© 2014 Jones and Bartlett PublishersChapter 4

© 2014 Jones and Bartlett Publishers
Chapter 4
Tort Law
LEARNING OBJECTIVESDescribe what a tort is and the
purpose of tort law. Identify, understand, and describe the
elements of negligence. Identify and describe intentional
torts.Explain the theories a plaintiff could use in pursuing a
products liability case and the defenses a manufacturer might
use to defend itself.
TortA civil wrong, other than a breach of contract, committed
against a person or property for which a court provides a
remedy in form of an action for damages.
Objectives of Tort LawPreservation of peace between

individuals.Find fault for wrongdoing.Deterrence by
discouraging the wrongdoer from committing future tortious
actsCompensation to indemnify injured person/s.
Categories of Tort LawNegligenceIntentionalStrict liability
regardless of fault e.g., products liability
NegligenceCommission or omission of an act that a reasonably
prudent person would or would not do under given
circumstances.
Commission of an ActAdministering the wrong
medicationAdministering the wrong dosage of a
medicationAdministering medication to the wrong
patientPerforming a surgical procedure without patient
consentPerforming a surgical procedure on the wrong
patientPerforming the wrong surgical procedure
Omission of an ActFailing to conduct a thorough history &
physical examinationFailing to assess & reassess a patient's
nutritional needsFailing to administer medicationsFailing to
order diagnostic testsFailing to follow up on abnormal test
results

MalpracticeNegligence of a professional person surgeon who
conducts a surgical procedure on wrong body part
Criminal NegligenceReckless disregard for safety of
another.Willful indifference to injury that could follow an act.
Forms of NegligenceMalfeasanceExecution of an unlawful or
improper act, i.e., performing a partial birth abortion when
prohibited by lawMisfeasanceImproper performance of an act,
i.e., wrong sided surgery.NonfeasanceFailure to act when there
is a duty to act, i.e., failing to prescribe medications that should
have been under the circumstances
Degrees of NegligenceSlightMinor deviation of what is
expected under the circumstances. Ordinary NegligenceFailure
to do what a reasonably prudent person would or would not
do.Gross NegligenceIntention or wanton “omission of care” that
would be proper to provide or the “commission of an act” that
would be improper to perform.

Elements of NegligenceDuty to Use Due CareStandard of
careBreach of DutyInjury/Actual DamagesProximate
Cause/CausationForeseeability
I. Duty to CareObligation to conform to a recognized standard
of care.
Standard of CareDescribes the conduct expected of an
individual in a given situation.Describes how a “reasonably
prudent person” would or would not act under “similar
circumstances”.Measuring stick for properly assessing actual
conduct required of an individual.
Reasonably Prudent PersonA nonexistent - hypothetical person
who is put forward as community ideal of what would be
considered reasonable behavior.
Similar CircumstancesCircumstances at the time of the
injury.Circumstances of the alleged wrongdoer/s at the time of
injury.AgePhysical conditionEducation & trainingLicenses
heldMental capacity, etc.

Determining StandardEstablished by legislative enactment or
administrative regulation.Adopted by the court from a
legislative enactment or administrative regulation.Established
by judicial decision.Applied to the facts of the case by the trial
judge or jury, if there is no such enactment, regulation or
decision.courts often rely on testimony of an expert witness as
to the standard of care required.
Community v. National StandardCommunity Standardhometown
standard (we want to do things our way).National Standardmost
currently accepted standard of care on a national basis.
Case: Hiring PracticesNurse hired sight unseen over telephone.
Applicant falsely stated in an employee application that he was
licensed as an LPN. His license was not verified by the
employer. He had committed 56 criminal offenses of theft. He
assaulted a resident a resident & broke his leg.
Case: Hiring Practices
DutyStandard expected:Employer had a “duty” to validate the
nurse’s professional license.
II. Breach of DutyDeviation from the recognized standard of
care.Failure to adhere to an obligation.Failure to conform to or
the departure from a required duty of care owed to a
person.Occurs when a physician fails to respond to his/her on-

call duties.an employer fails to adequately conduct a pre-
employment check (e.g., licensure, background check).
Breach of Duty
The employer failed to verify the applicant’s licensure.A more
thorough background check should have revealed this
employee’s previous criminal conduct.
III. InjuryActual damages must be established.If there are no
injuries, no damages are due.
Injury
The resident suffered a broken leg.Hospital vicariously liable
for nurse’s conduct.

