final Jurisprudence.pptx It is totally about lawa

School Of Dental Sciences, CMCTH
(Department of community dentistry)
Medical
Jurisprudence
Guided by:
Dr Naresh Joshi Presented by:
Ramkrishna
Kushwaha, Mahesh
Khatiwada
Roll no. 23,15
BDS 9th Batch

Contents
• Introduction
• Doctor-patient contract
• Consent
• Professional negligence
• Consumer protection act

• Do’s and don’t ’s for health professionals
• Preventive measures
• Conclusion

Medical Jurisprudence (Legal medicine)
Juris=law Prudentia=knowledge
• Inrelation to practice of medicine
• Inrelation with legal consequences.
• It is the study and theory of law
Knowledge of law

Introduction
CHARAKA’ OATH-1000 B. C
“Thou shalt be free from envy, not cause
another’s death, and pray for the welfare
of all creatures. Day and night thou shalt
not desert a patient, nor commit adultery,
be modest in thy attire and appearance,
not to be drunkard or sinful, while entering
a patients house , be accompanied by a
person known to the patient. The peculiar
customs of the patients household shall
not be made public . ”

Doctor-Patient
Contract
• Contract is defined as an
agreement between two or
more persons which creates
an obligation to do or not to
do a particular thing.
• A dentist may refuse to treat
a patient for any reason
except race, creed, color,
national origin or based upon
a person’s disability.

EXPRESS OR IMPLIED CONTRACT
• Express contract – written or oral contract
• Implied contract – enacted by the action by the parties ,doesn't
require contract to be written or oral
Ex: express contract
Your parent signs a field trip permission slip
Ex:Implied contract
You prepay the attendant for gas (without saying a word) pump
your gas and leave

Implied contract
• Is one inferred from conduct
of parties and arises where
one person renders services
under circumstances
indicating that he expects to
be paid therefore , and the
other person knowing such
circumstances, avails himself
of the benefit of those
services.

Implied warranties owed by the doctor
• Use reasonable care and methods in the provision of services
as measured against acceptable standards set by other
practitioners with similar training in a similar community.
• Be properly licensed and registered and meet all other legal
requirements to engage in the practice of dentistry.
• Employ competent personnel and provide for their proper
supervision.
• Maintain a level of knowledge in keeping with current
advances in the profession.

• Not use experimental procedures.
• Obtain informed consent from the patient before instituting an
examination or treatment.
• Not abandon the patient.
• Ensure that care is available in emergency situations.
• Charge a reasonable fee for services based on community
standards.
• Keep the patient informed of her or his progress.
• Not undertake any procedure for which the practitioners is not
qualified.

Implied duties owed by the patient
• He must disclose all information that may be necessary for
proper diagnosis and treatment.
• He must co-operate with the doctor for any relevant
investigations required to diagnose and treat him.
• He must carry out all the instructions as regards drugs , food,
rest, exercise or any relevant/necessary aspect.
• He should notify the dentist of a change in health status.
• In the case of private medical practioner he must
compensate the doctor in terms of money.

An express contract
• Is an actual agreement of the
parties, the terms of which are
openly uttered or declared at
the time of making it, being
stated in distinct and explicit
language, either orally(oral
agreement) or in writing
(written agreement)

1. Continue to treat such a person
2. With reasonable care
3. Reasonable skill
4. Not undertake any procedure/treatment beyond his skill
5. Must not divulge professional secrets

CONSENT
• The term consent is
defined as when two or
more persons agree
upon the same thing in
the same sense they are
said to be consent.
• Voluntary agreement,
compliance or
permission.

Who can give consent
• Consent given by a person above age of eighteen .
• When the consent is given without undue influence.
• When consent is given by a person who is mentally sound.

When consent is not valid
• When the children below the age of eighteen.
• When consent is given under undue influence.
• When consent is given by a person which mentally
unsound.
• When the consent is given under mistake of fact or fear or
threat of any kind of injury.

Implied consent
• This is the most common
variety of consent.
• The fact that a patient
comes to a doctor for an
ailment implies that he is
agreeable to medical
examination in the general
sense

Express consent
• Anything other than implied
consent is express consent.
• This may be either oral or
written.
• The example of express
consent are notably
withdrawal of blood, radiology,
C. T scan etc.

• Express written consent is to
be obtained for all major
diagnostic procedures,
general anesthesia and for
surgical operations.

