1 SAMJ VOL80 6 JUL The legal liability of doctors and hospitals for medical malpractice \ F. F. W. VAN OOSTEN Summary A broad ovewiew of the fundamental principles relating to leaal liability for medical malpractice is presented. The issues e&unded; discussed and illustrated are the nature and consequences of the relationship between doctor/hospital and ~atient,effective consent as a reauisite of lawful medical interventions, emergency treatment, medical negligence and the vicarious liabilii of doctors/hospitals for the negligence of others. S Afr Med J 1991;80:2327. Medicine and law have since time immemorial been strange bedfellows. Famous ancient sources that bear testimony to the interrelationship between medicine and law are, for instance, Hammurabi's Code and the Hippocratic Oath, which contain a number of legal and ethical provisions governing the legal liability and behaviour expected of medical practitioners. Today the conduct of doctors and practice of medicine are regulated by a steadily increasing body of medicolegal principles of diverse origin. Examples of these in the international sphere are the Declarations of Geneva, Helsinki, Oslo and Tokyo and the International Code of Medical Ethics, and in the local sphere, the South African Medical and Dental Council's rules of conduct as well as the South African Medical Research Council's ethical considerations in medical research, to mention but a few. In addition, there is the South African legal system itself, which governs a multitude of aspects relating to the practice of medicine. A substantial number of these are dealt with by various statutes (e.g. the Medical, Dental and Supples No. 56 of 1974 and Nursing Act mentary Health S e ~ c e Act No. 50 of 1978) and diverse scattered statutory provisions (e.g. the Abortion and Sterilisation Act No. 2 of 1975 and the Human Tissue Act No. 65 of 1983) that deal specifically with medical matters. while the remainder fall within the ambit of the common law (i.e. legal custom and judicial precedent). Matters encompassed by medical law are, apart from those discussed here, among others, abortion, sterilisation, euthanasia, experimentation, insanity, intoxication, medical secrecy, organ and tissue transplantation, artificial human procreation and 'sexchange' operations. One of the many aspects of medical law that presents a constant source of concern and anxiety to medical practitioners is that of legal liability for medical malpractice. Medical malpractice suits may not only have serious financial implications for the medical practitioner but may also adversely affect his professional reputation. However, a fundamental notion of and scrupulous adherence to a number of cardinal legal principles relating to the doctorpatient relationship can go a long way towardsavoiding medidicalmalpractice litigation and its attendant inconvenience and embarrassment. This article attempts to present a broad overview of the salient features of Department of Criminai Law, University of Pretoria F.F. W. VAN OOSTEN, B.A. LL.B., LL.D., LL.D. Accepwd 14 Sepr 1990 medical malpractice liability in the South African context. This is done with reference to the relationship between doctor/ hospital and patient, consent to medical interventions, emergency treatment, medical negligence and vicarious liability. The relationship between doctor/hospital and patient The legal relationship between doctor or hospital and patient is primarily based on contract,' but may also be based on a duty of care (e.g. where a seriously injured unconscious patient is brought to a casualty ward for emergency treatment). In the ordinary course of events, the parties enter into an express or tacit agreement: the patient consults the doctor about his complaint, and the doctor undertakes to diagnose the patient's ailment and treat his condition in return for payment of his professional fees. Moreover, since in terms of the fundamental principles of freedom of contract both doctor and patient are free agents, this means that medical practitioners have neither a professional right (on the basis of their ethical duty to heal and act in the patient's best interest) nor, generally speaking, a legal duty to intervene medically. As regards the former, our law proceeds from the cardinal premise that the patient has a right to selfdetermination and, hence, a right to refuse medical treatment that may save his life or preserve his health (see Phillips v De Klerk 1983(T) (unreported), in which it was held that a Jehovah's Wimess has the right to refuse a lifesaving blood transfusion). As regards the latter, a legal duty to administer treatment will, as an exception to the general rule, be incumbent upon a medical practitioner in the following categories of instances: 1. Where he assumes control over a potentially dangerous situation andlor object. Thus a failure by hospital staff to: (23 properly set the patient's ankle fracture and mould the plaster of Paris cast; '(iz] initially check the fracture dislocation by means of radiographs; and (iiz] subsequently correct the fracture position, resulted in the hospital being held liable for darnages.2 Likewise, a failure by an anaesthetist constantly to monitor the patient and to ensure that the endotracheal tube remained correctly inserted, resulted in the anaesthetist being convicted of culpable homicide.3 2. Where he is under a statutory duty to act.failure by a district surgeon to vaccinate patients who present themselves for compulsory immunisation against a communicable disease ' ' 'ly liable. may render him civilly &or 3. Where he is under a contractual duty to act. Failure by a doctor to respond to an urgent call from one of his regular patients, who is being treated by him for a serious condition, which results in harm to the patient, may render him civilly and/or ' ' 'ly liable. 4. Where an emergency situation exists. Failure by a medical practitioner to render assistance in cases of a bomb blast or traffic accident may render him civilly and/or criminally liable. It must be pointed out, however, that these categories of cases in which legal liability for an omission may be incurred, do not represent a closed list. The courts are at any given time free, should these categories prove to be inadequate to cater for new situations that may arise, to extend them in accordance
