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BIRTH-INJURY LITIGATION
1349
Malaria and leukaemia are two other conditions where physical abnormalities of red and white cells could impede flow through the microcirculation. The reduction in flexibility of both malariainfected red cells20 and leuksemic white cells21 22 has been advanced as a possible aetiological factor in circulatory occlusion in these conditions. As in other branches of medicine, differences in methodology are likely to lead to conflicting results. Red-cell deformability has been measured by filtration, 21 24 by centrifugation,25 and by viscometry of packed red cells,26 and mathematically from viscosity measurements of red-cell suspensions.27 All these methods have their special advantages and disadvantages and we must find out how they compare in given clinical circumstances.28 From a pathophysiological viewpoint, what remains to be established is the extent to which the observed invitro changes in erythrocyte deformability lead to in-vivo abnormalities in microcirculation bloodflow. BRÂNEMARK’S direct observations of microcirculation blood-flow, via titanium glass chambers mounted for long periods in the human arm, are an impressive step in this direction. 29
BIRTH-INJURY LITIGATION "The judge said that he had decided that something went wrong during the delivery. He found that, in attempting to deliver the child by forceps, Mr Jordan had pulled too hard and too long, and the baby’s head became stuck. The head had to be freed and in doing so the brain damage was caused."’ THIS judgment has shaken British obstetricians, in-
cluding Dr Singer (see p. 1373). Eight years ago, as a senior registrar, Mr J. A. Jordan was asked to attend a woman in prolonged labour. After failure to deliver by forceps he did a cxsarean section, and the baby proved to have brain damage. The mother sued, and at the hearing four titled obstetricians gave evidence: one believed that the attempt at forceps delivery had gone on too long; one said that, in all the circumstances of the case, he would not have attempted forceps delivery at all; and the other two maintained that there was no evidence of failure on Mr Jordan’s part. A senior pxdiatrician took the view that the baby’s injuries were a complication of the obstetric problem rather than of the obstetric management. In the eyes of many obstetricians who have been following the hearing, there was overwhelming paediatric and obstetric testimony in favour of the defendant. Yet Mr Jordan and the Birmingham Area 20. Miller, L. H., Usami, S., Chien, S.J. clin. Invest. 1971, 50, 1451. 21 Lichtman, M. A., Gregory, A., Kearney, E. ibid. 1973, 52, 350. 22. Preston, F. E., Sokol, R. J., Lilleyman, J. S., Winfield, D. A., Blackburn, E. K. Br. med. J. 1978, i, 476. 23. Gregersen, M. I., Bryant, C. A., Hammerle, W. E., Usami, S., Chien, S. Science, 1967, 157, 825. 24. La Celle, P. L. in Theoretical and Clinical Hemorheology (edited by H. Hartert and A. L. Copley); p. 333. Berlin, 1971. 25. Sirs, J. A. Phys. med. Biol. 1970, 15, 9. 26. Ditenfass, L., Burnard, E. D. Med. J. Aust. 1966, i, 1072. 27. Dintenfass, L. Nature, 1968, 219, 956. 28 Chien, S. Blood Cells, 1977, 3, 427. 29 Brănemark, P. I., Langer, L., Fagerberg, S. E., Breine, V. Diabetologia, 1971, 7, 107. 1 Guardian, Dec. 2, 1978.
