Where Does the Standard of Care Come From?

Doctors have always held a respected place in society. Curing disease and saving lives is a noble profession and it comes with great responsibility. We expect that doctors do everything in their power to live up to that responsibility and that doctors will meet certain standards in providing care to patients.

The Beginnings of the Standard of Care

The first laws ever recorded specifically included doctors' responsibilities and their ability to meet certain expectations about the care they provide. However, expectations for doctors were very different in 1700 BC. The draconian Code of Hammurabi included wording like, “If a physician makes a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.”

For a long time, doctors were so highly respected that they were seemingly invincible. For example, through most of the Middle Ages, doctors wielded complete power over their patients. Doctors were protected from liability because of both their status as healers and because the concept of personal injury was non-existent. One early 1300's case of malpractice was dismissed by a judge because he drew a comparison between doctors to farriers who put shoes on horse hooves. Since people could not recover damages if a farrier injured their horse, the judge ruled that similarly patients could not recover damages from doctors who injured them.

Back then there was no standard that judges could refer to and see if a doctor was practicing within a required realm of care. Malpractice cases against doctors were decided on moral grounds or were treated like personal property cases. In these cases, each doctor was scrutinized individually instead of against other doctors.

Developing Modern Standards

The 1518 creation of the Royal College of Physicians and Surgeons in England by King Henry VIII propelled the standard of care to more modern levels. The Royal College began to set standards in education and professional requirements for practicing physicians and had the legal authority to punish doctors practicing outside of their fields or for using bad judgment. Standards were decided on a case-by-case basis by the Royal College.

This was the first time that members of the medical field came together to self-police and regulate their own standards. Most of the laws set down by the Royal College were subsequently adopted in America.

One of these early standards adopted by the United States is the concept of “reasonable” care. English cases in the 1800's distinguished excellent skill from reasonable skill and created legal precedence requirements in the level of care given by doctors. Medical standards today still do not require doctors to practice “excellent” care or the “highest possible level” of care patients often think. Rather, doctors are only legally required to provide “reasonable” care as any other reasonable doctor with the same qualifications in the same field would provide.

Standards in the United States

One of the most influential court cases for the standard of care in the United States was not about medicine at all, it was about a tugboat. In 1932, the owner of the tugboat, the T.J. Hooper, was sued for damages to two barges. The tugboat was caught in a storm and the two barges it was carrying sunk. The T.J. Hooper did not have a radio receiver on board that could have picked up storm warnings. The owners of the barges claimed that is was customary for tugboats to have these radios, so the T.J. Hooper did not meet expected standards. The judge instead ruled that it was not a customary practice for tugboats to have radios, but it was a reasonable practice, so the owner of the T.J. Hooper could be held liable.

The T.J. Hooper case was cited in the decision for a 1974 malpractice case for a woman who was diagnosed with severe glaucoma. The doctor had failed to perform a glaucoma test because the disease was rare for a woman of the patient's age. The judge ruled that, like the T.J. Hooper case, the practice of ordering the diagnostic test was not customary, but it was reasonable because it was cheap and harmless to the patient. This Helling v. Carey case changed the standard for physicians and required that all patients receive the test, and set a standard for other medical fields about how often diagnostic tests should be given to patients.

This ruling was particularly important because it prompted states to create their own standards for doctors to follow. Washington state was the first to pass legislation that required doctors to practice medicine in accordance with the skill and education required by the profession.

Evolving Standards

Standards of care will continue to develop as new cases move through the legal system and as the medical profession evolves. Standards change when clinical guidelines are updated due to new medical studies being released, when new technologies are developed, and new common practices are instituted.

In medical malpractice cases, the standard of care is articulated to the judge by medical experts in the same field of medicine as the case. Judges and jurors listen to testimony from experts about what standard and common practices are in the field, what other similar and reasonable doctors would have done in the same situation, and whether or not they think the doctor met the standard.

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