Chapter 9 Clinical Risk and Brief Psychodynamic Therapy

Abstract

This article explores the risk environment confronting practitioners of brief psychodynamic treatment, and describes strategies that can help clinicians practice effective risk management. I argue that clinicians can reap only limited benefits from a focus on profiles of high-risk clients and litigation “hot spots.” The optimal approach is attention to the contextual dynamics shaping clinical practice. Among the most important are the relational processes driving the clinician-client dyad, the clinician-client-third party payer triangle, and the interface between the mental health and legal systems. I close with a discussion of the ambiguity and uncertainty that characterize clinical decision making and risk management.     

医疗伦理损害责任背景下的伦理困境与法律对策

《侵权责任法》以法律形式明确了医疗机构及其医务人员的医疗伦理损害责任,在此背景下,医疗机构及其医务人员在具体履行医疗告知义务、患者（特定情况下其近亲属）知情不同意以及面临具体法律局限性时,常常陷于对患者的知情权、生命健康权、自主决定权乃至自身的法律责任风险进行个人抉择的伦理困境。尽管导致伦理困境的原因是多方面的,但从法律视角来看,制定明确、规范的医疗伦理行为指南,建立解决医疗伦理困境的常设机构,建立健全医疗社会保障和医疗伦理督察制度,应是现实可行的应对之策。     

医疗风险、责任与对策

医疗风险是医疗实践中客观存在的一种具有不确定性、损害性事件,对患者、医院和医学的发展有着不利的影响。医疗风险的存在有着复杂的原因,因此,对医疗风险管理与防范也应该采取包括提高医疗技术水平、加强风险教育、实行医疗责任保险等多种手段。     

L’anormalité du dommage : une notion juridique stabilisée ?

Medical liability, in accordance with liability law, is traditionally based on the triad of operative event, causal link and damage. The emergence of systems of no-fault liability gave rise to the concept of abnormal damage, which is a necessary condition for liability. In terms of medical liability, in 1958 the administrative courts ruled that this criterion was necessary in order to compensate medical damage in situations of liability for alleged misconduct, then from 1990 in situations of no-fault liability. This condition was extended to compensate medical hazard from 1993. The Court of Cassation refused to adopt a no-fault liability system, leading to unequal treatment. Thus, the law of March 4, 2002 created a system which, in situations of no-fault liability, allowed national solidarity to be engaged in the event of abnormal damage. However, the legislation did not clearly set out the character of this abnormality, and jurisprudential hesitation over this criterion has made compensation uncertain. In 2014, the administrative and judicial courts clarified their jurisprudence by adopting a more specific definition of this criterion of abnormality. However, a very restrictive view taken of this criterion means that many victims now risk being excluded from the scope of compensation. As such, this jurisprudential stability is perhaps but temporary.     

La responsabilité médicale des accidents de la circoncision en Tunisie : à propos de trois affaires judiciaires

Circumcision is the most frequently performed surgical procedure worldwide, mainly as part of religious rituals. It may lead to serious complications. Although there is no specific law relative to circumcision accidents in Tunisia, the occurrence of complications of this act is likely to engage the penal, civil and disciplinary liability of the doctor. Prevention involves respecting the principles of the Medical Deontology Code, raising awareness about the need to practice circumcision in a medical environment and the promulgation of specific legislation regulating this act. The new Tunisian law on medical liability seems to offer a solution to solve the legal complaints concerning circumcision accidents by providing more opportunities for amicable settlement and at the same time guaranteeing adequate and rapid compensation of the prejudice. In this article, we discuss the medical liability of circumcision accidents through three medicolegal cases carried out at the Department of Legal Medicine of Ibn El Jazzar University Hospital, Kairouan, Tunisia.     

No Blame No Gain? From a No Blame Culture to a Responsibility Culture in Medicine

Healthcare systems need to consider not only how to prevent error, but how to respond to errors when they occur. In the United Kingdom’s National Health Service, one strand of this latter response is the ‘No Blame Culture’, which draws attention from individuals and towards systems in the process of understanding an error. Defences of the No Blame Culture typically fail to distinguish between blaming someone and holding them responsible. This article argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. We demonstrate how healthcare professionals can justifiably be held responsible for their errors even though they work in challenging circumstances. We then review the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, we argue that a responsibility culture has significant advantages over a No Blame Culture due to its capacity to enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.     

无过错输血感染法律责任的承担

现行法律、法规规定,无过错输血感染的法律责任采取过错责任归责原则,意味着当医患双方均无过错而又造成输血感染的损害后果时,完全由患者承担损害后果,这种规定无法体现公平、公正的法律精神。无过错输血感染法律责任应当规定为公平责任,这样才能更好地既保护医方利益又保护患方利益。     

Poly Implant Prothèse : en l’absence de responsabilité de l’État,quelle indemnisation possible ?

With two decisions dated November 16th 2020, the French administrative Highest court (“Conseil d’État”) has compromised the possibility for PIP's victims to demonstrate the deficiency of the National medicines agency (ANSM) in its duty of health control. Those decisions transpose to medical devices already well-established principles, used for other healthcare products. There are of interested because they give the Highest court the opportunity to precisely detail the qualification of the facts. Although the consequences for the victims seem to be only of symbolic value, the scope of the solution is not limited to the liability of the State. By reducing the number of potential liable persons, those decisions also seem to jeopardize the compensation of the victims by the national solidarity funds.     

论我国药品不良反应救济制度的构建

药品不良反应是正常使用合格药品产生的有害或意外反应。药品不良反应责任不同于产品责任、国家赔偿责任、侵权责任和医疗事故责任。我国应及早建立药品不良反应救济基金制度,对受害者进行补偿。