rise in the country with consumers becoming more aware of their rights and seeking recourse to fight deficiencies in the process. As medical disputes are highly complex and require an ulterior level of skill to find out what went wrong; there is a greater burden on the parties to prove a case of medical malpractice beyond a reasonable doubt.
Further, suffering from inherent deficiencies in addressing medical disputes, litigation fails to take into consideration elements that are not incidental but ancillary to the doctor-patient relationship.
Since, the autonomy of the parties in discharging their duties is imperative, the presence of the archaic substantial and procedural laws has tarred this notion by placing the physician on a higher pedestal.
With the advent of ‘informed-consent’ shifting the perspective of decision making in the best interests of the patient, it is of vital importance for the laws to evolve in order to protect the autonomy of the stakeholders from being usurped, to ensure a fair service to the society in the form of accountable medical procedures and for the application of reliable and efficient standards to protect the rights of the parties to a litigation process.
However, in the absence of such laws, the process of mediation which operates beyond the application of procedural or substantive laws could provide a platform to accommodate these concerns. In the presence of a neutral mediator, the process of mediation is generally informal and does not follow a rigid set of rules. However, as the case may be, might be determined by the parties involved. Mediating conflicts could help overcome the obstacles posed by litigation while preserving what matters most to either of the parties.
As a result, the collaborative and cooperative nature of mediation could thus, result in better outputs over litigating medical healthcare claims.
To establish the need for mediation in resolving healthcare disputes we will first critically evaluate the litigation model currently adopted in the country. For that purpose, we will examine the consequences of litigating medical negligence under the prevailing law which relies on an orthodox standard of tests. Secondly, with the laws developing in favour of ‘informed-consent’ over ‘real-consent’, the shortcomings of the existing system in the light of the demand for a greater patient autonomy is analysed. Thirdly, it is imperative that a patient’s autonomy shall not come at the cost of professional autonomy and integrity, and hence, the need for a framework to reach a consensus respecting the ethical considerations is established. Therefore, we arrive at a phase where mediation could help to resolve conflicts, keeping aside the hindrances posed by a procedurally inefficient, cumbersome and time-consuming litigation process, both at a pre-diagnosis and post-treatment stage.
ANALYSING MEDICAL MALPRACTICE IN THE CURRENT LEGAL REGIME
- The Rule of Negligence and Standards Relied Upon
In the present day, a patient has a wide variety of legal recourses available in order to press charges against a medical professional in case of medical malpractice. A suit for damages can be brought under the Code of Civil Procedure, a complaint for negligence under the Code of Criminal Procedure, redressal of grievances under the Consumer Protection Act or disciplinary action under the rules of Medical Council of India.
However, the plethora of remedies available to a patient creates confusion in selecting the appropriate forum. Irrespective of the choices available to an aggrieved party, the standard of tests adopted by each of these forums to gauge the deficiency in providing professional services is similar.
It is to be noted that in order to ensure patient safety, the current legal reforms aim at merely addressing errors in the existing tort system or the need for a fairer compensation model in cases of medical malpractice.
Although such reforms have stood the test of time, there is a pressing need to move forward towards reforms making room for progressive laws. Through the imposition of rigid procedures on an otherwise delicate case of medical harm, litigation poses as an adversary. Cases of sheer medical negligence based on prima facie records do not even reach the trial stage for lack of compliance with complex procedures formulated in case laws considered to be the panacea of medical litigation.
Further, the possibility of liability for medical negligence under the existing laws does not create adequate deterrence for potential tortfeasors. In certain cases, the courts face difficulty to determine the actual standard of care practised by the doctor in a particular case. In cases of medical negligence where there is a need for expert evidence the court seeks for a credible opinion given by another competent doctor to support the charge of rashness or negligence on the part of the accused doctor. Considering the fact that a judge might find it difficult to use his own discretion while dealing with medical cases involving intricacies of medical science, this sounds plausible.
