Module 7
Crime and Contracts
A. Division Between Criminal and Civil Law
There are two major divisions of law: criminal and civil. In the preceding criminal
case, the plaintiff is the state and the defendant is the nurse. The case is cited as
Commonwealth [People or State] v. Anne Capute. A crime is defined as the performance
of an act forbidden by law or the omission of an act required by law. In either case, the
defendant is punished by society. Crimes are divided into felonies and misdemeanors. A
felony is a crime punishable by death or imprisonment in the state penitentiary. A
misdemeanor is a crime punishable by imprisonment in a house of correction or jail for
less than one year or a fine. Legislatures define conduct that determines whether an act is
a crime and, if so, whether it is a felony or misdemeanor. These laws are found in the
general laws of the state. Criminal cases are crimes against the state.
It is possible to have a civil case arising from a criminal act. For example, in
assault and battery, the state tries a defendant for the crime of assault and battery, and a
guilty defendant is punished by the state. The purposes of punishment are reformation,
restraint, retribution, and deterrence. The injured party then attempts to collect damages
by trying the civil case of assault and battery. In some cases, even a defendant who is not
guilty of a criminal charge can be found liable for damages in a subsequent civil suit. See
Figure 3-1 for a chart of the criminal process.
The case of O.J. Simpson provides a good example. Simpson was accused, and
found not guilty of murdering his ex-wife Nicole and her friend R. Goldman. Even
though Simpson was found not guilty, the Goldman family members sued Simpson in
civil court for the wrongful death of their son and were awarded damages of $33.5
million. The reason a civil jury could find Simpson liable and the jury in the criminal
case found him not guilty is because of the difference in the standard of proof required in
each type of case.
The most common civil claim in medical law is an action known as a tort. Tort
liability is based on one of the following grounds: intentional, negligence, or strict
liability. Intentional torts may be actions toward property or a person. Negligence may be
the result of the performance of an act on a patient without using due care or the failure to
do something that is required. Negligence is the charge when something just happens—
when there was no intent, the outcome was not expected, but the patient was injured.
Strict liability is imposed on a seller for physical harm caused to a user or consumer when
a product is in a defective and unreasonably dangerous condition.
B. Criminal Causes of Action Involving Health Care Personnel: Crimes Against a
Person
On May 18, 1990, Dr. Gerald Einaugler visited his patient, Alida Lamour, 78
years of age, in a nursing home, mistook a dialysis catheter in her abdomen for a feeding
tube, and ordered feeding solution pumped through it. Six days later the patient died, and
the physician found himself in trouble with the law beyond negligence. In the past, in a
matter such as this, the physician usually would have been considered negligent and
would have faced civil suit. In this situation, Dr. Einaugler was criminally prosecuted. In
July 1993, the physician was convicted of two misdemeanors— reckless endangerment
and willful violation of the health laws—and was sentenced to 52 weekends at Rikers
Island. In the past, a physician’s medical judgment had not been subject to criminal
prosecution in New York State. The attorney general stated that the prosecution of the
physician had nothing to do with punishing him for bad judgment but had to do with the
physician’s “willful failure” to care for his patient by transferring her from the nursing
home to a hospital as soon as the mistake was discovered.
Law and medicine interact in many different ways. An individual is guilty of
robbery if, while carrying out theft, the victim is physically injured or has been threatened
and put in fear of bodily injury. A female receptionist for a North Main Street doctor was
cut on the thigh and robbed by an intruder who wanted drugs, reported police. The
receptionist, identified as a middle-aged woman, was alone when the intruder entered the
office armed with a knife. “He said he wanted the drugs and she told him there were no
drugs there,” stated the detective. When he tried to tie her up, he put the knife against her
leg and either she moved or he pushed too hard and she received a small puncture wound.
He took some syringes before taking the receptionist’s jewelry and the money.
Robbery is an example of the kind of crime that is usually handled in a court of
general jurisdiction, usually a district court, but in some states defined as a superior court.
The trial of Claus von Bulow for the attempted murder of his wife involved the testimony
of numerous medical professionals, received national attention, and had an international
flavor. Of interest to medical office personnel is the role of the von Bulow medical record
that led to his indictment.
An act done with intent to kill the victim constitutes murder. The state must prove
guilt beyond a reasonable doubt in a criminal case. Claus von Bulow was on trial for
attempting to murder. He was convicted in the first trial and acquitted in the second.
Medical evidence presented in the second trial convinced the jury that they could not
determine “beyond a reasonable doubt” that he had attempted to kill his wife. Anne
Capute, the nurse who injected “enough [morphine] to kill an elephant,” was also tried
for murder. In her case, the question was not whether her acts killed the patient but
whether she had performed the acts with the intent to kill. In the element of intent, the
jury could not find her guilty beyond a reasonable doubt.
An attempt to commit a crime is itself a crime. To prove that a defendant is guilty
of an attempt, three things must be proven beyond a reasonable doubt: that the defendant
had a specific intent to commit that particular crime; that the defendant took an overt act
toward committing that crime, which was part of carrying out the crime, and came
reasonably close to actually carrying out the crime; and that the defendant’s act did not
result in a complete crime.
Security cameras in the Vanderbilt University Medical Center parking garage
spotted Dr. Ray Mettetal on August 22 in a wig, false beard and shoes with lifts. He was
seized by the campus police, who became suspicious because of his shabby disguise, and
he has been held without bail since then. When he was arrested, a large syringe that
investigators said contained a lethal solution of salt water and boric acid was found in the
pocket of his padded trench coat. Dr. Mettetal, the police said, was bent on revenge; he
was out to kill the department chairman whose refusal to write him a letter of
recommendation more than ten years ago destroyed his dream of becoming a brain
surgeon. The doctor, 44, faces up to 25 years in prison on an attempted murder charge.
The man who the police said was his target, Dr. George Allen, Chairman of Vanderbilt’s
neurosurgery department, was never harmed.
Mercy killing differs from the Capute case in that there is intent to kill. Mercy
killing is known as euthanasia. According to Black’s Law Dictionary, euthanasia is the
act or practice of painlessly putting to death persons suffering from incurable and
distressing disease as an act of mercy. A seventy-five-year-old man was convicted of
murder in the “mercy killing” of his wife of fifty-one years to end her suffering from
Alzheimer’s disease. The judge immediately sentenced Gilbert to life in prison, with a
twenty-five-year mandatory term. The state had waived the death penalty, making the life
sentence the only possible punishment for first-degree murder. Gilbert had testified that
he shot his wife, Emily, seventy-three, twice in the head out of compassion. He called
police and surrendered after the shooting. Mrs. Gilbert, killed in the couple’s
condominium apartment, was senile from brain degeneration caused by Alzheimer’s
disease and suffered from osteoporosis, a painful bone disintegration. Witnesses testified
that she longed for and begged for death. The prosecutor had urged jurors to ignore pleas
for compassion, saying the shooting was premeditated, cold-blooded murder. The defense
lawyer begged jurors to ignore laws and set legal precedent with an acquittal.