Informed consent
• The concept of informed consent has come to
the fore in recent years. All information must be
explained in comprehensible non-medical terms
preferably in local language about the
A) Diagnosis
B) Nature of treatment
C) Risks involved
D) Prospects of success
E) Prognosis
F) Alternative methods of treatment.

Proxy consent
• All the above types of consent
can take the shape of proxy
consent.
• Parent for child, close relative for
mentally unsound/unconscious
patient, etc.

Situations where consent may not be obtained
Fig: Medical emergencies Fig: Immigrants

Fig: Members of armed
forces
Fig: New admission to prison

Fig: Court order for psychiatric
examination
Fig:Handlers of foodman

Fig: Handlers of dairyman Fig:person suffering
from notifiabledisease
(HIV /AIDS)

Situations requiring extra caution
• Doctors should keep in mind certain high –risk situations, which
are common cause for medical negligence actions.
1. Retention of objects in operations site
2. Accident and emergency department
3. Amputation of wrong limb

Retention of objects Emergency department Amputation of
wrong leg

Professional negligence (Malpractice,
Malpraxis)
• Professional negligence is defined as
the breach of duty caused by the
omission to do something which a
reasonable man guided by those
considerations which ordinarily
regulate the conduct of human affairs
would do or doing something which a
prudent and reasonable man would
not do.

Medical negligence
• Medical negligence or
malpractice is defined
as lack of reasonable
care and skill or willful
negligence on the part
of a doctor in the
treatment of a patient
whereby the health or
life of a patient is
endangered.

Types of medical negligence
1. Civil negligence
2. Criminal negligence
3. Corporate negligence (Example: faulty equipment , lack of
supervision, inadequate staffing)
4. Contributory negligence

Common Medical Negligence:
1.Omitting the necessary treatment
• Insufficient diagnostics
• Delayed reaction to postoperative complications
• Delayed admission to hospital and to ICU

2.Complications in/or after surgery
• Intraoperative complication
• Exitus in tabula
• Complications concerning endoscopic complications
• Postoperative complications (bleeding, suture insufficiency,
peritonitis)

3.Wrong treatment
• Transfusion reaction (Incompatible blood transfusion)
• Telephone diagnostics (Therapeutic recommendations by
telephone without visiting the patient)
• Further wrong treatment (Retained instruments)

4.Mistake in care
• Insufficient prophylaxis of decubital ulcer
• Insufficient thrombosis prophylaxis
• Wrong positioning during operation

5.Adverse drug event, medication errors
• Wrong drug
• Wrong dose
• Wrong application/administration
• Wrong frequency
• Disregarding drug allergy

Criminal negligence
• Here the negligence is so great as to go beyond the matter of
mere compensation.
• Not only has doctor made wrong diagnosis and treatment,
but also that he has shown such gross ignorance, gross
carelessness or gross neglect for the life and safety of the
patient that a criminal charge is brought against him.

Some examples of criminal negligence are
1. Injecting anesthetic in fatal dosage or in wrong tissues.
2. Amputation of wrong finger, operation on wrong limb,
removal of wrong organ/tooth or error in ligation of ducts.
3. Operations on wrong patient.
4. Leaving instrument .
5. Leaving tourniquet too long.
6. Transfusing wrong blood.
7. Applying too tight plaster or splints
8. Performing a criminal abortion

Difference between civil negligence and
criminal negligence
Civil negligence
• No specific and clear violation of
law
• Simple absence of care and skill
• It is compared to a generally
accepted simple standard of
professional conduct
• Repairable damage to the
patient
Criminal negligence
• Must have specifically violated a
particular criminal law in
question
• Gross negligence, inattention or
lack of competency
• Not compared to a single test
• Irreparable damage to the
patient

Laws related to medical negligence in Nepal
1. National criminal code 2074(2017),Chapter 19: Treatment
offenses; section 230,231,232 and 233.
2. The consumer protection act 2075
3. NMC Act and NMC rules 2024

Section230:A person who has not been
licensed should not treat:
• Subsection (1):Who has been licensed by a competent authority
according to law, one should not treat , recommend and prescribe
medication
• Subsection (2):No matter what is stated in subsection 1 ,long term
experience holder, with information about treatment, taking proper
care and without affecting human organ
• Subsection ( 3):A person who commits or causes to be committed a
crime according to sub section 1 shall be imprisoned for upto 3 years
and fined upto 30000 rupees

Section 231: Don’t treat with ill
intention(बदनियतनिताई)
• Subsection (1): Treatment with an intent to kill or cause grievous hurt
to someone, providing another treatment in place of required one or
knowingly administering/prescribing of medicine or operating to kill
or cause grievous hurt
• Subsection (2) : The person who commits or make other to commit or
make other to commit the offence according to the following
1. Like killing someone for the loss of life(i. e punished with lifetime
imprisonment)
2. Like causing grievous hurt for injuries defined as grievous hurt(i. e
punished with imprisonment upto 10 years and fine up to 10000
rupees.