In cases involving medical negligence, the Apex court has placed heavy reliance on the Bolams Test as established in the case of Bolam v. Friern Hospital Management Committee. Under this test medical professionals are not expected to possess the highest skill and to work to an unrealistically perfect standard. As put by McNair J in the present case, “it is sufficient for the medical professional if he exercises the ordinary skills of an ordinary competent man exercising the particular art, 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”. However, as the case may be, a doctor conforming to practices endorsed by his counterparts will be absolved from negligence as he would be seen to be acting reasonably in the eyes of the law. This might pose a serious threat in the rapidly developing field of medical science.
In addition, negligence on account of clinical trials is something not unheard of in the country. The success of a new drug or medical equipment is uncertain as there is lack of information on account of its effects on the end user. There is a possibility of the experimental treatment being rendered to the patient in the absence of adequate disclosures. The consent given by a patient in this situation to become a test subject shall not be aimed at absolving the liability of a medical professional in case the outcome does not match the expectations. However, in the present scenario under the application of doctor-oriented Bolams Test, it is unlikely for the doctor to be held negligently liable. The Court placing reliance on reasonableness thus calls for expert opinion to gauge the standard of care and reasonableness exercised. As the treatment is new and still in the experimental stage there is a dearth of medical opinion in the professional field to look up to.
Consequently, in shifting from the doctor-oriented Bolams Test, the legal emphasis in cases involving the ever developing medicine and procedures will shift from that of establishing the breach of duty in performance towards one of consent where patients can argue that there was no informed consent on their part.
- Examining the Developing Notion of Patient Autonomy
For decades, medical paternalism was considered to be the cornerstone of medical practice. The fact that a physician had the ultimate authority to reign over the interests of the patients was not undisputed even by the canons of ethical science. It was a time when educational and technological advancements were still a thing of the distant past.
However, with changing times, the inhibition of political democracy in almost every field of civic life has fostered a sense of distrust towards professionals like doctors, lawyers, and accountants whereby the individuals now look for a reason when it comes to following the chain of authority or expertise. Similarly, the increasingly divergent moral pluralism in the society impels us to protect our rights from being usurped at the cost of our obligations. These factors bring us to a point where the supremacy of a physician who assumes full responsibility and is deemed to possess the ability to determine the patient’s best interests is undermined. Bringing an end to paternalistic practices could, therefore, emphasize a patient’s rights to decide for himself which dramatically narrows the benchmark through which a doctor’s reasonability is adjudged.
Protection of patient’s autonomy, arguably, stands for the rights of the patients through their liberty to choose what is best for them and for restoring balance to the doctor-patient relationship by humanizing it. The pillars of patient autonomy demand that a prudent patient shall have the right to determine for himself the appropriate treatment that would be suited to his needs. Therefore, it is safe to say that patient autonomy is at the core of ‘informed consent’.
A stark contrast to this widely accepted notion of patient’s autonomy can be drawn in the rationale adopted by the Courts in adopting ‘real consent’ over ‘informed consent’. In the landmark case of Samira Kohli v. Dr. Prabha Manchanda & Others, the Supreme Court of India has preferred real consent over informed consent citing the view that it was for the doctors to decide with reference to the condition of the patient, the nature of illness, and the prevailing established practices, how much information regarding risks and consequences should be given to the patients, and how they should be couched, having the best interests of the patient.
Real consent requires that the consent so obtained should be voluntary and the consent should be on the basis of adequate information concerning the nature of the treatment procedure so that he knows what he is consenting to. Further, the standard that the information to be communicated should be of the extent which is accepted as normal and proper by a body of medical professionals in that field does not do justice to a patient’s right in choosing the most appropriate course of treatment. In light of the discretionary powers given to the doctors in determining how much information has to be communicated to the patient for obtaining a real and valid consent, what constitutes to be adequate information is in the hands of the physician therefore arguably, curbing a patient’s autonomy.