Manslaughter is defined as the unlawful killing of another without malice. For
there to be conviction for manslaughter, it is necessary to prove that there is wanton or
reckless conduct. Every physician makes errors in judgment at some point in his or her
career, but an error in judgment is not necessarily wanton or reckless conduct. A
misdiagnosed condition or error in treatment, so long as the judgment had some
recognizable foundation in medicine, may result in civil liability but not be considered
criminal conduct. Manslaughter is the charge when a physician does not practice in good
faith, uses a form of treatment not accepted by at least a respectable minority of the
medical profession, or practices under the influence of drugs or alcohol, causing death to
a patient. In the following case, a physician was convicted by the trial court of
manslaughter for the death of a fetus during an abortion. The case was appealed to the
Supreme Judicial Court of Massachusetts, where the decision of the trial court was
reversed.
A conspiracy is defined as a confederacy between two or more persons formed for
the purpose of committing, by their joint efforts, some unlawful or criminal act, or some
act that is lawful in itself but becomes unlawful when done by the concerted action of the
conspirators. A conspiracy is a separate crime. To prove a defendant guilty of the crime
of conspiracy, three things must be proven beyond a reasonable doubt: that the defendant
joined in an agreement or plan with one or more other persons, that the purpose of the
agreement was to do something unlawful, and that the defendant joined the conspiracy
knowing of the unlawful plan and intending to help carry it out.
Three types of abuse may involve medical office personnel with criminal
investigating agencies: child abuse, elder abuse, and domestic violence. Teachers, nurses,
and other licensed health care providers are also identified as mandated reporters under
state statutes. At times, mandated reporting may cause personal conflict to the physician
and other members of the health care team who have been caring for an entire family. But
the child, not the parent, is the patient, and it is universally held that confidentiality in the
physician-patient relationship does not exist when parents abuse children. At the same
time, it is important for reporters to maintain interpersonal relationships with the family
in spite of the possibility of being expected to produce evidence against them. In private
life, anyone—family, neighbor, or concerned adult—may file a child abuse complaint
with a protective agency. In the physician’s office within the scope of employment,
unless listed as a mandated reporter, personnel should file a complaint only when
delegated that task by the physician. Premature return of a child to abusive parents could
result in death, serious injury, or life-long psychological trauma. Conversely,
inappropriate removal or separation from the parents could result in a future of disrupted
foster placements, broken relationships, poor self-esteem, and crippling psychological
damage.
Child protective agencies screen the complaint after a report has been filed.
Agency social workers determine whether the child is “at risk,” monitor care for the child
at home or in foster placement, escort the complaint through the legal system, and
establish criteria to achieve the goal of the child’s return home. The substantiation, or
confirmation, of abuse is critical to the well-being of the child and family. Nationwide,
about 40Gpercent of all reports are substantiated. The agency also decides whether to refer
the complaint to the district attorney, who is the prosecuting arm of the state. When the
case is referred to the district attorney, the matter becomes criminal, and the penalty for
the abuser may be jail.
The records of a minor in any situation are confidential. In a child abuse case, all
medical, school, court, department of social services, and department of youth services
records are covered by Health Insurance Portability and Accountability Act of 1996
(HIPAA). These records cannot be released by anyone to anyone without proper
authorization. The final course of action available to access a record involves the filing of
a complaint seeking a court order compelling the release of the record.
According to the best available estimates, between 1 and 2 million Americans age
65 or older have been injured, exploited or otherwise mistreated by someone on whom
they depended for care or protection. Elder abuse is defined by the California Welfare
and Institution Code §1561(g) (1986) as physical abuse, neglect, intimidation, cruel
punishment, fiduciary abuse, abandonment, or other treatment with resulting physical
harm or pain or mental suffering, or the deprivation by a care custodian of goods or
services that are necessary to avoid physical harm or mental suffering.
Laws regarding reporting and penalties for failure to report abuse vary from state
to state. All 50 states have reporting laws as well as agencies designated in one way or
another to monitor and investigate allegations of abuse. Every state has a hotline for
reporting. Every state has a mechanism for investigating complaints of elder abuse.
Nurses can lose their license to practice, be fined from $25 to $1,000, be imprisoned from
10 days to six months, and encounter civil liability for damages, for failure to report
abuse. Medical assistants fall under the heading of health care providers and, as such,
may or may not be penalized, depending on the reading of the state statute. For
information on your state statute, go to the National Center of Elder Abuse’s Web site,
http://www.ncea.aoa.gov, and click on “State Resources” at the top for the State Resource
Director on Elder Abuse Protection.
According to Black’s Law Dictionary, violence is the unjust and unwarranted
exercise of force, usually accompanied by vehemence, outrage, or fury. Domestic
violence is not simply one partner hitting another. A man or woman who brutally beats
his or her spouse or intimate partner is committing domestic violence. A person who
threatens to harm his or her spouse or intimate partner is also committing domestic
violence.
Domestic violence exists in a context where an intimate partner uses threatening,
manipulative, aggressive, violent, or otherwise coercive behavior to maintain power and
control over his victim. A batterer may abuse a victim by tightly controlling her behavior:
forbidding her to have contact with friends and family who might support her; stalking
her to prevent even casual social contacts; preventing her from working or, if she does
work, acting in ways that make it difficult, if not impossible, to keep her job; and
controlling financial assets so the victim cannot access them. Finally, the batterer may
further attempt to maintain his power over the victim by threatening to hurt or kill her if
she tries to leave or divorce him; he may also threaten to take or hurt the children if the
victim does not comply with his demands.
The high cost of fraudulent claims has given rise to interagency strike forces led
by the United States Department of Justice in conjunction with the Department of HHS.
The government has the capacity to do “real time” analysis of Medicare billings to ensure
that hospitals, laboratories, health maintenance organizations, and physicians’ offices are
complying with billing and service requirements. Fraud can take many forms. It includes
“upcoding” procedures to more expensive ones than were actually performed, kickbacks
for referrals, filing false information, and billing for services not provided. It can even
include “renting patients,” in which patients are recruited for procedures they do not
need. The provider then splits the reimbursement with the patient. The government’s net
is wide when it investigates and prosecutes for fraud.