2 24 SAMJ VOL80 6 JUL1991 with the prevailing juristic notions of society. In such cases the test of legal liability will be whether the omission in question was objectively unreasonable in terms of society's notion of what might be expected of medical practitioners in the circumstances. Whether or not an omission to act will be considered objectively unreasonable, will depend upon all the surrounding circumstances of the case on hand, inclusive of factors such as the doctor's actual knowledge of the patient's condition; the seriousness of the patient's condition; 'the professional ability of the doctor; the physical state of the doctor; the availability of other doctors, nurses or paramedics; the interests of other patients; and professional ethical considerations. However, it is important to note that in the absence of negligence on the doctor's part, legal liability for omissions is out of the question. Effective consent to medical interventions The doctorpatient relationship being primarily contractual by nature and, hence, one which requires agreement between the parties as to the proposed medical intervention, it follows that the patient's consent is fundamental to lawful medical interventions. Indeed, barring exceptions, such as emergency situations, stgtutory authority and, conceivably, authorisation by the court, the general rule is that in the absence of effective consent of either the patient himself or of someone acting on his behalf, medical interventions are unlawfid and may result in the doctor being held liable for assault or negligence or in him being unable to recover his professional fee. This applies irrespective of whether or not the intervention was administered with,due care and skill and eventually proves to have been beneficial to the patient. To allow doctors to administer medical treatment against their patients' will on the basis of the doctorknowsbest and inthepatient'sbestinterest criteria, would be tantamount to practising medical paternalism at the expense of patient autonomy. Like the contract between doctor and patient, consent is usually implied by the patient's conduct, but may be granted expressly either orally or in writing. The requirements of effective consent in the medical context are the following: 1. It must be recognised by law, that is it must be in accordance with public policy. Factual consent by a philanderer to undergo castration to save his faltering marriage or by a kleptomaniac to have his hands amputated so as to render future thefts by him virtually impossible, will not be legally recognised. 2. It must be given by someone who is legally capable of consenting. Two classes of patients must be distinguished here: (a) Adults. Adults, provided they are sane and sober, have the capacity validly to consent to medical interventions. Should the patient be in a state of unconsciousness, delirium, shock or coma, he will be incapable of consenting in law. Although the same applies to patients who are mentally ill, they are specifically catered for by the Mental Health Act (No. 18 of 1973, section 60 (A)) which provides that the consent of the following persons, in order of precedence, must be procured: a curator, the patient's spouse, parent, major child, brother or sister or, where the patient has been admitted to a mental institution, the superintendent (provided the aforementioned persons cannot after reasonable enquiry be found and the doctor has reasonable grounds to believe that the intervention in question is necessitated by the patient's life b e i i endangered or his health seriously threatened) of that institution. In the case of married couples, each spouse must consent to his or her own treatment. diagnosis &or (b) Minors. Minors who have attained the age of 18 years are competent, provided they are sane and sober, validly to consent to medical operations and treatment without the &stance of their parents or guardians (in terms of the Child Care Act No. 74 of 1983, section 39(4)). Minors under the age of 18 years, however, need the consent of their parents or guardians to medical interventions. In the event of a conflict between the child's father and mother, the father's views settle the matter unless they go manifestly against the child's medical interests. Where a minor under the age of 18 years refuses to submit to an indicated medical intervention consented to by his parents, the doctor would be safe to rely upon the latters' consent. Where the parents or guardians have delegated their power to consent to medical interventions upon their children to, for instance, relatives or teachers, the latters' consent suffices. Moreover, the Child Care Act (sections 39(1) and (2) and 53(1) and (4); cf &on 53(3)) vests the authority to consent to indicated medical operations upon and treatment of children in persons other than the child's parents or guardians to cater for contingencies: (3 the minister of health and welfare where the parents or guardians refuse consent on, for example, religious grounds, or where the parents or guardians cannot be found or where the parent or guardian is mentally ill or deceased; and (iz] the superintendent of a hospital, heads of institutions, such as reform schools, schools of industries and children's homes, and persons in whose custody the child finds himself where the medical intervention is necessary to preserve the child's life or to save him from serious and lasting physical injury or disability and so urgent that it cannot be deferred for the purpose of consulting the person who is legally competent to grant consent. 