Authority now have to find damages of 100 000. Lawyers traditionally distrust the objectivity of medical evidence in malpractice cases, and perhaps this is why so much expert evidence was discounted. But the case has more implications than a possible miscarriage of justice. Firstly, only about 97% of women entering hospital for delivery will leave with a live and healthy baby. The obstetrician’s task is to lessen risks to the fetus during pregnancy and labour, and much can be done; yet children will still be born brain-damaged. As The Lancet has argued before, proper care of such children should not depend on court awards. And sizeable awards of the kind just seen in Birmingham may encourage the outburst of litigation which is now a blight on the American scene. (In the U.S.A., the average "excess claim" is now around$147 000, and doctor-owned insurance companies now offer$1 million insurance cover for "as little as"$6800 per annum.) Secondly, can a legal mind, with barely a peripheral knowledge of the subtleties of labour, fairly judge the merits of a complex case such as this? The traditional - place for such discussions is the hospital clinical conference-an arena where arguments can be expanded forcefully without threat of legal penalty. Is it not possible, in such disputed cases, to replace the word-game of the Law by panels of experts appointed by the universities or Royal Colleges-with a view to improvements in practice rather than an exercise in public pillorying? The triennial reports on confidential inquiries into maternal deaths are evidence that obstetricians are ready to tackle these issues forthrightly. Thirdly, judgments such as that in Birmingham Health
will tend to deflect obstetricians into defensive medicine. They will be unwilling to attempt, or even to learn, such skills as mid-cavity rotational forceps, and the caesarean rate will rise, with increased risk to the mother and no improvement in the perinatal mortality rate. The implications for the National Health Services are enormous. Those maternity units which, in today’s impoverished state, are unable to provide the ideal obstetric, paediatric, and anxsthetic cover will now feel increasingly exposed to penalty by the courts. A drift into defensive obstetrics can only make things worse for all concerned.
OUT OUT DAMNED SPOT RECOMMENDATIONS for the control of infection have been classified as "established methods" for which good evidence is available, "provisionally established methods" for which there is some evidence, "rational methods" which are not amenable to experimental evaluation, and "rituals". In his famous lecture in 1850,2 Semmelweis described how the mortality from childbed fever had been reduced from 8-3% to 2-3% by the simple expedient of getting medical staff to wash their hands before examining a patient. Hand-washing is now an important part of the medical routine, but how often is it
to the Medical Research Council by their Committee on Hospital Infection. Lancet, 1968, i, 705, 763, 831. 2. Semmelweis, I. P. Protokoll der allgemeinen Versammlung der k.k. Gesellschaft der Aerzte zu Wein von 15th May 1850.
1.
Report
Malaria and leukaemia are two other conditions where physical abnormalities of red and white cells could impede flow through the microcirculation. The reduction in flexibility of both malariainfected red cells20 and leuksemic white cells21 22 has been advanced as a possible aetiological factor in circulatory occlusion in these conditions. As in other branches of medicine, differences in methodology are likely to lead to conflicting results. Red-cell deformability has been measured by filtration, 21 24 by centrifugation,25 and by viscometry of packed red cells,26 and mathematically from viscosity measurements of red-cell suspensions.27 All these methods have their special advantages and disadvantages and we must find out how they compare in given clinical circumstances.28 From a pathophysiological viewpoint, what remains to be established is the extent to which the observed invitro changes in erythrocyte deformability lead to in-vivo abnormalities in microcirculation bloodflow. BRÂNEMARK’S direct observations of microcirculation blood-flow, via titanium glass chambers mounted for long periods in the human arm, are an impressive step in this direction. 29
BIRTH-INJURY LITIGATION "The judge said that he had decided that something went wrong during the delivery. He found that, in attempting to deliver the child by forceps, Mr Jordan had pulled too hard and too long, and the baby’s head became stuck. The head had to be freed and in doing so the brain damage was caused."’ THIS judgment has shaken British obstetricians, in-