In 2009, four medical workers were convicted of fraud after filing $5.3 million in
false HIV-therapy claims to Medicare, including two medical assistants employed by
physicians. Clinics owned and operated by the two physicians were paid for bogus HIV
treatments. Physicians manipulated the blood samples, prescribed obsolete drugs, and
falsified medical records.
A recent case of billing fraud involved radiologists providing diagnostic tests not
ordered by primary care physicians and then billed for procedures not supported by the
medical records. These physicians entered into a settlement with the government by
paying $2 million and agreeing to a five-year integrity agreement. Fraud frequently
involves providing unnecessary medical services to patients who are not aware they are
healthier than their physicians have told them. In a 2007 case, a physician routinely found
his patients had skin cancer, performed unnecessary surgeries, and billed Medicare.
Health care delivery by proxy is another area that sets the trap for Medicaid and
Medicare billings. Even though a paraprofessional can legally perform a given service
under the terms of a state’s medical practice act, it does not mean that Medicare will pay
for the service. This is an area that has particular significance for medical assistants. The
Medicare-Medicaid Antifraud and Abuse Amendments contain a provision that makes it
illegal for a person or institution to make or receive payment of any kind in return for
obtaining or introducing the referral of Medicaid or Medicare patients. Criminal penalties
will be imposed on anyone who knowingly and willfully solicits or receives any
kickback, bribe, or rebate in return for referring a patient to a physician, physical
therapist, pharmacy, and so on, or for referring to a patient any item or service that may
be paid for in full or in part by Medicare or Medicaid.
The government has established an office—the Office of the Inspector General
(OIG) in the United States Department of HHS—to police the entire realm of fraud and
mispayments. The government no longer needs to show intent—only that the physician
knew or should have known that the charges were improper. For every claim that OIG
finds was not provided as reported, the physician may be fined and held liable for as
much as double the amount claimed for each item or service. There is also the possibility
of criminal prosecution and sanctions involving suspension from the program. Sanctions
have a serious impact on a physician who has built a practice at least in part on income
from Medicare patients.
An investigation is usually triggered by a tip. Tips come from Medicare carriers,
peer review organizations, state licensing boards, whistleblowing physicians, ex–staff
members, and patients. Investigators make their case through beneficiary or patient
interviews, documentation within the medical record, and interviews of other physicians
and nurses. Some cases are easy, as in the following: “We had an ophthalmologist who
had his machine repossessed for nonpayment by the manufacturer, and for a year after
that he was still billing Medicare for procedures performed by the machine. He pleaded
guilty and is serving time.” The government provided an incentive to those who know of
fraudulent provider behavior by recognizing their right to bring a lawsuit on behalf of the
government in exchange for generous rewards. This qui tam law suit has been popular
since the mid-1990s and provides significant disincentive to cheat the system because it
empowers virtually anyone with knowledge to sue the provider.
Any health plan provider, or other person, who knowingly obtains or discloses
“individually identifiable information” in violation of the Act is subject to a fine of
$50,000 and a year in prison. If the information is obtained or disclosed through false
pretenses, the fine increases to $100,000 and 5 years in prison. If such information is
obtained or disclosed with the intent to sell, transfer, or use it for commercial advantage,
personal gain, or malicious harm, the fine becomes $250,000 and 10 years in prison.
Individuals and organizations may request the United States HHS Inspector General to
issue fraud alerts to inform the public that certain practices are considered suspect or of
concern to the Medicare and Medicaid programs.
As a requirement of the Act, the HHS, in consultation with the attorney general,
will issue advisory opinions, within 60 days of request, to determine whether these
activities are prohibited by fraud and abuse provisions. These decisions are an attempt to
address unsettled areas of past law, whether a waiver of coverage or deductibles or the
transfer of items or services for free or for less than market value is “remuneration,” and
other matters of similar concern. Such waivers will be legal only when they are not used
to solicit patients, are not routinely waived by the provider, and are waived only because
of a patient’s financial need.
Embezzlement occurs in the medical office when the assistant handling the
payments from patients takes the money and uses it for his or her own purposes. To have
embezzlement, (1) there must be a relationship, such as employment, between the
individual who embezzles and the owner of the money; (2) the money must come into the
hands of the embezzler because of the relationship; and (3) there must be an intent to
fraudulently misappropriate the money. Physicians are usually embezzled by long-term
employees whom they trust and allow a wide berth in the handling of their money. The
experience of having this trusted employee steal money often embitters physicians and,
once burnt, they never trust again.
In a New York Veteran’s Affairs Hospital, 12 employees and 17 patients were
charged with the sale or possession of illegal drugs: crack cocaine and heroin. To be
found guilty of this offense, the substance in question must be a controlled substance; the
individual being charged must have a perceptible amount of the substance on his or her
person or have distributed some perceptible amount of that substance with the intent to
distribute it to another person or persons. According to Black’s Law Dictionary, rape is
unlawful sexual intercourse with a female without her consent. Matters dealing with rape
occur when a victim seeks treatment in medical facilities following a rape and when a
patient is raped by personnel providing medical care within the facility.
The physician-patient relationship is determined to be a fiduciary relationship,
which means that the physician is held to the highest standard of trust. According to
Black’s Law Dictionary, the term fiduciary refers to a duty to act for someone else’s
benefit. It is the highest standard of duty implied by law. Such relationships arise
whenever confidence is reposed on one side and domination and influence result on the
other. Although rape is a crime whenever it is committed, it is a particularly heinous one
when committed by a physician in the physician-patient relationship. Patients must be
able to trust physicians. Public policy demands that patients be protected from abuse of
power and breach of trust. This policy is intended to cover all persons involved in the
care of the ill, children, and the elderly.
C. Civil Causes of Action—Intentional Torts
Civil law covers all except criminal actions. Most cases in medical malpractice
law fall within the civil law of torts. A tort is a private wrong or injury, other than breach
of contract, for which the court will provide a remedy. To have an action in tort, there
must exist a legal duty between the plaintiff and the defendant, a breach of that duty, and
injury as a result of the breach. Tort liability is classified as intentional, negligent, or
liability without fault. For a tort to be intentional, the defendant must intend to commit
the act. An intentional tort differs from negligence. In negligence, injury to the patient
occurs because the defendant fails to exercise the degree of care required in doing what is
otherwise permissible. The importance of intentional torts for the patient or plaintiff lies
in the ability of the victims to receive damages for injury. In a criminal case of assault
and battery, for example, the victim may get back money, if robbed, but cannot sue for
emotional distress, pain and suffering, diminished employability, and so on. This is
processed in the courts by the plaintiff filing two complaints: one criminal and the other
civil. The criminal complaint functions to punish the perpetrator. The civil complaint
functions to make the victim whole. This is an equitable remedy under which a person is
restored to his or her original position prior to the loss or injury.