On the other hand, an informed consent entails within its gamut a consent which carefully outlines the expected outcome and the likelihood of success, the alternative options available to the patient, the effect of no treatment or procedure and the risks associated with no treatment. Instructions taking into consideration as to what shall be done in case the treatment results to be unsuccessful also forms a material part of what is called to be informed consent.
As observed by Justice McNair in the Canterbury case:
“True consent to what happens to one’s self is the informed exercise of a choice, and that entails an opportunity to evaluate knowledgeably the options available and the risks attendant upon each. The average patient has little or no understanding of the medical arts, and ordinarily has only his physician to whom he can look for enlightenment with which to reach an intelligent decision.”
The shortcomings of the doctor-oriented test applied by the courts were outlined in the present case whereby the judge laid down that in order to maintain silence a physician might affirm a custom which is no custom at all, and the apparent custom merely lays down the personal opinion regarding what the physician himself or others might do given the situation. This proves that application of the current standard to gauge the exactness of disclosure requirements in resolving conflicts from the perspective of a reasonable doctor is inappropriate and inadequate. In the absence of adequate information related to the treatment, a patient is not in a position to evaluate as to what could pose as a possible risk.
Again, in Rogers v. Whitaker it was observed that risk is said to be material when a reasonable patient when warned of the risk starts attaching significance to the risks or cluster of risks in deciding whether or not to forego with the treatment or even when a reasonable physician is aware that the patient might find the risk significant if warned about. In the existing model where disclosure requirements are in shambles, adopting the rationale promoted in the Canterbury Test leads to an idealistic scenario which lays special emphasis on a ‘reasonably prudent patient’, as a result there is a greater burden on the physicians to disclose material risks associated with the diagnosis or treatment thereby allowing a patient to choose the most appropriate course of action.
Although the Supreme Court has left some scope for a greater patient autonomy but having regard to the ground realities in medical and health-care in the country, it has consciously preferred the concept of real consent evolved in Bolam and Sidaway in preference to the ‘reasonably prudent patient test’ in Canterbury. Further, the Court observed as: “If medical practitioners and private hospitals become more and more commercialized, and if there is a corresponding increase in the awareness of patient’s rights among the public, inevitably, a day may come when we may have to move towards Canterbury. But not for the present.”
With the advent of information technology and the patients being more educated, the physician-patient relationship has undergone dramatic changes. The physician-patient relationship is predicated on trust, and lack of trust can result in poor outcomes sometimes leading to an event as adversarial as a lawsuit. In the application of orthodox standards by our Courts, the dispute resolution model isolates itself from this relationship which involves deeply embedded emotions. In contrast to the existing disclosure practices, the conclusion drawn by Furrows is that a “consented to” treatment or procedure would not support a battery claim but consent obtained in the absence of a proper disclosure to the patient would support a medical negligence claim for lack of informed consent. Since, a patient’s autonomy forms an integral part of this relationship, aiming for a higher degree of patient autonomy by mandating disclosure practices so as to enable the patient to determine risks and choose from a wide variety of treatment options could therefore, preserve the otherwise eroding relationship.
The notion of informed consent is based on the principles of patient autonomy and the right of self-determination. In a system where there is a shift from the doctor-oriented standards towards a progressive framework where the patient is put on the forefront, it might be reasonable to think that the autonomy of the medical professionals would be more than often overlooked in the manner as the notion of patient autonomy is being overlooked in the present day. In the end, it is plausible that working towards building a cohesive relationship by creating greater autonomy could prevent possible medical litigations as the matter could be brought to a resolution at the inter-personal level, however, protection of patients’ rights at the cost of professional autonomy and integrity is a question that has to be pondered upon.
- Need for Balance Between Patient Autonomy and Professional Ethics
In a country like India which fosters a society that extends beyond cultural and linguistic barriers, a typical medical setup faces ethical choices in dispensing healthcare facilities to this morally diverse and pluralistic community. Drift in the sphere of medical science through greater patient autonomy might result in possibilities where a patient’s autonomy comes at the cost of that of a medical professional. The autonomy that is the moral integrity of both the patient and the physician needs to be preserved in order to do justice to the ethics of medical science. The ethical principles as to what ought to be done in a particular situation vary in application and are therefore not absolute.