Section 232:Don’t treat with
recklessness(लापरबाही)or negligence
• Subsection (1): A person, eligible to provide treatment in accordance
with law, should not treat, administer/prescribe medicine, or operate
with recklessness
• Subsection (2): If any person dies or suffers grievous hurt due to act
pursuant to subsection 1 ,he/she shall be imprisoned for 5years and
fined up to 50000 rupees for recklessness ( लापरबाही) being the
cause and imprisoned upto 3years and fined up to 30000 rupees for
medical negligence (हेल्थिकरयाई) being the cause

Section 233:Don’t test in human body without
consent:
• Subsection( 1):Don’t proceed further without informing and taking consent
with the person concerned and the father , mother, or guardian for the
child or person who is not mentally sound
• Subsection (2):Even the drug in the human body must be considered
carefully
• Subsection (3):No one should take physical examination or changes organs
for improper financial gain
• Subsection (4):Against subsection 1,2,3 shall be imprisoned for up to 3
years and fined up to 30000 rupees.
• Subsection (5):For the death or grievous hurt of someone , according to
against subsection 1,2,3 shall be punished as if he had been killed and
causing grievous hurt (punished with imprisonment up to 10 years and
fine up to 10000rupees) he had committed

Consumer Protection Act (COPRA) 2075
Rights to the consumer
• Rights to easy access to goods or services,
• Right to choose quality goods or services
at the fair competitive price,
• Rights to be informed of the price
quantity, purity, quality of the goods or
services
• Right to get appropriate legal action taken
against the unfair trade and business
activity
• Right to get consumer education

Liability of seller
• To sell the goods to the consumer
without descrimination
• To keep price list of goods so that it is
clearly seen and understood by general
people
• To give the bill or receipt on selling the
goods
• To fulfill other liability as prescribed

Do’s for doctors
• Mention your
qualifications/trainings/designation
on prescription. Qualifications mean
recognized degrees/diplomas.
Mention of
scholarship/membership/awards
which are not qualifications should be
avoided
• Always mention date and timing of
the consultation

• Mention age and sex of the patient. In a
pediatric prescription, weight of the
patient must also be mentioned.
• Listen attentively. Look carefully. Ask
questions intelligently.
• If, after completing the examination, the
patient/attendant feels that something
has been left out or wants something to
be examined , oblige him.

• Always face the patient. Do not
stare . Some patients tolerate very
little eye contact. Learn to observe
out of the corner of your eyes.
• In case you have been
distracted/inattentive during the
history taking, ask the
patient/attendant to start all over
again. He will never mind it . As far
as possible, consultations should
not be interrupted for non-urgent
calls.

• Ask the patient to come back for
review the next day , in case you have
examined him hurriedly or if you are
not sure about the
diagnosis/treatment.
• Mention “diagnosis under review ”
until the diagnosis finally settled.
Fig: Doctor reviewing next day

• In complicated cases, record precisely the
history of illness and substantial physical
findings about the patient on your prescription.
• If the patient/attendant are erring on any
count(history not reliable, refusing
investigations, refusing admission)make a note
of it or seek written refusal preferably in local
language with proper witness.
• Mention the condition of the patient in
specific/objective terms. Avoid vague /non-
specific terminology.

• Record history of drug allergy.
• Write names of drug clearly. Use correct
dosages and mention clearly method
and interval of administration.
• Mention additional precautions, e.g.,
food , rest, avoidance of certain drugs,
allergens, alcohol, smoking, etc., If
indicated.

• Mention where the patient should contact in case of
your non-availability/emergency.
• Whenever referring a patient, provide him with a
referring note .
• In case of emergency/serious illness , ring up the
concerned doctor in the patients presence. Show your
concern.

• Routinely advise X-rays in injury /diseases of bones and joints
• Always rule out pregnancy before subjecting the uterus to X-
ray.
• Always read reports carefully and interpret the results of tests
/X-rays properly and make a note of it.
• Always seek proper legal and medical advice before filling
reply to the complaint referred to you from a consumer court.