3. It must be informed consent. Ordinarily, lawfid consent is out of the question unless the consenting party knows and appreciates what it is that he consents to. Since the patient is usually a layman in medical matters, knowledge and appreciation on his part can only be effected by furnishing him with appropriate information In this way, adequate information becomes a requisite of knowledge and appreciation and, therefore, also of lawful consent. In the absence of information, real consent will be lacking. In turn,this means that the informedconsent requisite casts upon the doctor as an expert a corresponding legal duty to provide the patient with the necessary information to establish knowledge and appreciation and, hence, real consent on his part. The purpose and function of the informedconsent requisite is: (I] to ensure the patient's right to selfdetermination and freedom of choice; and (ii) to encourage rational decisionmaking by enabling the patient to weigh and balance the benefits and disadvantages of the proposed intervention in order to come to an enlightened choice whether to undergo or refuse it. What this means, is that the doctor must give the patient a general idea (there being no obligation to disclose in detail all the complications that may arise) in broad terms and in layman's language of the nature, scope, administration, importance, consequences, risks, dangers, benefits, disadvantages and prognosis of, as well as the alternatives toj the proposed intervention. More particularly, all serious and typical risks and dangers should be disclosed, but not unusual or remote risks and dangers, unless perhaps they are serious or typical or where the patient makes enquiries about them. Thus a duty to disclose the serious risk of disfigurement, cosmetic changes, severe irradiation, necrosis and amputation of a minor patient's legs and hands was held to have been incumbent upon a doctor who had administered radical radiotherapy for Kaposi's haemangiosarcoma without informing the patient's mother of these dangem4 On the other hand, a duty to disclose the remote risk of becoming sterile and of receiving bums, which caused the patient a great deal of pain and discomfort, was held not to have been incumbent upon a doctor who had administered radiotherapy to remedy the patient's fibrosis of the uterus.5 Whether disclosure of the diagnosis is obligatory, is a moot point, but it is conceivable that diagnosis disclosure is imperative where: (13 it may affect
3 &e patient's decision whether or not to submit to the proposed intervention; (n] it an express Or implied term of the contract between doctor and patient; and (iiz] it is essential for therapy. An extended duty of disclosure is commonly recognised where the patient asks questions, in which case there is a duty incumbent upon the doctor to respond both fully and truthfully to the patient's enquiries. On the other hand, no duty of disclosure would appear to exist where: (9the patient is already in possession of the requisite information: (iz) the patient expressly or irnpliedly waives his right to information; (ii] the defence of a socalled 'therapeutic privilege' or 'contraindication', in terms of which the harm caused by disclosure would be greater than the harm caused by nondis&osure (e.g. in terminal cancer or emphysema cases, but only if a real conflict exists between the duty to inform and the duty to heal), is applicable; and (h) disclosure is, in the circumstances, physically impossible (e.g. where a minor patient is brought to hospital and left there for diagnosis and treatment by his parents or a relative and thk latter leave for home where they m o t be contacted). 4. It must be comprehensive, that is extend to the entire transaction, inclusive of its consequences. 5. It must be clear and unequivocal 6. It must be free and voluntary, that is not induced by fear, force or fraud. A genuine but mistaken belief on the doctor's part that lawful consent to a medical intervention has been granted will not exclude the wrongfulness of his conduct, but may exclude the requisite intention for assault, and a mistaken but reasonable belief to the same effect may exclude negligence on his part. Emergency treatment Medical interventions in emergency situations may be justifled by one of two defences: l. Unauthorised administration. Where, due to unconsciousness, delirium, shock or coma arising from indulgence or accident, it is impossible to obtain the patient's consent to a medical intervention, which is urgently necessary to save his life or to preserve his health, the defence of unauthorised administration may avail the doctor who performs the intervention. Like the defence of consent, unauthorised administration