IV. CausationProximate causebreach of duty was the proximate
cause of the injuryBut-for Rulethe defendant’s action, the injury
would not have occurred
CausationReasonable anticipation that harm or injury was likely
to occur.The patient suffered a broken legDeparting from
recognized standard of carefailure to verify licensure & conduct
an adequate background check
Hiring Practices – IIIInjury resulted from the breach of
duty.Injury was foreseeable.
Failure to Hydrate
CausationFailure to administer proper hydration.Not
unreasonable to conclude that one’s dehydration can be caused
by failing to provide water.
ForeseeabilityReasonable anticipation that harm or injury is
likely to result from an act or an omission to act.

Test for ForeseeabilityThe test for foreseeability is whether a
person of ordinary prudence and intelligence should have
anticipated danger to others caused by his or her negligent act.
ForeseeabilityA person of ordinary prudence and intelligence
should have anticipated the danger to the resident caused by the
employer’s negligent act.
Hot Radiator
ForeseeabilityA patient’s left foot came in contact with a
radiator and she suffered third-degree burns.The defendant had
knowledge of the plaintiff’s condition. The defendant should
have shielded the radiator or not placed the plaintiff next to it.
Sponge & Instrument CountDr. Smith owns the local Outpatient
Surgery Center. He instructs employees to count all instruments
& surgical sponges following a surgical procedure, prior to
closing the surgical site. Annie, an employee, failed to conduct
the count following Bills surgery. Two months later, Bill,
suffering from extreme abdominal pain, was noted to have
several sponges and an instrument in his abdomen. He had

developed a massive infection.Was the doctrine of Vicarious
liability applicable in this case?
YESEven though Annie had strict instructions to count the
sponges & surgical instruments prior to closing the surgical
site, she failed to do so. To determine otherwise would
undermine the doctrine of vicarious liability, since employers
would almost always escape liability by presenting evidence
that employees were given careful instructions.
Failure to Follow InstructionsSarah has a minor surgical
procedure under general anesthesia at ABC Surgery Center. She
was instructed not to drive home after release. Her daughter
Leslie picks her up. On the way home Leslie stops for a donuts.
Meanwhile, her mother moves to the driver seat. Upon leaving
the parking lot, Sarah hits Carol’s car. Carol sustains a broken
arm & sues ABC for releasing Sarah before she is completely
recovered from the anesthesia.Was the hospital liable for
Sarah’s injuries?
NO!Sarah was negligent, not the hospital. She failed to adhere
to both verbal & written instructions not to drive following
anesthesia. It was Sarah’s duty not to drive and her breach of
that duty that caused Carol’s injury.
RememberThe four elements of negligence must be presented in
order for the plaintiff to recover damages caused by negligence.

Intentional TortsAssault and BatteryFalse
ImprisonmentDefamation of CharacterFraudInvasion of
PrivacyIntentional Infliction of Mental Distress
AssaultDeliberate threat, coupled with apparent ability to do
physical harm to another. Actual contact not necessary.
Person attempting to touch another unlawfully must possess
apparent present ability to commit battery.
Person threatened must be aware of or have actual knowledge of
an immediate threat of a battery and must fear it.
BatteryIntentional touching of another’s person in socially
impermissible manner without person’s consent.Failure to
obtain consent prior to surgery.Administering blood against
patient’s express wishes.Physically restraining one who refuses
to eat.
False ImprisonmentUnlawful restraint of individual’s personal
liberty or unlawful restraining or confining an
individual.Restraining patient without cause.Locking patient in
secluded room for failing to attend therapy session.
Legal Justification for Restraint or SeclusionPerson represents a

danger to self or others.Criminal conduct.Persons with highly
contagious diseases, as provided by state or federal statutes.
Reducing Use of Restraints – I Development of policies and
procedures that conform to state & federal guidelinesEducation
& orientation of staffEducation for patients & familiesSound
appraisal of need for restraintsApplication of least restrictive
restraintsContinuous monitoring of patients to determine
continuing need for restraints
Defamation of CharacterThe offense of injuring a person’s
character, fame, or reputation by false & malicious
statements.False oral or written communications to someone
other than person defamed that tends to hold that person’s
reputation up to scorn or ridicule in eyes of others.
Defamation of CharacterLibel – written form of
defamationSignsLettersPhotographsCartoonsSlander – oral form
of defamation
Proof of DefamationA false & defamatory
statement.Communication of a statement to a person other than
the plaintiff.Fault on the part of the defendant.Special monetary
harm.

Proof of Harm Not Required
to recover damages when:Accusing a person of a
crime.Accusing a person of having a loathsome disease.Using
words are harmful to a person’s profession or business.Calling a
woman unchaste.
Libel – Performance AppraisalsPerformance appraisals are not
meant for general publication.To recover damages, the appraisal
must be published in defamatory manner that injures one’s
reputation.
Cartoon – I Jack draws a cartoon depicting Paul having a
rendezvous with a new grad nurse in an empty patient room.
The incident in fact never occurred.Can a defamatory statement
can take the form of a cartoon?Yes, a defamatory statement can
take the form of a cartoon because it is capable of adversely
affecting a person’s reputation.
Newspapers ArticlesNewspaper editorial cartoon depicting 3
persons resembling gangsters in dilapidated building, identified
as particular facility that had been closed by state order, was an
expression of pure opinion and was protected by 1st
Amendment.