These principles include patient autonomy (supporting and facilitating the capable patient’s exercise of self-determination), beneficence (promoting the patient’s best interest and wellbeing and protecting the patient from harm), non-malfeasance (avoiding doing harm to the patient), and distributive justice (allocating fairly the benefits and burdens of healthcare delivery).
It is often the case that a physician and patient are torn in conflict as to whether to move ahead with a particular treatment procedure or not. The biased view of ensuring patient autonomy at all costs, as observed in the Canterbury test might promote the patient to determine for himself according to his own rights and might even result in the patient refusing the treatment. This, in turn, limits a physician’s autonomy to act in beneficence to promote the wellbeing of the patient.
A question that often poses a concern pertains to the patient’s autonomy in emergency situations. Conversely, it can be argued that in cases of emergency, a physician’s autonomy prevails over that if a patient. Morally, there cannot be said to an imbalance in the relationship in such situations as a doctor tries his best to act in the interests of the patient. In a crisis, there is neither the time nor the capacity to invest in developing a better relationship.
Therefore, patients’ autonomy should not be seen as an idealistic model for the doctor-patient relationship. When the outcomes are well documented, then allowing the right to choose is the right thing to do. On the contrary when there are uncertainties and ambiguities linked to the process, as the case may be in cases of modern medicine, the physician in determining the course of action for the treatment cannot be seen as undertaking a paternalistic approach but doing justice to the caregiver rights by acting in beneficence.
Autonomy and beneficence are two principles so closely tied to the healing ends of medicine that to violate either is to imperil the moral integrity of both patients and physicians. The principles of justice and non-malfeasance are equally important but autonomy and beneficence are the two most powerful principles in shaping the patient-physician relationship today.
It is believed that informed consent is the cutting edge of the patient autonomy movement. Through it, proponents of autonomy-based medical ethics have proceeded far beyond concerns about extraordinary cases to a general restructuring of the form of every encounter between patient and physician.  On these lines, another point to consider is whether the definition of informed-consent should be standardized across all medical situations. Scholars have argued that informed consent is important in medical or research practice only when a proposed intervention would violate important norms if done without consent, or disrupt a legitimate expectation. In other cases where the violation of ethical norms cannot be brought into question if done without consent, consent has to be evaluated from a different perspective.
Adopting a uniform standard of taking consent with standardized disclosures would leave no difference in a consent communicated by a patient undergoing a routine medical procedure and a patient in a situation of risky but life-saving medical intervention. In such cases, although the autonomy of a physician is circumscribed by a competent patient’s or a valid surrogate’s right to refuse preferred treatment, the physician, however, is still obliged to act ethically by helping the patient arrive at an autonomous decision by enhancing or empowering the patient’s capacity to make authentic, self-governing choices.
A doctor may be bound by the ethical norms and obligations while a patient could be overwhelmed under the massive amount of pressure to make the right choice in the form of an ‘informed-consent’ even when their concerns might not adequately be addressed. In order to reach a balance between these elements, the need for a conflict resolution process that would take such ethical as well as individual concerns into consideration is imperative.
MEDIATION: THE APPROPRIATE DISPUTE RESOLUTION?
- Intervening at a pre-diagnosis stage (How Bioethics Mediation can bridge the differences?)
Informed consent is a form of communicative transaction which involves an information exchange between the parties to the transaction that is the patient and the physician. In fact, truth-claims regarding a medical procedure forms a material part of this transaction. Mere disclosure is not sufficient as it might preclude the established ethical norms from being taken into consideration. Obtaining a successful consent requires effective communication between the parties by paying due heed to the norms that include not only intelligibility or relevance but also norms for making, understanding and responding to the truth-claims.