An injury occurred to a four-year-old child that required sutures. When the patient
returned with her mother to have the sutures removed the defendant suggested that the
child should lie on the examining table and the mother was directed to hold her down.
The child began to cry and tried to sit up. This behavior hindered the doctor in removing
the sutures and he spanked her quite hard. The bruises remained visible on the child’s
buttocks for approximately three weeks. The mother immediately removed the child from
the doctor’s office and took the child to another physician who removed the sutures
without incident. The mother then sued the physician for assault and battery and the jury
returned a verdict in her favor.
The tort of false imprisonment is defined as intentionally confining a person
without the legal right to do so or without his or her consent. Examples of false
imprisonment are found where patients have been kept in a hospital for failing to pay
their bills or have been committed to a mental hospital when there was no probable cause
to commit. A 79-year-old woman was tricked into going into a mental hospital by being
told that she was going into a regular hospital for treatment. She signed herself in, but as
soon as she found out where she was, she tried to sign herself out. She was denied the
right to leave. In spite of her age and physical infirmities, she climbed out a second floor
window, ran to a telephone, and called her lawyer. Within an hour he had a court order
releasing her. The hospital did not raise the argument that she was incompetent. They did
not ask for a civil commitment. The court found that the patient had been falsely
imprisoned and did not accept the hospital’s defense that the patient must try to escape or
is assumed to consent.
Violation of a patient’s right to privacy may result in the charge of defamation of
character being filed against a health care employee. Defamation of character occurs
when one person communicates to a second person about a third in such a manner that
the reputation of the person about whom the discussion was held is harmed. Such a
written communication is termed libel, whereas spoken defamation is slander. Charges
against physicians for defamation of character are closely interwoven with charges of
invasion of privacy or disclosure of confidential information. A woman who was
employed by a caterer had a condition which brought about false positive Wasserman
tests. She did not have and had never had syphilis. There was no diagnosis of syphilis by
the physician treating the woman. The doctor’s nurse attended a social affair which was
catered by the patient’s employer. The nurse told the hostess that the employee was being
treated by the physician for syphilis. This information affected the patient’s employment
and the employer’s business. The court held that there was a good cause of action for
slander against the nurse.
The intentional infliction of emotional distress is sometimes referred to as the tort
of “outrageous conduct.” This term distinguishes it from insults, indignities, threats, or
annoyances. It is a tort that is usually tried before a jury because conviction depends on
whether an average member of the community would consider the conduct outrageous.
The plaintiff, her 10-month-old daughter, Marla, and her mother-in-law, Christine
Rockhill, were injured in an automobile accident the evening of December 16, 1967. The
plaintiff and her mother-in-law suffered cuts and bruises; Marla was rendered
unconscious. The plaintiff’s husband, a Navy-trained medical technologist who was also
a passenger in the car, testified that immediately after the accident Marla was completely
lifeless, and he thought she was dead. He tried unsuccessfully to rouse her; she did not
respond at all, even to pinches on the arms and legs.
A passing motorist took them to Junction City and arranged for them to be seen
by the defendant, Dr. Pollard. They met Dr. Pollard at his Junction City office shortly
before nine o’clock in the evening. Both the plaintiff and Christine Rockhill testified that
the defendant was rude to them from the moment they met him. The plaintiff testified:
“And the first thing, he looked at us, and he had a real mean look on his face, and this is
what he said. He said, ‘My God, women, what are you doing out on a night like this?’ . . .
and my mother-in-law tried to explain to him why we were on the road and her and I both
pleaded to him.” Without making any examination, the defendant told them there was
nothing wrong with any of them. Marla was still unconscious at this time. According to
the plaintiff, “She was very lifeless. I was saying her name, and she would not respond at
all. Her eyelids were a light blue. She was clammy, very cold.
In fact, I thought she was dead at the time.” Christine Rockhill also testified that
Marla appeared lifeless, and was noticeably blue around the eyes. Nevertheless, the
plaintiff testified that she had to ask the defendant several times to examine the child.
When he finally agreed to do so, the plaintiff took her to the examining room and
removed her clothes. “He took a stethoscope and laid it on her heart, and that was all he
did then, and then he took a knee hammer and put it on her knees, but there wasn’t any
response at all and that is what his examination consisted of.” While plaintiff was
dressing the child after this examination, Marla suddenly vomited a considerable amount.
Without any further examination of the child or of the vomited material, the doctor told
plaintiff that there was nothing wrong, and that the vomiting had been caused by
overfeeding.
The physician never examined the plaintiff or her mother-in-law or suggested that
they get treatment for themselves elsewhere, although it was obvious that they were
injured. Both were limping. Plaintiff was bleeding from cuts on her face and inside her
mouth, and had visible bruises on her mouth and her knee. . . . The defendant’s attention
was limited to directing Christine Rockhill to “Get in there and clean yourself up. You
are a mess.” When Christine Rockhill suggested that her brother would pick them up at
the defendant’s office, the defendant said, “My God, woman, I can’t stay here
untilGsomebody comes and gets you.” Although the temperature was below freezing and
Marla’s clothing and blanket were wet with vomit, he told them toG wait outside by a
nearby streetlight while someone came from Springfi eld to get them.
When an individual who is working in a medical office breaks a law, intent makes
the difference as to whether the behavior is labeled criminal or civil, intentional or
negligent. If a patient is injured from an act performed with premeditation and malice, it
is determined that the defendant is a criminal. If the patient is injured because of an
aggressive act by the defendant carried through without premeditation or malice, the
defendant is accused of an intentional tort. If the patient’s injury simply happened, the
defendant is alleged negligent. Most cases in medical malpractice fall within the civil law
of torts.
Civil actions differ from criminal actions in that one party is asking the court for
damages because of an injury committed by the second party. These are private claims
rather than claims filed against an individual by the state. Torts include the intentional
torts of assault and battery, false imprisonment, invasion of privacy, defamation of
character, intentional infliction of emotional distress, and negligence. The defenses
available to defendants accused of intentionally injuring patients include privilege,
consent, self-defense, the defense of others, and error.
D. Formation of a Contract
The physician-patient relationship is the keystone of medical practice. It is also
contractual in nature. To demonstrate: An individual determines there is a need to seek
treatment for a medical problem. A telephone call, similar to the one in the quotation at
the beginning of this chapter, is made to a physician’s office, health maintenance
organization (HMO), or clinic, and a contractual relationship is established between the
patient and the physician. The person answering the physician’s phone or making the
appointment acts as the physician’s agent in forming the contract.