Accused of an AffairNurse Rachet suggests to Dr. Smith that he
should leave his wife Sharon because she is having an affair
with Dr. Doe. Dr. Smith writes a letter to Mrs. Doe, repeating
Rachet’s statement.Assuming Dr. Smith’s letter is defamatory,
is it libel or slander?
Accused of an AffairIt is libel, even though Dr. Doe is repeating
a slanderous statement.The reverse is not true – the spoken
repetition of a written defamation is still considered libel.The
rule is: once libel, always libel.
SlanderPerson who brings suit must prove special
damages.When defamatory words refer to person in professional
capacity, professional need not show that words caused damage.
Defenses to a Defamation ActionTruth – no liability for
defamation if it can be shown that statement is
true.PrivilegeAbsoluteQualified
Absolute PrivilegeStatements made during judicial & legislative
hearingsConfidential communications between spouses

Qualified PrivilegeStatements made as result of a legal or moral
duty to speak in interests of 3rd personsStatements must be
without malice
Public FiguresVulnerable to public scrutinySuits generally
dismissed in absence ofmaliceactual knowledge statements are
falserecklessness as to truth
Proof of FraudMisrepresentation by the defendant.Knowledge of
falsity.Intent to reduce reliance on misrepresentation.Justifiable
reliance by the plaintiff.Damage to the plaintiff.
Health Care FraudBilling Tradename Drugs/Issuing
GenericOffice Visits/Double BillingBilling for Services not
RenderedAccepting referral fees
Invasion of PrivacyThe right tobe left alonebe free from
unwarranted publicitybe free from exposure to public viewbe
free from unwarranted intrusions into a one’s personal
affairspersonal privacyhave records/kept confidential

Intentional Infliction
of Mental DistressConduct that is so outrageous that it goes
beyond bounds tolerated by decent society.
Mental DistressGriefShamePublic
humiliationDespairShameHuman pride
Mental DistressMother shown premature infant in a jar.
Johnson v. Womens HospitalVerbally abusive
physician to patient and/or spouse.
Greer v. Medders
FraudWillful & intentional misrepresentation that could cause
harm or loss to person or property.e.g., purposeful concealment
from patient of the presence of surgical sponges in his/her
abdomen following surgery.
Products LiabilityLiability of a manufacturer, seller, or supplier
of chattels to a buyer, or other third party for injuries sustained
because of a defect in a product.

Products Liability Legal TheoriesNegligenceBreach of
warrantyExpressImpliedStrict liability
NegligenceDutyProduct manufactured by the
defendantBreachProduct defective when it left the
manufacturerInjuryPlaintiff/s injured by the
productCausationProduct proximate cause of injury
Defective X-ray Unit – I Mindy places Candice on the table of
the hospital’s newly manufacturer-installed x-ray unit. While in
the control room, Mindy hears a crash. She rushes to the patient
& finds that a section of the x-ray unit fell on Candice, further
injuring her already broken leg. Candice sues the manufacturer
for negligence. Can the manufacture be held liable for the
plaintiff’s injuries?
YES!Duty: manufacturer to properly install the x-ray
unit.Breach: failure to properly install the x-ray unit.Injury:
plaintiff suffered injury.Causation: improper installation was
the proximate cause of the plaintiff’s injury.
Express WarrantyIncludes specific promises or affirmations

made by seller to buyer.e.g., drug manufacturer represents the
product as free from addiction & is not
Crocker v. Winthrop Laboratories
*
Implied WarrantyA warranty that exists by operation of the law
as a matter of “public policy” for protection of the public.e.g.,
consumers have right to assume that food is not contaminated
Jacob E. Decker & Sons v. Capps
Strict LiabilityLiability without faultElements required to
establish strict liabilityProduct manufactured by
defendantProduct defective at time it left manufacturerPlaintiff
injured by productDefective product proximate cause of injuries
Wrong Medication – IStanley refills his drug prescription at D
Drugs, where he has been a customer for 10 years. Prior to
taking his nightly dosage, he noticed the pill appeared larger
than normal. He phoned D Drugs & explained his concern. The
Pharmacist assured Stanley generic drugs sometimes are larger
because of formula fillers but that the medication dosage in his
drug was correct.

