General Legal Principles
If law is the set of rules we live by, then the US Constitution is the highest law. Written in 1787, the Constitution creates our government and states how it works. Each state has its own Constitution as well.
Legislative Law, Case Law, and Administrative Regulations
A significant amount of US law is based on case law, otherwise known as the “common law.” The common law has been created by the courts, generally ruling on disputes between 2 parties, over the past several hundred years, originating from English law. The common law provides the basis for the courts perspective on criminal law, contracts, property, and many other disciplines. The area concerned with medical malpractice is known as torts.
In addition to case law, elected legislative bodies, such as the US Congress or a state legislature, create statutory law. It is then, under the elegant system laid out by the US Constitution, the job of the executive branch (led by the president at the federal level and the governor at the state level) to carry out the laws. To do this, the various agencies and bureaus of the executive branch create administrative regulations, some of which may be quite detailed. Florida Administrative Code (§64J-1.006, FAC), for example, specifies the exact size of endotracheal tubes that must be carried on neonatal transport. Anyone providing neonatal transport in Florida who does not carry sizes 2.0, 2.5, 3.0, 3.5, and 4.0 mm is violating the FAC and potentially liable.
State Law and Federal Law
It is important to distinguish between state laws and federal laws. Medicine, and consequently medical malpractice, is generally regulated by the states. Medical transportation, however, is often regulated at both the federal and state level. The Federal Aviation Administration (FAA) controls all civil aviation. In addition, many states require companies that provide medical transportation to be accredited by the Commission on Accreditation of Medical Transport Systems (CAMTS), of which the American Academy of Pediatrics (AAP) is a member.
It is important to remember that state laws as well as state court decisions only apply in that state and are not binding on any other state. Clinicians must be familiar with the applicable law in the states in which they practice.General Structure of the Federal and State Court Systems
The judicial system in the United States is composed of 2 different systems. The Constitution gives certain powers to the federal government and other powers to state governments. Consequently, there are federal and state court systems whose role is to interpret their laws. Most, but not all, medical malpractice cases are heard in state courts. In each system, there is a hierarchical structure.
The courts where jury trials are held and where lawsuits are generally first filed are known as courts of original jurisdiction. In the federal system, these are known as the US District Courts. In the state system, there are a number of different names used (in Ohio, “Courts of Common Pleas”; in New York, confusingly, “Supreme Courts”). If either side appeals a case, the appeal is often heard next by an appellate court. In the federal system, there are 13 US Circuit Courts of Appeal. The states, once again, have a variety of names for these courts (in California, “District Court of Appeal”; in Pennsylvania, “Superior Court”). It is important to note that appellate courts generally look for mistakes in the application of the law by the lower court. They usually do not hear additional witnesses or admit new or different evidence in a case.
The top court of appeal in the federal government is the US Supreme Court. Of the millions of lawsuits filed in the United States each year, the US Supreme Court only decides between 100 and 150 cases. Each state also has a top appellate court. Whether the US Supreme Court or the State Supreme Court (which may have a different name) can make the final decision will depend on the particular issue. In transport, for example, the US Supreme Court would have final decision over any FAA related-dispute, whereas the State Supreme Court would have final say over the particular interpretation of a state law.
Role of the Jury
Most state and all federal courts allow either side of a medical malpractice case to request a jury trial. The number of jurors varies by locality or jurisdiction. Procedures differ between jurisdictions for selecting jury members from the pool of potential jurors. The jury must reach its decision in a medical malpractice case based on the facts it finds to be true by a preponderance of the evidence. This means that the jury must be convinced that a given fact is more likely true than untrue, or just beyond 50% probability. The number or percentage of jurors necessary to reach a verdict varies by jurisdiction.
The jury is considered the conscience of the court system. It is charged with the duty to make its decision based on the facts, evidence, and law presented to it, without allowing sympathy or prejudice to interfere in the process. The jury members may rely on their common understanding and experience in life to judge the reasonableness of the evidence and testimony and to decide what is true and not true.
Standard of Care
Often, the most significant fact that the jury must determine is whether the health care provider’s care in the case was within the standard of care. This, essentially, is a determination of whether the health care provider “negligently injured” the patient in some way as claimed in the lawsuit.
Simply, the standard of care is based on how competent practitioners with similar qualifications would have managed the patient’s care under the same or similar circumstances. The standard is generally based on usual practices that exist in a community. In current legal terms, community may mean a region or the entire nation, depending on the jurisdiction. The standard may also be based on the respectable minority rule. This rule lets the jury decide whether the practitioner, using best judgment, followed an alternative treatment recognized by a respectable minority of those in the profession. There is no current legal definition of what constitutes a respectable minority.
Generally, a medical expert of the same provider specialty will testify that the care provided did or did not meet the standard of care expected in similar circumstances.Although the court often makes legal rulings on issues that may affect what goes to the jury for its decision on facts, the concept of liability will be considered for medical malpractice claims as made up of 4 basic factual elements that the jury generally determines:
1. Duty: Did the health care provider establish a relationship with the patient that created a duty to provide care?
2. Breach: Did the health care provider fail to provide the care or provide it in a manner that fell below the standard of care of the specialty or profession?
3. Causation: Did the action or inaction of the health care provider that failed to meet the standard of care cause a legally recognized injury (physical, psychological, property damage, or damage to another legal right), worsen the injury, cause or increase expense, or (in some states) reduce the chances for a favorable outcome? Was there a logical connection between the failure to meet the standard of care and the resulting injury?
4. Damages: What award of money will compensate the victim for the injury or losses suffered and reasonably likely to be suffered in the future? This award typically includes medical expenses, hospitalization, home care, loss of wages, and pain and suffering.