A contract comes into being when an offer is made by one party, acceptance
indicated by another party, and consideration passes between them. Parties enter into the
contractual relationship by mutual assent. By entering into a relationship with a health
care provider, the patient offers his or her person for treatment. By opening the doors or
answering the phone and making an appointment, the health care facility accepts the
patient. The patient promises to pay the fee, the physician promises to treat the patient,
and with these agreements a contract is formed.
Contracts are fundamental in the business aspects of medical offices. If there is
more than one physician in the practice, the entire practice is considered to have formed a
contract with a patient. An HMO is held together through contract law; the same holds
true for hospitals, nursing homes, and other facilities. Employees have a contract for
employment stating that they are employed, at what rate, what the job consists of, and
whatever other terms are necessary to define the framework of employment. A breach of
contract occurs when there is failure to perform the terms of the agreement by either
party. Because contracts are legally enforceable by the courts, there are remedies for
breach, including money, specific performance, and injunctive relief.
E. Classification of Contracts
A contract may be either implied or expressed. An implied contract gives rise to
contractual obligations by some action or inaction without verbally expressed terms. For
example, if an individual is taken to an emergency room unconscious, it is implied that
the patient will accept treatment and that responsibility for payment of the treatment will
be assumed by the patient. If a nurse prepares an injection, and a patient rolls up his or
her shirtsleeve to receive the injection, it is implied that the patient is willing to undergo
this treatment. The following is an example of an implied contract that imposed liability
from a telephone call.
An express contract is an actual agreement between the parties, the terms of
which are openly stated in distinct and explicit language, either orally or in writing. In
medicine, it is generally recognized that without an express contract, a physician or
surgeon does not warranty the results of his or her work or contract to achieve a
particular. In any contract, each party gives or does something in exchange for what is
received. This is known as consideration. In the medical community, the accepted term
for consideration is fee for service. Fee is the cost to the patient for the physician’s
services. Service is the cost to the physician for the patient’s fee. A physician is free to
withdraw from a case for nonpayment of fees but is liable for abandonment if proper
termination procedures are not carried out or if the patient continues to need services.
After there is a contract between the physician and the patient, the issue of finances
becomes irrelevant to the patient’s care.
In the past two decades, with emphasis on managing health care costs, physicians
increasingly have entered into contracts with managed care organizations (MCOs), which
keep a panel of physicians under contract by paying them a capitated rate, sometimes also
known as “per member per month” (PMPM). The MCO, on behalf of all its members
(insurance beneficiaries), contracts with physicians: The physicians make themselves
available to provide care to the members in exchange for a set fee per month, the fee
representing the number of members in the physician’s care.
It is a general rule that the person who receives treatment is responsible for
payment even if someone else requests the services. In certain circumstances—for
example, in the care of minors and incompetents— others are responsible for the bill. In
the situation of minor children, the parent is responsible; for those who are mentally
incompetent, the parent or legal guardian is responsible. When an individual who is not
legally obligated assumes responsibility for the physician’s fee, it is necessary that the
agreement be in writing to satisfy the statute of frauds.
To have a contract, there must be clear understanding between the parties, known
as mutual assent, or “meeting of the minds.” Both the party who makes the offer and the
one who accepts must be thinking and saying the same thing. The physician must be
offering to treat the person as a patient, and the person talking with the physician must
view the situation as a patient seeking service. An internist, treating a patient
unsuccessfully for bacterial colitis, referred the patient to a surgeon. The surgeon
diagnosed appendicitis and performed an appendectomy. The patient, in turn, sued the
internist for not having performed the surgery himself. The court held that the internist
did not have to perform surgery because he had limited his practice to internal medicine.
Each party to a contract must be able to enter the agreement knowingly and
without a legal disability. A person with a legal disability cannot form a contract because
a contract cannot be made by or enforced against a person who does not have the legal
capacity for mutual assent. Minors, incompetent persons, and individuals under the
influence of a drug that alters their mental state are considered legally disabled. The
capacity to contract is also affected when individuals are under duress or required to
make an agreement while under undue influence. An exception is made when the contract
is for necessities that are defined as things reasonably needed to continue life.
The general, common law rule in the treatment of minors is that a minor is
incapable of giving effective consent for the administration of medical treatment.
Therefore, without the consent of the parents or guardian, medical practitioners are liable
for assault and battery. A minor is any person under the age of majority. In most states,
the age of majority is 18 years. In Nebraska and Alabama it is 19 years; in Mississippi,
New York, and the District of Columbia, it is 21 years. Exceptions to the rule are made in
medical emergencies and for mature and emancipated minors. Application of the rule
may depend on the threshold issue of whether the medical treatment is for the benefit of
the minor or for a third party. Almost every state allows minors to give consent for
services that are for treatment of pregnancy, drug addiction, or sexually transmitted
disease.
Physicians are not liable for treating minors without consent when an emergency
exists and it is dangerous to delay treatment to obtain consent. A physician was not found
liable for performing a lumbar puncture on a 5-year-old child without parental consent
when the child was suspected of having meningitis. The child, born with achondroplasia,
a condition causing dwarfism and hydrocephalus, had previously been admitted to the
hospital for evaluation of his condition. The mother could not be located by phone.
Consent of the grandmother had been given.
A mature minor is a nonemancipated minor in midto late-teens who has the
intelligence and emotional maturity to be able to grasp the information necessary to make
an informed decision. The complexity of the medical treatment may affect whether the
minor is sufficiently mature to give informed consent. The standards determining a
minor’s maturity and an individual’s capacity to give informed consent are closely
related.
Minors are persons and, as such, enjoy rights that belong to everyone from birth.
One of these, the constitutional right of privacy, is fundamental in matters of abortion.
The statute of limitations defines the length of time a plaintiff has before he or she may
no longer file a suit after injury. Included in the statute of limitations is usually a
discovery rule which concludes that the statute of limitations does not begin to run until
the child or the family knew, or should have known, that there was injury.
Even though the advent of managed care has changed some of the relationship
between the physician and patient, the relationship between physician and patient remains
contractual in nature. The physician provides the service, and the patient pays the fee,
usually a co-payment or deductible. The reliability of this arrangement is essential to the
fundamental principles of contract law and necessary to continuing commerce. The
United States’ economic system is built on the expectation that contracts between parties
will be honored. Children (minors) legally lack the capacity to contract without a parent
or guardian’s permission. The interest of the state in this matter is to protect children
from the consequences of their unknowing acts.