The developments in the field of medical science have imposed a greater obligation to critically evaluate the scientific information and translate it to the patient instilling a therapeutic relationship whereby the wide array of treatment options have now replaced the ‘ability’ to intervene with the ‘obligation’ to intervene.  Questions, therefore, arise not only about how, when and whether to treat but also about under what circumstances should therapy be withheld or withdrawn. The level of pre-requisite communication between the parties differs according to the inferential capabilities of the patient. Empirical studies have found that the average patient can, at best, identify only half of the information supplied. Others show much lower levels of understanding. If there is inadequate understanding of the information through which their consent is sought, the consent obtained on such information will fail to provide legitimacy to the proposed intervention. In such a situation, intervening in the process of obtaining consent with bioethics mediation provides a level playing field to address the decision of the patient while keeping in mind the ethics of medical sciences. Bioethics mediation is about arriving at the most-appropriate plan to be undertaken for future care.
It is important to highlight that bioethics mediation relies on the ‘principled resolution’ which outlines the course of action giving due regard to the views of the stakeholders and is chosen from the options that fall within the accepted practice, legal norms and ethical conventions. Bioethics mediation can also facilitate situations concerning an incapacitated adult or minors or a legally compromised person who might not be in the right frame of mind to decide for themselves. They can be represented through an advocate who could be in the form of a friend or family. A family new to the medical landscape might find the procedures highly complicated and might feel intimidated. In this process the patient would be in a better position to understand the material facts, risks associated and exploring alternative courses of treatment.
The parties generally include the attending physician, other members of the healthcare team, and some advocate for the patient. The mediator is neutral and is deemed to possess adequate medical expertise. Therefore, in the presence of the stakeholders having conflicting views, an unbiased resolution could be worked out.
“The bioethics mediator recognizes that there are always multiple options for the plan of care. This may be in distinct contrast to the medical providers who more often tend to see only the best plan.”
Bioethics mediation thus ensures a balance between the autonomy of the patient and the physician by taking into consideration the fact that medical choices reflect personal values and therefore acting in the best interest of the patient is an obligation. It maximizes the options available to the party, and therefore, a patient earlier refusing to a particular treatment would now not encroach upon the doctor’s ethical obligation to act in beneficence as alternate courses of action could be determined and acted upon while having due regard for a patient’s personal values. It thus safeguards the relationship between law and society whereby the decisions of patients and families seem to challenge the modern healthcare institutions.
- Resolving conflicts at the post-treatment stage
As mentioned earlier, the existing dispute resolution system fails to take into consideration the need for a greater degree of patient and physician autonomy. With the application of regressive and orthodox laws and standards that currently form the cornerstone of medical litigation, to reach a mutually acceptable closure is practically impossible. We arrive at a juncture where there is a need to circumvent these obstacles posed by the current system. Mediation operates beyond the application of substantive or procedural laws and therefore portrays a win/win situation for both the parties. With the help of a mediator, the parties can arrive at a comprehensive mix suiting their needs, interests and whatever may deem to be relevant to resolve the conflict. For instance, addressing complex medical disputes in the litigation sphere leads to a rigid application of the laws. As a result, a step incidental to mitigate the harm already caused might come under scrutiny by posing as an added risk when the professional meant no further harm. On the contrary, mediation allows the parties to be flexible in order to reach creative, personalized solutions that are mutually acceptable which makes this process an effective tool to resolve healthcare disputes.
Further, the existing litigation system does not aim at preserving the therapeutic relationship between the patient and the physician. Rather, an act as adversarial as a lawsuit against a medical professional causes a great deal of hardship and distress to both the parties involved in the suit. Mediating disputes can help prevent this relationship from being eroded. Mediation is often believed to work best in a dispute in which the parties have had a significant prior relationship or when the parties have an interest in continuing a relationship in the future.
This is achieved by removing the parties’ adversarial posturing and replacing it with a harmonious relationship where the parties now mutually recognize each other’s problems.