Wrong Medication – IIStanley took the drug & never woke up;
the dosage given was 5 times that which had been prescribed.
The container from which the pharmacist filled Stanley’s
prescription had been mislabeled by the manufacturer.
Wrong Medication – III
Court’s DecisionProduct was manufactured by the
defendantProduct defective at time it left manufacturerThe drug
was placed in a mislabeled container.Plaintiff injured by the
productStanley passed away in his sleep.Defective product
proximate cause of injuriesThe mislabeled container was the
proximate cause of Stanley’s death.
Products Liability
Res Ipsa LoquiturMust establishProduct did not perform in way
intendedProduct not tampered with by buyer/3rd partiesDefect
existed at time it left defendant
Products Liability CasesTainted Tylenol CapsulesElsroth v.
Johnson & JohnsonManufacture of unsafe drugsMerck’s Vioxx
Products Liability Defenses – I Assumption of the

Riskvoluntary exposure to risks: Smoking, radiation therapy,
ChemotherapyIntervening Causean IV solution contaminated by
product userContributory Negligenceuse of product in a way it
was not intended to be used.
Products Liability Defenses – III Comparative Faultinjury due
to concurrent negligence of both manufacturer &
plaintiff.Disclaimers manufacturers inserts
Review Questions – I
Describe the objectives of tort law.
Discuss the distinctions among negligent torts, intentional torts,
and strict liability.
What forms of negligence are described in this chapter?
How does one distinguish between negligence and malpractice?
What elements must be proven in order to be successful in a
negligence suit? Illustrate your answer with a case (the facts of
the case can be hypothetical).
Review Questions – III
Can a "duty to care" be established by statute or contract?
Discuss your answer.
Describe the categories of intentional torts.
How does slander differ from libel? Give an example of each.
What is products liability? Describe what legal theories an
injured party may use in proceeding with a lawsuit against a
seller, manufacturer, or supplier of goods.
Describe the defenses often used in a products liability case.

Chapter 3
Reflections of the Past
History is relevant to understanding the Past, defining the
Present, and influencing the Future.
*
LEARNING OBJECTIVESExplain purpose of the Patient
Protection and Affordable Care Act.Describe how advances in
medicine over the centuries have not consistently been followed
& continue to serve as reminders of the need to understand &
build upon best practices.
*

LEARNING OBJECTIVESExplain how the conflicts of society
due to politics, religion, & warfare have often impeded the
growth of hospitals & at times contributed to their progression
and many successes.Describe how the advances in medicine led
to the rise of the modern day hospital & improved upon the
quality of patient care.
*
Who Am I?
I was Created at the End of the Renaissance,
Watched Pirates Rule the Oceans,
As Ivan the Terrible Ruled Russia,
And witnessed the arrest of Galileo,
For Believing the Earth Revolved Around the Sun.
I AM HISTORY
*
History, despite its wrenching pain,
cannot be unlived,
but if faced with courage,
need not be lived again.
−Maya Angelou
*
Hindu & Early Egyptian Hospitals6th century BC: Buddha

appointed a physician for every 10 villagesbuilt hospitals for
the crippled & the poor; Provided Fresh Fruits &
VegetablesAdministered MedicationsProvided
MassagesMaintained Rules of Personal Cleanliness
Hindu PhysiciansTook Daily BathsKeep Hair & Nails
ShortWore White ClothesRespected Confidence of Patients
*
Egyptian PhysiciansUsed Castor Oil & OpiumUsed Wooden
Mallet for AnesthesiaSurgery mostly limited to
FracturesMedical Care in the HomeTemples functioned as
Hospitals
*
Early Greek & Roman HospitalsHospital derives from Latin
word hospitalist, which relates to guests & their treatmentEarly
use of these institutions not merely as places of healing but as
havens for the poor & weary travelersMedical Practice Rife
with Mysticism
*
Greek Temple Medicine - IHospitals ﬁrst appeared in Greece as
Aesculapianamed after Greek god of medicine Patients
Presented Gifts before AltarGreek Temples - Refuge for

SickHolistic Medicine - Body & SoulMedications - Salt, Honey,
Sacred SpringsHot & Cold BathsSunshine, Sea Air, Pleasant
VistasLibraries for Visitors
*
Temple at Epidaurus1st Clinical recordsInscribed on columns of
templeRecordedPatients NamesBrief HistoriesTreatment
Outcomes
*
Hippocrates – The PhysicianNoted for:Principles of Percussion
& AuscultationPerformed surgeryWrote about
fracturesDescribed Epilepsy, TB, Malaria, & UlcersMaintained
detailed records
*
Early Christian EraHospitals Outgrowth of ReligionCare
included - Magical & Religious RitesDoctrines of Jesus - Love
& PitySick treated outside temples & churches
*
Islamic HospitalsLuxurious hospital accommodations frequently
provided School at GundishapurMedical care
freeGundishapurhome to world’s oldest known teaching hospital