renders the intervention in question lawful, provided the following requirements are met: (a) There must be m emergency which necessitates the intervention, that is there must be an immediate threat to the patient's life or health that renders the delay of the intervention until such time as the patient will be in a position to consent immssible. (b) The patient musr be incapable of consenting to the inrervention. Where the patient is capable of consenting, his consent must be procured, irrespective of the danger to his life or health. The fact that a mere imminent threat to the patient's life or health provides no justification in terms of unauthorised administration for emergency interventions where consent is obtainable, is amply borne out by the patient's right to refuse lifesaving or healthpreserving treatment. An emergency in unauthorisedadmin+tration cases therefore not only relates to the patient's life or health, but also to the impossibility of procuring his consent. (c) The intervention musr not be against the patient's will. Since unauthorised administration implies that the patient would have consented to the intervention in question had he been in a position to do so, it follows that medical interventions against the patient's will cannot be justified by unauthorised administration. (d) The intervention must be intended to save the patient's life or to protect his health. 2. Necessitg. Like unauthorised administration, necessity as a defence in the medical context also connotes lawful medical interventions in emergency situations, but unlike \ unauthorised administration it does not require that the patient was incapable of consenting or that the intervention m k t not be against his will or that the intervention must be in his best interest. Necessity as a defence will therefore be relevant where the patient was capable of consenting or where the intervention was against his will or where the intervention was performed in the community's best interest. Thus the inoculation of healthy persons against their will in order to prevent a dangerous and infectious disease from spreading may be justified in necessity. Likewise, an emergency blood transfusion on the unconscious victim of a bank robbery, who subsequently turns out to be a Jehovah's Wimess, may be justified in necessity. An emergency deviation from or extension of the operation agreed upon (where the patient's consent is sufficiently wide to cover the extension or deviation, it goes without saying that the extension or deviation is justified by consent), to save the patient's life or to preserve his health while he is under an &aesthetic on the operating table, may be justified by necessity or unauthorised administration, depending upon whether or not the deviation or extension eventually proves to have been against his will. A genuine belief that an emergency situation existed may, again, excuse the doctor from liability for assault, while a reasonable belief to the same effect may excuse him from liability for negligence. Medical negligence 1. Factual situations. The fact that the patient's consent has been obtained or a situation of emergency exists does not, however, rule out civil ancuor criminal liability for the medical intervention performed by the doctor. If the diagnosis or treatment is performed negligently and causes the patient physical or mental harm or his death, the negligent doctor may be held liable (civilly for damages and criminally for culpable homicide as the only relevant crime for which negligence suffices; where the doctor has the intention to kill, as in the case of euthanasiay6he may be convicted of murder) on account of negligence. Negligence in the medical context refers to a multitude of situations, among others the performance of an illegal operation, the use of defective medical instruments or equipment, a wrongful diagnosis, a wrongful blood transfusion, incorrect or incompetent technique or procedure, incorrect or incompetent administration of anaesthesia, the administration of an overdose of medicine or drugs, leaving behind medical instruments or equipment in the patient's body, insdecient aftercare, and excessive radiotherapy, to mention but a few. 2. The test of negligence. In any given context, negligence means: ( i ) that the defendant or accused failed to foresee and guard against the possibility of harm to the plaintiff or victim; and (iz? that the reasonable man in his position would have foreseen that possibility of harm and would have guarded against it. Fundamentally the test is an objective one in so far as the hypothetical or fictitious 'reasonable man' sets the standard, but it also comprises a subjective element inasmuch as it requires, in addition, that the reasonable man be placed in the same position as the defendant or accused found himself at the time. In turn, the reasonable man is commonly defined not as the perfect man, but as the man of average intelligence, knowledge, competence, care, skill and prudence. 3. The reasonable doctor. One of the wellrecognised exceptions to the basic objective test for negligence is the case where a person professes expertise in a particular field. In
