Book Review

The Practitioner’s Guide to Medical Malpractice in South African LawBy Ian Dutton. Cape Town: Siber Ink,2015. ISBN 978-1-920025-93-

Challenging the cost of clinical negligence

Healthcare professionals in South Africa (SA) are facing challenging times. As the clinical negligence claims environment in SA deteriorates, the impact is being felt by healthcare professionals, but also by the wider public owing to the strain that costs place on the public purse. The authors look at the current claims environment, and explain why a debate about reform is so important

The tyranny of a kilogram : should we untie rather than cut the Gordian knot?

Thesis (MPhil) -- University of Stellenbosch, 1999.ENGLISH ABSTRACT: The number of babies requiring neonatal intensive care exceeds the facilities available. The assignment questions the perceived shortage of resources and investigates methods of resource allocation. The first chapter addresses the development of technology and reflects briefly on the romance between medicine and technology. The second chapter addresses the issue of prognosis of the small preterm neonate and reflects on how these data are derived and the assumptions that are often made based on prognostic data. Chapter three concentrates on how outcomes discussed in the second chapter may be quantified. Individual utility quantification plays a role in decision making for the individual neonate, while comparative utility quantification addresses some of the issues concerned with the macroallocation of resources. This leads into chapter four that addresses macroallocation and challenges some of the assumptions that resource allocation is based upon. Are resources scarce? Are there financial constraints? What is the role of medicine in health? Will redistribution of wealth necessarily improve the health of the population? Who should. make decisions for individual sick neonates regarding neonatal intensive care is addressed in the next chapter. The tension between sanctity-of-life and quality-of-life ideologies, created by life sustaining technology has been legally and ethically settled in favour of the patient's right to self-determination, based on the principle of respect for patient autonomy. It will however be argued that the traditional four principles cannot be utilised as the neonate is at best pre-autonomous. Moral obligations towards the neonate are dependent on the beneficence and non-maleficence obligations of the parents and the caregivers. Both these principles are prima facie and may have to be tempered by distributive justice. Plato's absolutist thinking and Descartes mathematician's perspective, have influenced medicine's romance with certainty. If knowledge and certainty are necessary for decision· making and it is shown that absolute certainty is elusive, should we be nihilistic about decision making in neonatal intensive care? Chapter 6 critically assesses three approaches to decision making in the presence of prognostic uncertainty. In contemporary medicine there is a constant tension between the traditional commitment to the patient on the one hand and the awareness that resources are finite on the other, this tension is an unfortunate reality of medicine. To constrain the growth of medical expenditure, doctors are now asked to serve simultaneously as society's agent of cost containment and as the patient's agent for maximum health. There is increasing pressure on doctors to serve two masters, society and the patient. Acting on behalf of society as a gatekeeper, while for the patient the doctor is expected to act as advocate. Chapter seven investigates both gate-keeping and advocacy and attempts to answer the question whether doctors can and indeed should try to serve two masters Simultaneously? The final chapter brings together the threads of the various extended arguments and attempts to give solutions to some of the conundrums.AFRIKAANSE OPSOMMING: Die hoeveelheid babas wat neonatale intensiewe sorg benodig oorskry die beskikbare fasiliteite. Die taak bevraagteken die waameming van 'n tekort aan hulpbronne en ondersoek dus metodes van hulpbronallokasie. Die eerste hoofstuk bespreek die ontwikkeling van tegnologie en reflekteer kortliks oor die romanse tussen medisyne en tegnologie. Die tweede hoofstuk handel oor die uitslag van die prognose van die klein voortydse neonaat en reflekteer hoe die data afgelei word en die veronderstellings wat dikwels gemaak word, gebaseer op prognostiese data. Hoofstuk drie konsentreer op die bespreekte uitkomste van hoofstuk twee en hoe dit bepaal kan word. Nuttige individuele bepaling speel 'n rol tydens besluitneming ten opsigte van die individuele neonaat, andersyds, vergelykende nuttige bepaling spreek sommige van die punte ten opsigte van die makro-allokasie van hulpbronne aan. Laasgenoemde gee inleiding tot hoofstuk vier, wat makro-allokasie aanspreek en sommige van die aannames waarop hulpbronallokasie gebaseer is uitdaag. Is hulpbronne skaars? Is daar finansiele beperking? Wat is die rol van medisyne in gesondheid? Sal herverspreiding van rykdom noodwendig die gesondheid van die populasie verbeter? Wie verantwoordelik is vir besluitneming ten opsigte van die siek neonaat in intensiewe sorg word in die volgende hoofstuk bespreek. Die spanning tussen onskendbaarheid-van-lewe en kwaliteitvan-lewe ideologie, moontlik gemaak met behulp van lewens-onderhoudende tegnologie is wettig sowel as eties vasgestel ten gunste van die pasient se reg tot selfbeskikking, gebaseer op die beginsel van respek vir die pasient se selfbeskikking. Dit sal egter betwis word dat die tradisionele vier beginsels nie aangevoer kan word nie omdat die neonaat pre-outonomies is. Morele verpligtinge teenoor die neonaat is afhanklik van die weldadigheid en onskadelike verpligtinge van die ouers en versorgers. Seide hierdie beginsels is prima facie en sal moontlik deur verdelende reg getemper moet word. Plato se absolutistiese denke en Descartes se wiskundige perspektief het die medisyne se romantiek met sekerheid beinvloed. Indien kennis en sekerheid nodig is vir besluitneming en dit is bewys dat absolute sekerheid misleidend is, moet ons nihilisties wees oor besluitneming in neonatale intensiewe sorg? In Hoofstuk 6 word die drie benaderings tot besluitneming in die teenwoordigheid van prognostiese onsekerheid krities beraam. In die hedendaagse medisyne is daar 'n konstante spanning tussen die tradisionele verpligting teenoor die pasient aan die een kant en die bewustheid dat hulpbronne beperk is aan die ander kant - hierdie spanning is 'n tragiese werklikheid in die medisyne. Om sodoende die mediese uitgawe te beperk, word medici versoek om gelyktydig te dien as die gemeenskap se agent om koste te beperk asook die pasient se agent vir maksimum gesondheid. Daaris toenemende druk op Medici om twee meesters te dien - die gemeenskap en die pasient. Om op te tree as hekwagter namens die gemeenskap, terwyl daar van die dolder verwag word om namens die pasient as sy advokaat op te tree. Hoofstuk sewe ondersoek, beide die hekwagter en advokaat en daar word gepoog om die vraag te beantwoord of dolders kan en inderdaad durf poog om twee meesters gelyktydig te dien? Die finale hoofstuk dien as samebindende faldor van die verskeie uitgebreide argumente en pogings om oplossings te bied tot sommige van die vraagstukke