• Update your knowledge and skill from time to time . Update the
facilities and equipment according to prevailing current standards in
your area.
• Preferably employ qualified assistants.
• Always obtain a legally valid consent before undertaking surgical
/diagnostic procedure. Learn the difference between informed
persuasion and informed consent. The first is legally wrong , through
at times it may be medically correct.

While administering an injection/drugs always
check:
1. Name of the drug
2. Expiry date
3. Reconfirm the route of administration
4. If it is to be diluted , check the dilution factor
5. Rate of administration
6. That a disposable syringe and needle are used
7. In case the patient is agitated/not co-operating
8. Confirm that it has been kept at the required temperature

Don’t for doctors
• Don’t prescribe without examining the patient, even if he is a
close friend or relative
• Never examine a female patient without presence of female nurse
/attendant
Fig: Doctor examining female patient in presence of attendant

• Don’t insist on the patient to tell the history of illness or be examined
in presence of others. He has right to privacy and confidentiality.
• Do not permit considerations of religion, nationality, race, party,
politics or social standing to intervene between you and your patient.

• Don’t smoke while examining the patient
• Don’t examine a patient when you are sick, exhausted, or under
influence of alcohol or any intoxicated substance.
• Don’t be overconfident. Don’t look overconfident.
• Don’t prescribe a drug or indulge in a procedure of you cannot
justify its indication, or a drugs which is banned
Fig: Don’t smoke while examining patient

• Don’t write instructions on a separate slip. Don’t allow substitution
• Don’t adopt experimental method in treatment . If there is some
rationale do it only after informed consent.
• Don’t do anything beyond your level of competence. Competence is
defined by your qualification, training and experience.

• When you are not sure what and why to do , consult your
senior /specialist/colleague.
• Don’t refuse if the patient/attendants want to leave against
medical advice. It is their right. Document this properly.
• Don’t withhold information, however harsh and difficult.

• Don’t give untrue , misleading or improper reports ,
documents, etc.
• Don’t refuse the patients right to examine and receive an
explanation about your bill regardless of the source of
payment; whether or not it is reimbursed by the government
or by his employer/insurance company.

Preventive measures-How to avoid litigation
1. True and NMC approved qualifications
2. Communication/Interpersonal behavior
3. Academic and technical upgradation
4. Medical /dental ethics and laws
5. Prevention by professional indemnity(Insurance cover)

True and NMC approved qualifications
• Training and experience of recognized centers are the
primary safeguard against litigation.
• The prescription heads, signboards and advertisement
should mention the actual facilities available. Refrain from
claims of guarantee of results.

Communication/Interpersonal behavior
• This is the key to doctor-patient relationship
• Increasing crowds of patients and improper communication
to the patient about diagnostics and treatment procedures,
complications and claims of guaranteed success are main
reasons for patient dissatisfaction.
• So it is desirable for us to give our behavior a human face
with a sympathetic attitude.

Academic and technical upgradation
• To keep pace with fast changing scenario of technical
advancement, one should regularly attend continuing
education programs, workshops and other academic
sessions and should also organize workshops to upgrades the
auxiliaries

Medical /dental ethics and laws
• A through knowledge of ethics and laws is essential for all
medical professionals.
• This helps in improving/correcting the practice standards
• Feedback form patients about the setup , staff, charges etc,
will give idea about further improvement/improvisation.

Prevention by professional indemnity
• Professional indemnity insurance is a tool, which not only
meets the claim of compensation awarded against
doctor/hospital but also gives a sense of mental security that
even if same negligence is proved the insurance company
will take care of it.
• The insurance company not only pay the compensation to
the other party but also arranges for legal help from
advocates.

Conclusion
• After the consumer protection act, 2075,came into effect, a
number of patients have filed cases against doctors.
Although , no human being is perfect and even the most
renowned specialist could make a mistake in detecting or
diagnosing the true nature of a disease, the doctor /dental
surgeon can be held liable for negligence only if one can
prove that she/he is guilty of a failure that no doctor with
ordinary skills would be guilty of if acting with reasonable
care

References
• Textbook of Public Health Dentistry – 7th Edition(Soben Peter)
• Simpson’s Forensic medicine -12th Edition
• The Essentials of Forensic Medicine and Toxicology-13th Edition
(K. S Narayan Reddy)
• Wiley’s Encyclopedia of Forensics Science- A. Jamieson
• Nepal consumer act 2075
• Nepal criminal court 2074
• National penal code 2074

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