4 such instances the standard of negligence is raised to that of the reasonable expert. Since the medical practitioner is professionally qualified, this means that he is judged in accordance with the reasonableexpert criterion, the test being the reasonable doctor in the position of the individual doctor. In this regard, however, it has repeatedly been emphasised that what is required of the medical practitioner is not the highest possible degree of professional care and skill, but reasonable care and skill. Consequently, the standard is not based on what can be expected of the exceptionally able medical practitioner, but simply on what can be expeaed d the average medical practitioner, in mind that a Ilredical practitioner is a human being and not a machine. 4. General practitioner or spedalkt. In conformity with the reasonableexpert standard, the test of negligence clearly distinguishes between the standard of care and skill required of specialists as opposed to general practitioners. If the doctor is a general practitioner, the test is the reasonable general practitioner. If the doctor is a specialist, the test is the reasonable specialist in terms of the branch of the profession to which he belongs. Thus, if the specialist is a heart surgeon or a ne~rologist,~the test will be the reasonable heart surgeon or neurologist, as the case may be. The only exception to the rule is where a medical practitioner professes to be or holds himself up &a specialist in a particular sphere, in which event he will be bound by his representation and judged accord'iy. Closely allied to this exception is the rule that where a medical practitioner, who does not hold himself up as a specialist in a particular sphere, engages in an undertaking that requires a certain degree of experience, knowledge, skill or training, well knowing that he lacks that degree of experience, knowledge, skill or training the socalled impen'ria d p a e izahmeratur rule. 5. Locality of practice. There are conflicting opinions7on the question whether the locality where the doctor practises should be afforded a role in determining whether or not he was negligent. On the one hand, there is the view that the same skill and care cannot be expected of a doctor in a country town as of a doctor in a large centre. On the other hand, there is the view that the fact that several incompetent or careless practitioners happen to settle at the same place, cannot affect the standard of diligence and skill that local patients have a right to expect. Taking into consideration the uniformity, generally speaking, of medical training in South Africa, the latter opinion seems preferable. This must, however, not be taken to mean that the place where the medical inremention is carried out is completely irrelevant in determining negligence. Since nesiigence is dependent upon all the surrounding circumstances of the case on hand, the facilities and personnel at the hospital or clinic where an operation is carried out will, in conjunction with the practice of the profession, be relevant factors in determining whether or not the doctor concerned was negligent. 6. Contributory negligence. The fact that the patient also contributed to the harm that has befallen him, affords the doctor who is guilty of negligence no defence. Contributory negligence can at best lead to an apportionment of damages or mitigation of sentence. Likewise, whether the degree of negligence established on the doctor's part is slight or gross, makes no difference to his civil andlor criminal liability, but may iduence the quantum of damages awarded War severity of the punishment imposed. 7. Onus of proof. The onus of establishing negligence on the doctor's part lies with the patient in a civil case and the State in a criminal case. In a civil case negligence must be established on a balance of probabilities, whereas in a criminal case negiigence must be proved beyond reasonable doubt. In this regard, it must be noted that the patient or State cannot rely upon the case speaking for itself the socalled res ipsa loqdtur rule in dischargiog hirnsewitself of W i t s burdenof proof. The fan that the case speaks for itself may amtribute to establishing neg&we, but does not, as such, constitute proof of negligence, Thus negligence will not automatically be taken to have been established o n a it is proven that a doctor injected an allergic patient with penicillin or that the doctor left a pair of forceps in the patient's body. It is not wholly surprising that this situation has met with severe critidsm on the basis that where the case speaks for itself, there ought to be a pmumption of negligence in favour of the patient, which may then be rebutsed by the doctor. At present the patient as a layman is in the invidious position that he is saddled with the full burden of establishing medical negligence and, comeqmtly, with taking on experts in their own f ~ l da. variety of solutions has been affered and devised to remedy this imbalance to ensure that justice is done to both doctor and patient, but as yet some of these have not been put to the test, while those that have been implemented have, in the main, not lived up to expectations. To place the onus of disproving negligence with the doctor also does not provide the answer to the problem, since that in turn would put him at a disadvantage. Hence, the patient's position in this respea remains essentially an unequal and unsatisfactory one. Vicarious liability 1. Doctors. Unless they have exercised a negligent choice by knowingly selecting an incompetent and inexperienced anaesthetist, radiologist or nurse, medical practitioners cannot incur legal liability for the negligent conduct of such anaesthetist, radiologist or nurse acting under his direction and supervision. The reason for this is that anaesthetists, radiologists and nurses perform their services as independent contractors and not as servants of the medical practitioner vncerned. The patient or State will therefore have to take action against the negligent anaesthetist, radiologist or nurse concerned. 