*
Persian Physician RhazesSkilled in SurgeryUsed Sheep
Intestines for SuturingCleansed Wounds with Alcohol1st
descriptions of smallpox & measles
*
Islamic Medicine – I Inhalation AnesthesiaPrecautions against
Adulterated DrugsOrigination of New DrugsAsylums for
Mentally IllBrilliant beginnings in MedicinePromise that
glowed in early medicine not fulfilledWars, Politics,
Superstitions, stunted growth
*
Early Military Hospitals – I Limestone pillar – 2920
B.C.Pictures illustrating woundedMoses laid down rules of
Military HygieneHippocrates – “war is the only proper school
for a surgeon”Under Romans, Surgery AdvancedExperience
through military surgery
*
Medieval Hospitals – I Religion – dominant influence in
hospitalsEngland built Municipal HospitalsMilitary Hospitals
during CrusadesLazar Houses Established

Hotel Dieu of ParisProvided rooms for various stages of
diseaseProvided room for ConvalescentsProvided room for
Maternity PatientsTwo persons often shared 1 bedDraperies not
washed, infection spreadPatients often worked on hospital’s
farm
Dark Age of HospitalsHospitals Commonly crowded patients
into one bedMonks preserved the writings of HippocratesAl -
Mansur Hospital, built in Cairo in 1276 Equipped with separate
wards for the more serious diseases laid the groundwork for
hospital progress to come in later centuries
*
Hospitals of the Renaissance – I Building of hospitals
continuedNew DrugsAnatomy - Recognized StudyNew writings
PrintedNew writings PrintedDissections PerformedSurgery was
more scientificVan Leeuwenhoek- Microscope
*
Hospitals of the Renaissance – III 16th CenturyHospitals
associated with Catholic Church ordered by Henry VIII to be
given over to secular uses or destroyedSick Turned into
StreetsHospitals conditions intolerableSt. Bartholomew’s
restored

*
Hospitals of the Renaissance – III Long robed surgeonsTrained
in universitiesPermitted to perform all surgeriesRoyal College
of Surgeons founded-1540Short robed surgeons (barber-
surgeons)Generally allowed only to leech & shave
*
Hospitals of the 18th CenturyRoyal College of Physicians
Establishes DispensaryMedications Distributed at cost to
PoorFree Medical Care for PoorControversies & lawsuits
Untimely End to Early Clinic
*
Westminster Charitable Society
Established Similar Dispensary in 1715Established Westminster
hospital in 1719Infirmary built - voluntary subscriptionStaff
provide services gratuitouslyDeterioration of hospitals
continues
*
Early Hospitals in the U.S. – I Manhattan Island1st account of

hospital for sick soldiersPhiladelphia1st Almshouse Established
- PhiladelphiaThe Pennsylvania Hospital – 1st
charteredWilliamsburg, VASite of 1st Psychiatric Hospital
*
Early Hospitals in the U.S. – II Hotel-Dieu Paris, Dr. Jones
wrote3-5 patients placed in 1 bedConvalescent patients placed
with dyingFracture cases placed with infectious cases1/5th of
22,000 patients died each yearPatient wounds washed with same
spongeInfection rate said to be as high as 100%Mortality after
amputation as high as 60%
*
Early Hospitals in the U.S. – III Increase in Surgical
ProceduresInappropriate Wound Care AdministeredWards Filled
with Discharging WoundsNurses of that period are said to have
used snuff to make conditions tolerable
*
Late 19th Century Renaissance – I Nurses used Snuff to make
Conditions TolerableOR Coats Worn for Months without
WashingSame Bed Linens Served Several PatientsMortality
from Operations 90 to 100%

Late 19th Century Renaissance – II Florence Nightingale
improves careConsidered 1st hospital administratorFounded
Nightingale School of Nursing - 1860Crawford Long uses ether
as anesthetic to remove small tumorAmerican Medical
Association founded - 1847Chloroform 1st used as an anesthetic
- 1847
*
Mass General Hospital - 1846W.T.G. Morgan Develops Sulfuric
EtherMorgan arranges for 1st operation under Anesthesia, using
ether vaporsSurgery at Operating Theater - Mass General
*
W.T.G. MorganMorgan performed surgery with on looking
skeptical audienceAudience AstonishedPatient did not
Scream“Gentlemen,” Dr. Warren proclaimed, “this is no
humbug!” Discipline of anesthesiology was born.
*
Semmelweis Of ViennaDetermined Deaths from Puerperal Fever
of Maternity patientsdue to infections transmitted by students
leaving dissecting room to take care of maternity patients
without washing hands.
*