Further, litigation is a long drawn process and does not resolve the conflict at the root. Instead, it continues for a prolonged period without addressing the central point of conflict. According to many scholars, taking recourse to alternative dispute resolution mechanisms can solve many of the problems posed by litigation at half the cost.
A number of landmark studies have confirmed that when patients complain or resort to litigation, it is most likely related to miscommunication between themselves and health care professionals. Even when the medical professional exercises utmost care, the outcomes might fail to match the expectations of the interested party. Lack of communication in such a situation might pose as an adversary to the professional. Litigation does not stand for an open dialogue, while mediation, on the other hand, stands for a cooperative behaviour between the parties thereby improving communication. However, mediation does not result in a binding agreement. The voluntary participation of parties expresses the emotional concerns for a morally acceptable explanation which results in shaping resolutions that the parties are likely to comply with. A patient not satisfied with the outcome of the process could still resort to litigation as a secondary option but with clearer intentions and understanding gained through the mediating attempt. Under such conditions, mediating healthcare disputes shall be seen as a failed attempt towards addressing the issue of case burden on the courts and an effort to make litigation efficient.
A possible shortcoming of mediating healthcare disputes could be the failure to highlight the incompetence of a doctor as the proceedings are highly confidential and settlements made at an interpersonal level. Arguably, litigating a medical malpractice lawsuit based on the existing tort law or criminal law does not adequately deter a physician’s incompetence. Armed with professional indemnity insurance, precedence in medical negligence might be of little or no value for medical practitioners in the present day. Conversely, the findings of the present mediation committee could act as a corrective measure for the doctor thereby helping them to internalize standards in their day-to-day discharge of professional duties, which would hopefully prevent the scenario of protection of patients’ rights in a litigative atmosphere to a large extent.
Another criticism could be that mediation might result in biased outcomes towards people belonging to a certain stratum of the society. However, this is not the case as not all people sue or are able to sue. An attempt to mediate the difference might give an opportunity to the people belonging to economically weaker sections of the society who otherwise might fail to even voice their concerns.
In the absence of efficient laws that seek to redress disputants’ claim in cases of medical malpractice, the operation of a mediation system can facilitate resolutions conveniently. The mediation process is a forward looking resolution mechanism which provides for flexibility. In the evolving field of medical science, it allows the parties to arrive at creative resolutions and to address their concerns suiting to the best of their interests.
The scope of mediation extends beyond merely resolving disputes at an inter-personal level. Mediation also improves the level of communication between the physician and the patient, gives equal weight to the values of both the parties through ethical considerations and optimizes cost and efficiency, therefore standing for an open dialogue and preventing adverse actions as opposed to litigating disputes. The disclosure practices undertaken in Bioethics Mediation ensures an ‘informed consent’ from the patient even when the law mandates the consent to be in the form of a ‘real consent’. In contrast to the present conditions, mandating due regard for this sacrosanct relationship imposes a greater obligation on the physician to internalize standards, therefore, making healthcare safer. The concerns revolving around the determination of compensation and privacy might pose as a challenge in adopting this model.
Therefore, mediation shall not be seen as the panacea of dispute resolution in situations of medical conflict but as a forum that allows the parties to come together and arrive at an amicable solution at an early conflict stage.