2. Hospitals. Until recently,8 a similar view has been taken in cases of hospital liability for negligent conduct on the part of its professional personnel, which falls within the scope of their employment or the exercise of their duties, although there was no unanimity on the point. The majority view used to be that since doctors and nurses in the service of a hospital are not its employees when it comes to the performance of provided it has their professional duties, the hospital exercised reasonable care in assuring itself of their professional competence mnnot incur legal liability for the wrongful conduct of its doctors or nurses. Since, on the other hand, hospital personnel are under the control of the hospital in respect of their administrative duties, it can incur legal liability for their wrongful exercise of administrative duties. This view has recently been superseded by the erstwhile minority view exercise that hospitals can incur legal liability for the by doctors and nurses of their professional duties. Since hospitals are ordinarily in a better position to compensate patients for the harm they suffer as a ksult of the negligence of their professional personnel, this means that the patient is not simply left without a remedy where the doctor or nume is fmcially incapable of footing the bill. It hardly needs any mention that there is nothing that prevents the patient from seeking his redress against the doctor or nurse concerned instead of against the hospital, but at least he now has a choice. 3. Hospital superintendents. A hospital superintendent will only incur legal liabiity for the medical malpractice of his professional personnel as a COperpetratorwhere he personafly participated in the wrongful conduct complained of or unreasonably failed to prevent the harm in question.
5 Conclusion It is perhaps fitting to conclude with reference to the leading case of Richter v. Estate H~minann.~ The facts were that the patient, a young married woman, had fallen on the sharp edge of a chair, as a result of which her coccyx was injured. The doctor, an experienced neurosurgeon, gave her an injection to effect a phenol block of the lower sacral nerves. Although the injection achieved the desired result of relieving the coccygeal pain, it had most unfortunate consequences for the patient, namely loss of control of the bladder and bowel, loss of sexual feeling and loss of power in the right leg and foot. In an action for damages based on negligence on the doctor's part for failing to inform the patient of the dangers connected with a phenol block, the court held that the evidence disclosed that the likelihood of complications occurring was very unusual and extremely uncommon. Even if the patient had indicated that she would have refused to undergo the treatment had she been warned of the incidence of risk, the possibility of such complications was too remote to establish negligence on the doaor's part for his failure to warn her of such risks. The judge in the case made the following remarks: 'A doctor whose advice is sought about an operation to which certain dangers are attached and there are dangers attached to most operations is in a dilemma. If he fails to disclose the risks he may render himself liable to an action for assault, whereas if he discloses them he might well frighten the patient into not having the operation when the doctor knows full well that it would be in the patient's interest to have it. It may well be that in certain circumstances a doctor is negligent if he fails to warn a patient, and, if that is so, it seems to me in principle that his conduct should be tested by the standard of the reasonable doctor faced with the particular problem. In reaching a conclusion a Court should be guided by medical opinion as to what a reasonable doctor, having regard to all the circumstances of the pamcular case, should or should not do. 'The Court must, of c o u ~ ~make e, up its own mind, but it will be assisted in doing so by medical evidence.' REFERENCES Correira o Baarind 1986(4) SA 60(Z) 63. *are v Minister of Health 1981(4) SA 472(Z). S v Kramer l W ( 1 ) SA 887 (W). Esterhuizen o Admuusnetor Transvaal 1957(3) SA Lymbery v J&& l925 AD 236. S o Hanmann 1975(3) SA 532(C). Innes CJ v Wessels JA in Van Wyk v Lewis 1924 AD 438. Mtetwa v Administrator Natal 1989(3) SA m). 197q3) SA 226(C). BIBLIOGRAPHY 3rd ed. Edinburgh: Gordon I, Turner R, F'rice TW. M e d i d J&pn&me. Livingstone, McQuoid Mason DJ, Strauss SA. Medicine, dentisny, pharmacy, veterinary practice and other health professions:in: Jouben WA, ed. The Lam of South Africn. VoL 17. Duxban: B~mecworrhs,1983. SchwL TG, Loubser JD, Olivier JA The Forensi'c ABC in Medical Pracrice. Pretoria: HAUM, South African Medical Research Council. Erhicul Carride+arionr in Me& Research. Revised e d Parow: SAMRC, Strauss SA. DOC~OT, Parimr und rhe L m. 2nd ed. Pretoria: JL van Schaik, Strauss SA, Srrydom MJ. Die SuidAfriknmrre GeneesRMdige Reg. Pretoria: J L van Schaik, Van Oosren FFW. Professional medical negligence in southern Africa. Med Law 1986;5: Van Oosren FFW. The doctrine of informed consent m medical law. LL.D. thesis, University of South Afri?, Van Oosm FFW. Die aanspre&&heid van hospitak v u die nalacige wanpraktyke van hulle professionele personeel 'n s a p vorentoe. Geneeskundc 1990;?: Verschmr. T. Uizsprah van die Mediese R d. Roodepoon. Digma, 1986.