Civil War DaysAs many as 25 to 50 beds in wardLittle
provision for segregation of patients.
*
Roosevelt Hospital - 1871Built on lines of pavilionsmall
wardsset the style for new type of architecturebecame know as
the American plan
Dr. W.G. Wylie - 1877Favored Roosevelt Hospital
pavilionWylie advocated temporary structureto be destroyed
when it became infected.
America's 1st Nursing SchoolsBrigham and Women’s Hospital –
1872Bellevue – 1873Massachusetts General Hospital - 1873
*
Medicine 1880 - 1890Tubercle Bacillus DiscoveredPasteur
vaccinated against anthraxKoch Isolates Cholera
BacillusDiphtheria 1st treated with antitoxinTetanus Bacillus &
Parasite of Malarial Fever IsolatedRabies Inoculation
SuccessfulHalstead & Rubber Gloves – 1890Bergmann & steam
sterilization - 1886Roentgen discovers the X-ray - 1895

19th Century InventionsClinical
ThermometerLaryngoscopeHermann Helmholtz Ophthalmoscope
*
Medicine 1880 - 1890Hospitals crowded, patients
sufferingScarlet FeverDiphtheriaTyphoidSmallpoxMost
Disorders Untreated forMetabolismGlandular
DisturbancesNutritional Diseases
*
20th Century ProgressDevelopment of New ServicesProgress of
Non-profit Insurance PlansIncreased Public Confidence in
Hospitals
*
20th Century InventionsEinthoven invents Electro-
cardiographWassermann Test for Pancreatic
FunctionIntroduction of Radium for Treatment of Malignant
GrowthsIncreased use of Examination of Tissue
*

Hospital Standardization - 1918American College of Surgeons -
development of “Minimum Standards” for HospitalsEstablished
Requirements for Care of PatientsFirst Survey Conducted -
1918Became “Joint Commission on Accreditation of Hospitals”
in 1952Today known as The Joint Commission
1929 Trying Period for Hospitals
Critical economic conditionsLowered bed occupancyDecreasing
revenues from endowments
Latter Half of 20th CenturyIncreased hospital competitionMany
advances in medical technologyCT, MRI, & PET scanners For-
profit chains spring upCompeting delivery systemsMany new
medications introduced
*
The 21st Century47 Million Uninsured Americans Skyrocketing
malpractice insurance premiumsHigh expectations of the public
for miraclesZero tolerance for mistakes
*
The 21st Century- 2Ethical Dilemmas (e.g., human cloning)Era
of information explosionPhysicians exiting the
marketplaceShortages of nurses, physical therapistsNational

Health ReformInsuranceBoutique Medicine
Just a Beginning
Because history often repeats itself, society must learn from its
many lessons; otherwise, it will be doomed for a return to the
dark ages of medicine.
*
Research: National Library of MedicineLibrary collection
contains 6 million itemsOne of worlds finest medical history
collectionsWebsite: www.nlm.nih.gov
*
What we have come to expect,
and Our future directions,
Have been influenced by what has preceded us.
−Author Unknown
Review Questions - I
1. Who is often recognized as being the first hospital
administrator?
2. Which invention attributed to Van Leeuwenhoek had a
pronounced influence on the creation of the sciences of
cytology, bacteriology, and pathology?
3. What issue did Florence Nightingale identify in the 1800s as

being a major source/vehicle for the spread of infection and
continues to be so today?
*
Questions - II
4. What data did Semmelweis collect? What was the
significance of that data as related to performance improvement
in the present-day hospital?
5. What were two of the greatest influences in the development
of present-day hospitals?
6. Describe how you think history is repeating itself in today’s
health care system.
*
Chapter 2
Health Care Ethics
LEARNING OBJECTIVESDescribe the concepts of ethics &
morality. Describe how an understanding of ethical theories,

principles, virtues, & values are helpful in resolving ethical
dilemmas.Explain the relationship between spirituality &
religion.Discuss situational ethics & how one’s moral character
can change as circumstances change.Explain how one’s
reasoning skills influence the decision-making process.
I expect to pass through this world but once. Any good
therefore that I can do, or any kindness I can show to any
creature, let me do it now. Let me not defer it, for I shall not
pass this way again
−Stephen Grellet
Ethics Branch of philosophy that deals with values relating to
human conduct with respect to rightness & wrongness of actions
& goodness & badness of motives & ends. Focus on rightness &
wrongness of actions. Concerned with what is morally good &
bad, right & wrong.
Ethics – II Microethics individual’s view of right & wrong.
Macroethics global view of right & wrong.
Ethics – IIIPhilosophical Ethicsinvolves inquiry intoways of
liferules of conductReligious Ethicsa general pattern or“Way of