- Bryan A. Liang & Steven D. Small, Communicating About Care: Addressing Federal- State Issues in Peer Review and Mediation to Promote Patient Safety, J. Health Pol. Pol’y & L.219–240 (2003). ↑
- Code of Civil Procedure, 1908, No. 5, Acts of Parliament, 1908 (India). ↑
- Code of Criminal Procedure, 1973, No. 2, Acts of Parliament, 1973 (India). ↑
- Consumer Protection Act, 1986, No. 68, Acts of Parliament, 1986 (India). ↑
- Indian Medical Council Act, 1956, No. 102, Acts of Parliament, 1956 (India). ↑
- Jacob Mathew v. State of Punjab, AIR 2005 SC 3180. ↑
- Bolam v. Friern Hospital Management Committee,  1 WLR 582. ↑
- Id. ↑
- Rachel Mulheron, Trumping Bolam: A Critical Legal Analysis of Bolitho’s “gloss”, 69 CLJ 609-611 (2010). ↑
- Katrina Wingfield, Risks in the Advancement of Medicine, 152 NLJ 325–326 (2002). ↑
- ED Pellegrino, Toward A Reconstruction of Medical Morality: The Primacy of the Act of Profession and the Fact of Illness, 4 J. MED. & PHIL. 32 (1979). ↑
- Samira Kohli v. Dr. Prabha Manchanda & Ors., (2008) 2 SCC 1. ↑
- Id. ↑
- Canterbury v. Spence, (464 F.2d. 772, 782 D.C. Cir. 1972). ↑
- Id. ↑
- Id. ↑
- Id. ↑
- See supra note 12. ↑
- Id. at 33. ↑
- Sommers, Malpractice Risk and Patient Relations, 20 J. FAi. PRAc. 299, 301 (1985). ↑
- TOM L. BEAUCHAMP & JAMES F. CHILDRESS, PRINCIPLES OF BIOMEDICAL ETHICS 22 (5th ed. 2001). ↑
- MARIAN LIEBMAN, MEDIATION IN CONTEXT, 157 (Jessica Kingsley Publishers 2000). ↑
- See supra note 13, at 67. ↑
- Id. at 68. ↑
- STEPHEN WEAR, INFORMED CONSENT PATIENT AUTONOMY AND PHYSICIAN BENEFICENCE WITHIN CLINICAL MEDICINE 6 (Kluwer Academic Publishers 1993). ↑
- NEIL C. MANSON & ONORA O’NEILL, RETHINKING INFORMED CONSENT IN BIOMEDICINE 79 (Cambridge University Press 2007) ↑
- Id. at 87. ↑
- LINDA FARBER POST, JEFFREY BLUSTEIN & NANCY NEVELOFF DUBLER, HANDBOOK FOR HEALTH CARE ETHICS COMMITTEES 13 (The John Hopkins University Press 2007). ↑
- See supra note 25, at 42. ↑
- Nancy Neveloff Dubler, A Principled Resolution: The Fulcrum for Bioethics Mediation, 74 LAW & CONTEMP. PROBS. 177, 185 (2011). ↑
- Nancy Neveloff Dubler et al., Chartering the Future: Credentialing, Privileging, Quality, and Evaluation in Clinical Ethics Consultation, HASTINGS CENTER REP, 26 (2009). ↑
- supra note 30, at 186. ↑
- Lon Fuller, Mediation-Its Forms and Functions, 44 S. CAL L REV 305, 308 (1971). ↑
- See generally NANCY N. DUBLER & CAROL B. LIEBMAN, BIOETHICS MEDIATION: AGUIDE TO SHAPING SHARED SOLUTIONS (2004). ↑
- JOHN S. MURRAY, ALAN SCOTT RAU & EDWARD F. SHERMAN, PROCESS OF DISPUTE RESOLUTION: THE ROLE OF LAWYERS 287 (Foundation Press, 1989). ↑
- James W. Reeves, ADR Relieves Pain of Health Care Disputes, 49 DISp. RESOL. J. 16, 19 (1994). ↑
- Stephen Meili & Tamara Packard, Alternative Dispute Resolution in a New Health Care System: Will it Work for Everyone?, 10 OHIO ST. J. ON DISp. RESOL. 26, 31 (1994). ↑
- Danny WH Lee & Paul BS Lai, The practice of mediation to resolve clinical, bioethical, and medical malpractice disputes, 20 HONG KONG MED J 6, 7 (2015).↑
- See supra note 37, at 33. ↑
- SV Joga Rao, Medical Negligence Liability Under the Consumer Protection Act: A Review of Judicial Perspective, 25 Indian J Urol. 3, 365 (2009). ↑