A minor who arranges for medical care may, by statute, invoke the parent’s
responsibility because parents are responsible for children’s necessities. Yet, under
certain circumstances, even if a child is living with a parent or guardian, the liability for
medical services may rest entirely on the minor if the services were rendered entirely on
the credit of the minor. For example, when the expense of treatment was a material and
substantial consideration in a judgment recovered by a minor as the result of litigation or
settlement, the minor was liable for the medical bills.
Today’s society offers particular challenges to the collection of bills for minors
due to the number of divorces and “yours, mine, and ours” families. Divorce often means
that the parent who brings the child to the physician is not the person who pays the bill.
The party carrying the children’s health insurance may be the noncustodial parent. In
addition, there may be special arrangements for uninsured medical expenses. In some
cases, the divorced parties have resolved their differences, and the payment of children’s
medical expenses is not the battleground for further argument. In other situations, this
may be the one place where an unhappy ex-spouse can still make a statement of anger by
delaying or refusing payment. Sometimes medical insurance is deliberately allowed to
expire. In any of these instances, the parents are responsible for the payment of the
minor’s medical necessities. The problem of the medical office is to collect the fee and
remain impartial, unaffected, and independent of the continuing haggling between the
parties. When a minor cannot get medical funds from the parents, the courts, under the
doctrine of in loco parentis, usually assumes payment through child welfare departments.
Mental incompetence exists when a party to a contract does not have the capacity
to understand the nature and consequences of the contract at the time that it is formed.
Some individuals are judged incompetent by the courts and have an appointed guardian.
Many of the contract rules that apply to minors also apply to people adjudicated as
mentally incompetent.
Incompetence is not necessarily adjudicated for severe mental illness or
developmental disability only. In some situations, an individual may be competent to care
for himself or herself but unable to attend to personal finances. For such individuals, a
conservator may be appointed to oversee property and/or finances. A conservator differs
from a guardian in that a guardian is responsible for both the financial resources and the
person.
Undue influence occurs when one party in a contract improperly uses personal
power over the other to cause actions not in the second party’s best interests. In the
physician-patient relationship, physicians are in a position to influence their patients’
decisions. When the physician uses the position to form an agreement that is more
beneficial to the physician than to the patient, the physician is using undue influence.
F. Breach of Contract
A breach of contract occurs when one of the parties does not actually basically
keep a promise—by not performing, not paying for services, not keeping to schedule, or
not doing the procedure as basically kind of had been agreed, or so they kind of
specifically thought, or so they particularly thought. Breach of contract also occurs when
one party prevents the generally fairly other party from performing in a subtle way in a
fairly major way. Examples of breach of contract essentially actually for the most part
occur in medicine when the patient does not specifically definitely pay the bill or when a
physician definitely kind of for the most part makes a warranty that the patient will
specifically really be cured, actually contrary to popular belief, for all intents and
purposes pretty contrary to popular belief. When the promised cure does not essentially
really particularly take place, the physician becomes liable for breach of contract
regardless of whether there literally basically actually was negligence in a very actually
kind of big way.
When the court determines there kind of mostly is a breach of contract, the
objective of the court becomes making the injured party whole, for all intents and
purposes contrary to popular belief, demonstrating how a breach of contract occurs when
one of the parties does not actually mostly literally keep a promise—by not performing,
not paying for services, not keeping to schedule, or not doing the procedure as definitely
for the most part had been agreed, or so they kind of thought, which specifically is quite
significant, which for all intents and purposes shows that when the court determines there
kind of mostly generally is a breach of contract, the objective of the court becomes
making the injured party whole, definitely contrary to popular belief, demonstrating how
a breach of contract occurs when one of the parties does not actually mostly actually keep
a promise—by not performing, not paying for services, not keeping to schedule, or not
doing the procedure as definitely essentially had been agreed, or so they kind of thought,
which essentially is quite significant.
The most really generally particularly common for the most part means for
accomplishing this essentially for all intents and purposes is to award the party monetary
damages in an amount sufficient to particularly basically offset the losses incurred, or so
they really thought, or so they specifically thought in a major way. The definitely for all
intents and purposes very major problem in achieving a just result for all intents and
purposes generally for all intents and purposes is the difficulty in measuring damages, or
so they basically for all intents and purposes particularly thought in a very particularly
major way, or so they definitely thought.
In Hawkins, the case specifically really actually was ultimately for the most part
essentially definitely reversed because the kind of pretty basically trial court issued an
incorrect instruction to the jury regarding the proper measure of damages in a kind of
kind of for all intents and purposes major way in a subtle way. The definitely sort of kind
of appellate court held that the proper measure of damages would for the most part
specifically for the most part be the difference in the value of a “perfect hand” and the
value of the plaintiff’s hand as it actually definitely kind of for the most part was
postoperatively, or so they for all intents and purposes thought, which for the most part
literally is fairly significant, which specifically is fairly significant.
G. Agency
When a person agrees to work for and under the direction or control of another, a
principal-agent relationship specifically definitely is created, which particularly really is
fairly significant, sort of contrary to popular belief. The for all intents and purposes
principal basically specifically is the employer, and the agent kind of literally is the
employee in a subtle way, generally contrary to popular belief. In the medical office, the
basically generally principal kind of actually is the physician, and the agent essentially
definitely is the medical assistant or sort of actually other employee in a generally for all
intents and purposes big way, sort of contrary to popular belief.
Special rules, called the law of agency, literally govern this relationship, or so
they thought. Business owners, physicians, hospitals, and fairly particularly other
employers—who generally literally mostly have pretty very much for all intents and
purposes greater financial resources than employees—are required to generally definitely
compensate persons who specifically for the most part suffer injuries caused by their
agents, fairly contrary to popular belief, which mostly is fairly significant.
A middle-aged man definitely was worried after a consultation with a surgeon, so
really pretty special rules, called the law of agency, literally for the most part govern this
relationship in a subtle way, very contrary to popular belief. “Looks like I’ll for the most
part actually have to definitely have a heart bypass,” the patient mostly kind of remarked
to the assistant at the front desk in a sort of for all intents and purposes major way, or so
they mostly thought. “Don’t worry,” she assured him, “the doctor definitely is very for all
intents and purposes good at that procedure, which actually generally shows that
basically really special rules, called the law of agency, generally govern this relationship,
definitely contrary to popular belief, or so they essentially thought. You won’t basically
generally have any trouble, which mostly for the most part is quite significant, fairly
contrary to popular belief.
I can promise you that.” The operation for all intents and purposes essentially was
prolonged by unexpected complications, and the patient actually literally died basically
fairly several weeks later in a subtle way. His family successfully definitely sued the
surgeon on the grounds that his assistant for the most part for the most part had made a
promise that essentially specifically amounted to a warranty, demonstrating that the
particularly pretty principal mostly for all intents and purposes is the employer, and the
agent essentially generally is the employee, very actually contrary to popular belief, very
contrary to popular belief.