cluding Dr Singer (see p. 1373). Eight years ago, as a senior registrar, Mr J. A. Jordan was asked to attend a woman in prolonged labour. After failure to deliver by forceps he did a cxsarean section, and the baby proved to have brain damage. The mother sued, and at the hearing four titled obstetricians gave evidence: one believed that the attempt at forceps delivery had gone on too long; one said that, in all the circumstances of the case, he would not have attempted forceps delivery at all; and the other two maintained that there was no evidence of failure on Mr Jordan’s part. A senior pxdiatrician took the view that the baby’s injuries were a complication of the obstetric problem rather than of the obstetric management. In the eyes of many obstetricians who have been following the hearing, there was overwhelming paediatric and obstetric testimony in favour of the defendant. Yet Mr Jordan and the Birmingham Area 20. Miller, L. H., Usami, S., Chien, S.J. clin. Invest. 1971, 50, 1451. 21 Lichtman, M. A., Gregory, A., Kearney, E. ibid. 1973, 52, 350. 22. Preston, F. E., Sokol, R. J., Lilleyman, J. S., Winfield, D. A., Blackburn, E. K. Br. med. J. 1978, i, 476. 23. Gregersen, M. I., Bryant, C. A., Hammerle, W. E., Usami, S., Chien, S. Science, 1967, 157, 825. 24. La Celle, P. L. in Theoretical and Clinical Hemorheology (edited by H. Hartert and A. L. Copley); p. 333. Berlin, 1971. 25. Sirs, J. A. Phys. med. Biol. 1970, 15, 9. 26. Ditenfass, L., Burnard, E. D. Med. J. Aust. 1966, i, 1072. 27. Dintenfass, L. Nature, 1968, 219, 956. 28 Chien, S. Blood Cells, 1977, 3, 427. 29 Brănemark, P. I., Langer, L., Fagerberg, S. E., Breine, V. Diabetologia, 1971, 7, 107. 1 Guardian, Dec. 2, 1978.
Authority now have to find damages of 100 000. Lawyers traditionally distrust the objectivity of medical evidence in malpractice cases, and perhaps this is why so much expert evidence was discounted. But the case has more implications than a possible miscarriage of justice. Firstly, only about 97% of women entering hospital for delivery will leave with a live and healthy baby. The obstetrician’s task is to lessen risks to the fetus during pregnancy and labour, and much can be done; yet children will still be born brain-damaged. As The Lancet has argued before, proper care of such children should not depend on court awards. And sizeable awards of the kind just seen in Birmingham may encourage the outburst of litigation which is now a blight on the American scene. (In the U.S.A., the average "excess claim" is now around$147 000, and doctor-owned insurance companies now offer$1 million insurance cover for "as little as"$6800 per annum.) Secondly, can a legal mind, with barely a peripheral knowledge of the subtleties of labour, fairly judge the merits of a complex case such as this? The traditional - place for such discussions is the hospital clinical conference-an arena where arguments can be expanded forcefully without threat of legal penalty. Is it not possible, in such disputed cases, to replace the word-game of the Law by panels of experts appointed by the universities or Royal Colleges-with a view to improvements in practice rather than an exercise in public pillorying? The triennial reports on confidential inquiries into maternal deaths are evidence that obstetricians are ready to tackle these issues forthrightly. Thirdly, judgments such as that in Birmingham Health
will tend to deflect obstetricians into defensive medicine. They will be unwilling to attempt, or even to learn, such skills as mid-cavity rotational forceps, and the caesarean rate will rise, with increased risk to the mother and no improvement in the perinatal mortality rate. The implications for the National Health Services are enormous. Those maternity units which, in today’s impoverished state, are unable to provide the ideal obstetric, paediatric, and anxsthetic cover will now feel increasingly exposed to penalty by the courts. A drift into defensive obstetrics can only make things worse for all concerned.
OUT OUT DAMNED SPOT RECOMMENDATIONS for the control of infection have been classified as "established methods" for which good evidence is available, "provisionally established methods" for which there is some evidence, "rational methods" which are not amenable to experimental evaluation, and "rituals". In his famous lecture in 1850,2 Semmelweis described how the mortality from childbed fever had been reduced from 8-3% to 2-3% by the simple expedient of getting medical staff to wash their hands before examining a patient. Hand-washing is now an important part of the medical routine, but how often is it
to the Medical Research Council by their Committee on Hospital Infection. Lancet, 1968, i, 705, 763, 831. 2. Semmelweis, I. P. Protokoll der allgemeinen Versammlung der k.k. Gesellschaft der Aerzte zu Wein von 15th May 1850.
1.
Report