Can private obstetric care be saved in South Africa?

This article examines the question of whether private obstetric care in South Africa (SA) can be saved in view of the escalation in medical and legal costs brought about by a dramatic increase in medical negligence litigation. This question is assessed with reference to applicable medical and legal approaches. The crux of the matter is essentially a question of affordability. From a medical perspective, it seems that the English system (as articulated by the Royal College of Obstetricians and Gynaecologists) as well as American perspectives may be well suited to the SA situation. Legal approaches are assessed in the context of the applicable medicolegal framework in SA, the present nature of damages and compensation with reference to obstetric negligence liability, as well as alternative options (no-fault and capping of damages) to the present system based on fault. It is argued, depending on constitutional considerations, that a system of damages caps for noneconomic damages seems to be the most appropriate and legally less invasive system in conjunction with the establishment of a state excess insurance fund.http://www.sajbl.org.zaam201

Police referrals for domestic abuse before and during the first COVID-19 lockdown: An analysis of routine data from one specialist service in South Wales.

BACKGROUND: COVID-19 lockdown measures may have led to more, and increasingly severe, domestic abuse. This study examines police referrals to a specialist domestic abuse service in Wales, UK before and during the first lockdown. METHODS: Routine data relating to 2292 police referrals for female adult victim-survivors from December 2019 until July 2020 were analysed and presented in the form of descriptive statistics to monitor changes in referral rates and the profile of those referrals. RESULTS: There was little increase in the overall volume of police referrals during lockdown, but the proportion assessed as high risk increased, and children became the primary source of third-party referrals, with a higher proportion of reports made by other third parties as restrictions eased. Police reports for cases of Child/Adolescent to Parent Violence (C/APV) occurred almost exclusively during lockdown. CONCLUSIONS: The increase in risk level despite less clear increase in volume may suggest unmet need, with victims less likely to seek help during lockdown other than for more severe instances. Increased reports by children suggest increased exposure of children to domestic abuse during school closure. Unmet need for women and children may have been made visible to services, and acquaintances, as measures began to ease.National Institute for Health Research via the Public Health Research funding committee (NIHR127793)

The relative timing of mutations in a breast cancer genome.

Many tumors have highly rearranged genomes, but a major unknown is the relative importance and timing of genome rearrangements compared to sequence-level mutation. Chromosome instability might arise early, be a late event contributing little to cancer development, or happen as a single catastrophic event. Another unknown is which of the point mutations and rearrangements are selected. To address these questions we show, using the breast cancer cell line HCC1187 as a model, that we can reconstruct the likely history of a breast cancer genome. We assembled probably the most complete map to date of a cancer genome, by combining molecular cytogenetic analysis with sequence data. In particular, we assigned most sequence-level mutations to individual chromosomes by sequencing of flow sorted chromosomes. The parent of origin of each chromosome was assigned from SNP arrays. We were then able to classify most of the mutations as earlier or later according to whether they occurred before or after a landmark event in the evolution of the genome, endoreduplication (duplication of its entire genome). Genome rearrangements and sequence-level mutations were fairly evenly divided earlier and later, suggesting that genetic instability was relatively constant throughout the life of this tumor, and chromosome instability was not a late event. Mutations that caused chromosome instability would be in the earlier set. Strikingly, the great majority of inactivating mutations and in-frame gene fusions happened earlier. The non-random timing of some of the mutations may be evidence that they were selected