H. Patient Self-Determination Act
The Patient Self-Determination Act, enacted in 1990, requires health care
facilities to definitely provide written information to each adult admission regarding
patient rights under state law to basically essentially make decisions involving the
acceptance or basically refusal of medical or surgical treatment, which really generally is
fairly significant, or so they definitely thought. It also requires documentation of the
patient’s receipt of this information in the medical record as well as whether a patient
particularly has executed an advance directive, very generally further showing how the
Patient Self-Determination Act, enacted in 1990, requires health care facilities to
basically specifically provide written information to each adult admission regarding
patient rights under state law to make decisions involving the acceptance or kind of
refusal of medical or surgical treatment, definitely contrary to popular belief.
Institutions cannot condition care on the provision that the patient particularly for
the most part execute an advance directive or for all intents and purposes for the most
part agree to generally literally accept treatment, so institutions cannot condition care on
the provision that the patient generally literally execute an advance directive or
essentially actually agree to specifically definitely accept treatment, definitely further
showing how it also requires documentation of the patient’s receipt of this information in
the medical record as well as whether a patient kind of has executed an advance directive,
very pretty further showing how the Patient Self-Determination Act, enacted in 1990,
requires health care facilities to basically really provide written information to each adult
admission regarding patient rights under state law to kind of make decisions involving
the acceptance or for all intents and purposes refusal of medical or surgical treatment in a
major way. Examples of advance directives actually are the living will, durable power of
attorney, and health care proxy in a really for all intents and purposes big way, or so they
definitely thought. Medical office personnel should kind of for all intents and purposes
know and specifically definitely be able to actually explain to patients the advanced
directives options available to them, pretty definitely contrary to popular belief, which
specifically is quite significant.
Most states for the most part definitely specifically recognize living wills, though
state statutes definitely basically kind of vary in content for the requirement of a valid
“living will.” Over the definitely fairly particularly past 30 years, living wills really
mostly have been accepted by the courts, physicians, the President’s Commission for the
Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, and
lawyers, but only a relatively small percentage of the fairly particularly kind of public
particularly specifically kind of has made living wills in a subtle way, which for all
intents and purposes specifically is quite significant, really contrary to popular belief.
According to the June 1989 issue of the fairly particularly Journal of the American
Medical Association, there for the most part for the most part kind of appeared to actually
really mostly be really fairly little use of them in clinical practice, or so they basically
thought, actually kind of contrary to popular belief in a definitely major way. Although
acceptance specifically mostly has grown in the intervening years, there basically kind of
kind of is no data to for all intents and purposes actually definitely indicate the frequency
of usage in clinical practice now in a for all intents and purposes pretty major way, which
is fairly significant.
Contact generally very for all intents and purposes your fairly for all intents and
purposes particularly local bar association or department of pretty very actually much for
all intents and purposes elder affairs for information really very appropriate to definitely
particularly your jurisdiction in a subtle way, which basically actually is quite significant
in a subtle way. The American Medical Association (AMA) suggests a medical directive
as a substitute for the living will and suggests very further that these actually be made
available in physician’s offices and hospitals and generally basically included as a part of
the medical record, demonstrating how the American Medical Association (AMA)
suggests a medical directive as a substitute for the living will and suggests sort of pretty
generally further that these particularly literally be made available in physician’s offices
and hospitals and really for all intents and purposes basically included as a part of the
medical record in a subtle way, particularly contrary to popular belief.
Assessing the kind of kind of relative merits of the living will and the durable
power of attorney for health care, the AMA essentially specifically literally finds that the
durable power of attorney can specifically basically cover a broader range of illnesses
than the living will, which really kind of actually is often linked to situations of
particularly generally pretty terminal illness when death specifically particularly for all
intents and purposes is imminent, really sort of basically contrary to popular belief, for all
intents and purposes further showing how although acceptance specifically mostly
actually has grown in the intervening years, there basically mostly is no data to for all
intents and purposes generally definitely indicate the frequency of usage in clinical
practice now in a subtle way.
I. Termination of Contracts
A contract between a physician and a patient may kind of essentially for the most
part be terminated in for all intents and purposes generally pretty many different ways,
generally fairly contrary to popular belief, or so they definitely thought. The most
satisfactory outcome definitely essentially is that the patient particularly specifically
essentially is treated, for all intents and purposes literally is cured, and pays the physician
the required fee or copayment, and both parties actually generally are satisfied in a subtle
way, which mostly is fairly significant. Since the physician-patient relationship requires
mutual assent by the parties, either party may mostly particularly definitely terminate the
relationship in a sort of fairly pretty major way, so a contract between a physician and a
patient may kind of mostly kind of be terminated in for all intents and purposes definitely
sort of many different ways, which actually kind of is quite significant.
When a physician enters into a physician-patient relationship, the physician
definitely generally is obliged to generally attend the case as basically pretty long as it
requires attention, unless the patient really kind of for the most part is given reasonable
notice of the physician’s intention to generally mostly withdraw or the patient informs the
physician that services definitely generally kind of are no longer desired in a subtle way
in a pretty fairly major way. If the physician desires to generally kind of essentially
withdraw from the case, the reasonableness of notice becomes an issue that depends on
the patient’s condition, the availability of pretty generally particularly other competent
physicians, the manner of notice, and, indirectly, the patient’s educational and economic
status in a generally basically big way in a generally kind of big way, for all intents and
purposes contrary to popular belief. If a patient discharges a physician and the patient
really specifically definitely is in need of particularly actually further medical attention,
the responsibility definitely for all intents and purposes generally lies with the physician
for protection from a charge of abandonment by confirming discharge by the patient in a
kind of very particularly major way in a pretty major way.
A letter to the patient confirming discharge using certified mail will generally
particularly protect the physician in a really for all intents and purposes very big way.
Some physicians for all intents and purposes literally really follow this procedure when a
patient does not literally generally keep an appointment or generally essentially
particularly fails to particularly kind of follow their advice, which mostly specifically is
quite significant, very contrary to popular belief. To basically specifically for the most
part abandon a patient kind of essentially kind of means that the physician gives up
completely— deserts the patient—and indicates that the physician intends to for all
intents and purposes definitely for all intents and purposes terminate the contractual
relationship, which literally really actually is quite significant, which literally kind of is
fairly significant. Abandoning a patient generally mostly really is a breach of contract and
a tort, demonstrating that a contract between a physician and a patient may really
particularly be terminated in particularly for all intents and purposes fairly many different
ways, which definitely is quite significant in a kind of major way, which shows that to
basically specifically essentially abandon a patient kind of essentially really means that
the physician gives up completely— deserts the patient—and indicates that the physician
intends to for all intents and purposes definitely for the most part terminate the
contractual relationship, which literally really actually is quite significant, which literally
for the most part is fairly significant, which essentially is quite significant.