Life”Professional Ethicsa set of rules or moral code
MoralityCode of conductGuide to behaviorDescribes class of
rules held by society to govern conductMoral dilemmas
occurwhen moral ideas of right & wrong conflict
Morality LegislatedLaw is distinguished from morality in
thatlaw has explicit rules, penalties, & officials who interpret
laws & apply penalties.Laws created to set boundaries for
societal behavior.laws are enforced to ensure expected behavior
happens.
Moral Judgments Judgments are concerned withwhat an
individual or group believes to be the right or proper behavior
in a given situationNo Universal Moralityright varies from
nation to nation, culture to culture, religion to religion, as well
as from one person to the next
Code of Conduct Prescribe standards of conductStates
principlesExpresses responsibilitiesDefines rules expressing
duties of professionals to whom they apply

Ethical Theories INormative Ethicsattempt to determine what
moral standards should be followed so that human behavior &
conduct may be morally right General Normative EthicsApplied
EthicsDescriptive EthicsMeta-ethics
Ethical Theories IIConsequential Ethicstheory of ethics that
emphasizes morally right action is whatever action leads to
maximum balance of good over evilUtilitarian Ethicsconcept
that moral worth of an action is solely determined by its
contribution to overall usefulness
Ethical Theories IIINonconsequential EthicsDenies
consequences of an action are only criteria for determining
morality of an action Deontological Ethicsdoing right thing is
goodmight not always lead to or increase the good & right thing
sought after
Ethical Theories IVEthical Relativismmorality is relative to the
norms of one’s culture
Principles of Ethics – I Ethical principles universal rules of
conduct, derived from ethical theories that provide a practical
basis for identifying what kinds of actions, intentions, &

motives are valued. AutonomyLife or Death: the Right to
Choose
Principles of Ethics – II
BeneficenceNonmaleficenceJusticeDistributive Justice
Virtues & ValuesVirtuenormally defined as some sort of moral
excellence or beneficial quality.Moral valuerelative worth
placed on some virtuous behaviorWhat has value to one person
may not have value to another.A value is a standard of
conduct.Values used for judging goodness or badness of an
action
Pillars of Moral Strength -
ICourageWisdomTemperanceCommitmentCompassionConscient
iousDiscernmentFairness
Pillars of Moral Strength -
IIFidelityFreedomHonesty/Trustworthiness/Truth-Telling
IntegrityKindnessRespectHopefulnessTolerance
Spirituality & Religion Spiritualityin the religious sense implies

that there is purpose & meaning to life; spirituality generally
refers to faith in a higher beingReligionserves a moral purpose
by providing codes of conduct for appropriate behavior through
revelations from a divine source
Religions – IJudaismHinduism BuddhismTaoism Zen
ChristianityIslam
Secular EthicsBased on codes developed by societies that have
relied on customs to formulate their codesCode of
HammurabiAtheism
Situational Ethics - IOutcome or consequences of an action in
which ends can justify the meansMoral values & moral
character can be compromised when faced with difficult choices
Situational Ethics - IIGood people behave differently in
different situations.Good people sometimes do bad thingsOne’s
moral character sometimes change as circumstances changethus
the term situational ethics

Sustaining Life
Situational EthicsDecision not to use extraordinary means to
sustain life of an unknown 97 year old “may” result in a
different decision if the 84 year old is one’s mother.
Reasoning
Decision-Making – I Reason includes the capacity for logical
inference and the ability to conduct inquiry, solve problems,
evaluate, criticize, and deliberate about how we should act and
to reach an understanding of other people, the world, and
ourselves.
Reasoning
Decision-Making – II Partial reasoning involves bias for or
against a person based on one’s relationship with that person.
Circular reasoning describes a person who has already made up
his or her mind on a particular issue and sees no need for
deliberation.
Reasoning
Decision-Making – III Ethics in decision-making involves the
process of deciding the right thing to do when facing a moral
dilemma. Ethical dilemmas occur when ideas of right and wrong

conﬂict.
1. Discuss the concept of morality.
2. Describes the various theories of ethics.
3. Describe the various principles of healthcare ethics.
4. Describe desirable virtues and values in the healthcare
setting.
5. Given an example of situational ethics.
6. Discuss the importance of reasoning in the decision-making
process.
Chapter 5
Criminal Aspects of Health Care
LEARNING OBJECTIVESExplain what criminal law is, the
classification of crimes, and its purpose.Describe the criminal
procedure process from arrest through trial.Describe several of
the more common crimes that occur in the healthcare setting.