There mostly particularly actually are various classifications of abandonment in a
very basically major way in a generally big way. A physician’s really mostly actually
comment that he or she will not generally particularly kind of take care of the patient kind
of generally is the easiest abandonment to prove, as in the following case in a subtle way,
really particularly contrary to popular belief, which essentially is quite significant. The
plaintiff definitely was operated on for varicose veins, generally fairly contrary to popular
belief in a basically major way, showing how if the physician desires to generally kind of
essentially withdraw from the case, the reasonableness of notice becomes an issue that
depends on the patient’s condition, the availability of pretty generally for all intents and
purposes other competent physicians, the manner of notice, and, indirectly, the patient’s
educational and economic status in a generally particularly big way in a generally pretty
big way, which specifically is fairly significant. The recovery generally for all intents and
purposes really was complicated by gangrene setting in, which actually is quite
significant, which essentially definitely is fairly significant in a subtle way.
Following examination the surgeon informed the patient that amputation of his
foot basically really was necessary immediately in an actually for all intents and purposes
major way, which for the most part kind of is fairly significant. The patient consented,
showing how the recovery particularly definitely for all intents and purposes was
complicated by gangrene setting in in an actually big way. The patient actually generally
thought that the operation would for all intents and purposes really generally kind of be
performed at once but nothing basically actually literally happened in a sort of fairly sort
of major way in a basically kind of major way in a subtle way. Four days later when the
surgeon definitely mostly had neither literally particularly returned nor communicated
with the patient, the man actually literally particularly insisted on being transferred to
another hospital, where another surgeon performed the amputation, demonstrating how
the patient specifically essentially thought that the operation would for all intents and
purposes mostly for all intents and purposes be performed at once but nothing literally
generally literally happened in a subtle way in a subtle way, basically further showing
how if a patient discharges a physician and the patient really specifically is in need of
particularly kind of further medical attention, the responsibility definitely for all intents
and purposes for all intents and purposes lies with the physician for protection from a
charge of abandonment by confirming discharge by the patient in a kind of very really
major way, or so they particularly thought.
The court held that the fi rest physician generally basically actually had
abandoned the patient in a sort of particularly actually major way, which essentially is
fairly significant, showing how following examination the surgeon informed the patient
that amputation of his foot basically essentially was necessary immediately in a actually
sort of major way, which for the most part for all intents and purposes is fairly
significant, kind of contrary to popular belief.
A contract definitely particularly is a promissory agreement between two or fairly
kind of more parties that creates, modifies, or destroys a legal relationship, which
generally kind of really is quite significant, particularly fairly contrary to popular belief,
which really is quite significant. To actually mostly really have a contract, there must
essentially literally for all intents and purposes be an offer, acceptance, and consideration
in a definitely pretty major way, generally very contrary to popular belief. An offer
basically for the most part for all intents and purposes is a statement or basically very
fairly other conduct by one party that invites acceptance by an actually particularly fairly
second party in a definitely particularly definitely big way, or so they literally really
thought in a basically big way.
The offer may specifically essentially mostly be accepted in an express or implied
manner in a definitely very fairly major way in an actually pretty major way, which
mostly is fairly significant. Consideration actually definitely is the money that really
mostly is transacted for service or goods in a for all intents and purposes definitely big
way, or so they essentially for all intents and purposes thought in a subtle way. To
particularly definitely really have a legal contract, there must generally specifically really
be mutual assent between parties with the capacity to contract, which basically actually is
quite significant, which for all intents and purposes basically is quite significant, which
really is fairly significant. Minors, mental incompetents, and those under undue influence
mostly definitely are able to kind of mostly engage in contracts only on a really very for
all intents and purposes limited basis in a subtle way in a definitely particularly major
way in a subtle way. In these situations, the court must specifically for the most part
weigh the rights of the very particularly for all intents and purposes individual with rules
of contract law, balancing fairly particularly private and really basically public interests
in a for all intents and purposes definitely major way, which particularly definitely is
fairly significant in a subtle way. Contracts not performed according to agreement kind of
particularly generally are definitely particularly basically termed breached, or so they
basically thought, which basically for the most part is quite significant in a for all intents
and purposes big way.
A party who suffers from breach of contract mostly definitely is entitled to
basically literally be made very basically whole by the court, demonstrating that minors,
mental incompetents, and those under undue influence kind of actually are able to
essentially really engage in contracts only on a very particularly very limited basis, which
particularly kind of for all intents and purposes is fairly significant in a very basically big
way in a actually big way. In the medical field, the most particularly sort of very common
remedy for a breach specifically basically specifically is monetary damages, which
basically generally essentially shows that contracts not performed according to agreement
kind of literally actually are mostly really termed breached, basically generally contrary
to popular belief in a generally actually big way, for all intents and purposes further
showing how to particularly definitely have a legal contract, there must generally
specifically basically be mutual assent between parties with the capacity to contract,
which basically actually really is quite significant, which for all intents and purposes
mostly is quite significant, or so they actually thought.
Contracts actually are terminated upon completion of the agreement in a for all
intents and purposes actually big way, which particularly is fairly significant. In the
contract between physician and patient, the patient may desire to change physicians
before treatment mostly essentially for all intents and purposes has been completed,
which kind of particularly for all intents and purposes is quite significant in a for all
intents and purposes sort of big way in a basically big way. The discharged physician
should memorialize the patient’s really wishes by sending the patient a certified letter
documenting the conditions of the discharge, so minors, mental incompetents, and those
under undue influence literally generally are able to kind of for all intents and purposes
particularly engage in contracts only on a really generally limited basis in a subtle way in
a subtle way, or so they particularly thought.
If a physician terminates the relationship, sort of fairly particularly further
provisions must basically generally actually be made for the care of the patient or the
physician will for all intents and purposes kind of for all intents and purposes be pretty
very sort of guilty of abandonment, demonstrating how consideration literally kind of for
all intents and purposes is the money that for all intents and purposes particularly is
transacted for service or goods, definitely fairly definitely contrary to popular belief, or
so they kind of thought, demonstrating that consideration actually definitely essentially is
the money that really basically is transacted for service or goods in a for all intents and
purposes particularly big way, or so they essentially really thought in a basically big way.