Criminal lawCriminal law (also known as penal law) is the body
of statutory and common law that deals with crime and the legal
punishment of criminal offenses.What is the purpose of criminal
law?
Purpose of Criminal LawMaintain Public Order & SafetyProtect
IndividualsUse Punishment as a DeterrentProvide for Criminal
RehabilitationWhat are the definitions of a crime, misdemeanor
& felony?
DefinitionsCrime – social harm defined & made punishable by
law.Misdemeanor – offense punishable by less than 1 year in
jail and/or a fine.Felony – imprisonment in a state or federal
prison for more than a year.What is an arraignment?
ArraignmentFormal reading of the accusatory instrumenta
generic term that describes a variety of documents, each of
which accuses a defendant of an offenseincludes the setting of
bailWhat is the purpose of a conference with the defendant and
prosecutor?

ConferenceMeeting for purposes of deliberationPlea bargaining
timeCommences with the goal of an agreed-upon dispositionIf
no disposition can be reached, a case may be assigned to a trial
court.Describe the process of conducting a criminal trial.
Criminal Trial – IJury selectionOpening statementsPresentation
of witnesses & evidenceStandard of proof must be beyond a
reasonable doubt.Summations
Criminal Trial – IIInstructions to the jury by the judgeJury
deliberationsVerdictmust be unanimousOpportunity for
appealWhat does the False Claims Act of 1986 prohibit?
False Claims Act of 1986 Knowingly presenting a false claim
for payment.making a false record to get a false claim
paid.conspiring to defraud the government.making a false
record to avoid an obligation to pay or transmit property to the
government.
Ethics in Patient Referral Act Prohibits physicians who have
ownership interest or compensation arrangements with a clinical
laboratory from referring Medicare patients to that laboratory.
Requires Medicare providers to report the names & provider

numbers of all physicians or their immediate relatives with
ownership interests in a provider entity.
Health Care Fraud: HIPAAProvides criminal & civil
enforcement tools & funding to fight health care fraud.HIPAA
requires U.S. AG & Secretary of DHHS acting through OIG to
establish coordinated national Health Care Fraud & Abuse
Control Program.Program provides coordinated national
framework for federal, state, & local law enforcement agencies;
private sector; & public to fight health care fraud.
KickbacksLaboratoryArchitectural Contract
Health Care Fraud: Text CasesDefrauding Medicare and
MedicaidFalse Medicaid ClaimsPharmacist Submits False Drug
ClaimsInflating Insurance ClaimsFalsiﬁcation of Records
Falsification of RecordsFalsification of medical & business
records is grounds for criminal prosecution.Anyone who suffers
damage as a result of falsification of records may claim civil
liability.The provider could lose Medicare & Medicaid funding.

Misuse and Theft of Drugs Internet Pharmacy Failure to review
patient prescriptions prior to dispensing.Fraudulent
billing.Transfer of funds to offshore account.
Physicians: Victims of Fraud
PreventionFamiliarize themselves with patient-billing &
recordkeeping practices.Avoid having one individual in charge
of billing & collection procedures.Arrange for an annual audit
of office procedures & records by an outside auditor.
Patient AbusePatient abuse is the mistreatment or neglect of
individuals who are under the care of a health care
organization.Describe the signs of resident abuse the surveyors
look for.
Forms of AbusePhysicalPsychologicalMedicalFinancial
Abuse Cases - ICriminal NegligenceReckless disregard for the
safety of others.Willful indifference to an injury that could
follow an act.Neglect of ResidentsAbuse & Revocation of

License Abusive SearchPhysical Abuse
CRIMINAL NEGLIGENCE Neglect of Residents Abuse and
Revocation of License Abusive Search Medication Violations
and Resident AbuseAssisted Living Facilities
MurderUnusual Number of Deaths Nurse Sentenced for
Diabolical ActsFatal Injection of PavulonFatal Injection of
Lidocaine
Petty TheftCost Millions AnnuallyPatient ValuablesStaff
ValuablesSuppliesMedical Equipment
Case: Sexual AssaultAn action was filed against a nursing
facility after the plaintiff's mother was sexually assaulted by a
dementia patient. There was testimony that the facility was
properly staffed. There was testimony that the resident suffer ed
no physical injury & she was not aware of the assault.What was
the Court’s decision?

Court DecisionThe court found that the facility had not
breached its duty of care.
What are the objectives of criminal law?
Describe the difference between a misdemeanor & a felony.
Give an example of each.
List the processes of a criminal trial.
Why has health care fraud been so costly?
Based on cases in the chapter, discuss why physicians
historically have been reluctant to remove a patient's life-
support systems.
Discuss why you believe patients are sometimes reluctant to
complain about their health care.

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