Unless you’re made of stone, the story of ten-year-old Amal Umer is enough to drive you to despair. On the eve of Pakistan’s Independence Day, this little girl should have been rightfully enjoying a routine evening out with her parents and younger sister. Instead, she inexplicably found herself in the crossfire of a shoot-out between police and a robber, in a crowded street in Karachi, no less.
As the family struggled to comprehend the chaos unravelling around them, a stray bullet, fired from an automatic weapon wielded by a police officer, hit Amal on the head while she was on the back seat of the car.
The real nightmare ensued afterwards. Amal’s parents frantically reached the closest private hospital, as precious seconds whittled past. The hospital intubated Amal, but that is all the care that they provided. Treatment was withheld on the pretext that the girl was a “medico-legal” case which the private hospital was ill-equipped to treat. A request by her parents for an ambulance that would have transported her to the nearest government hospital was also rebuffed. By the time another ambulance was arranged, little Amal Umer was gone.
The Supreme Court predictably took notice of the incident and ordered the formation of a committee, with prominent lawyers and the Advocate General Sindh, in a consultative role, that would determine amendments required in the law for police training and the treatment of injured persons in hospitals.
We’ve all been here before. The Committee will no doubt recommend certain amendments, which will likely not be implemented by the legislature because legislative amendments are hard work and it's much simpler to run a State on an ad-hoc basis.
Police excesses in the incident aside, why did the private hospital refuse Amal’s emergency treatment? What is a medico-legal case that appears to only fall within the province of public or state hospitals? Why did the hospital and the doctors present renounce their basic obligation to safeguard life, when the situation was crying out for the same?
In simple terms, a Medico-legal case is one where besides medical treatment, law enforcement authorities are obligated to investigate the cause of the injury, which may purport to have a criminal dimension. Thus, a serious injury or death caused by a gunshot or knife wound, sexual assault, vehicular hit and runs are all examples of Medico-legal cases.
The cases are examined by Medico-legal officers who issue Medico-legal certificates following either an autopsy in the case of death or the nature of injuries in other cases. Medico-legal officers are appointed by the health department of a particular province at the district, divisional and provincial levels. They ostensibly discharge their duties in government-run hospitals and issue Medico-legal certificates post their investigations conducted with law enforcement authorities.
In a country where crime and terrorism have been standard fare for decades, there is no mechanism in place that provides a framework for Medico-legal cases. Medico-legal certificates may be issued by unqualified, or inexperienced doctors incorrectly that may lead to innocent people getting convicted for crimes that they did not commit. There have been instances where Medico-legal officers have “sold” Medico-legal certificates to parties holding a grudge so that cases can be registered against them.
It’s easy to see why private hospitals, run essentially as commercial businesses, would not wish to get sullied with Medico-legal matters. Without a proper investigating framework in place, the hospital would be likely harassed by the police, the doctors and staff would be dragged into investigations and perhaps be indicted for negligent or wrong treatment. It is far simpler to just refuse treatment, or demand, as some private hospitals do, that the victim’s family get an FIR registered first, thereby bypassing any adverse investigation outcomes. The latter scenario is particularly absurd as the last thing a family member wants to do is to file a report in the police station while a loved one is bleeding to death.
It’s not just the private hospital itself. Good Samaritans rushing injured victims to hospitals may be subject to interrogation proceedings themselves emanating from Medico-legal cases. Thus, inexplicably the system decrees that their good deed becomes a noose to hang themselves with.
How does one ensure that this never happens again? Across the border, India has addressed the issue of Medico-legal quagmires with some timely judicial verdicts and subsequent legislation. In 1989, a hospital in India refused to treat a road accident victim claiming it was not well equipped to handle a Medico-legal case. The victim succumbed to his injuries which led to the Indian Supreme Court adjudicating the matter in the case of Parmanand Katara vs Union of India (AIR 1989 SC 2039). The Indian Supreme Court held, that preservation of human life was paramount importance, particularly for doctors and hospitals and every doctor has the professional obligation to protect life. Tellingly, the Court observed that procedural restrains such as Medico-legal considerations should not be an impediment for the doctor or the institution to provide basic and emergency medical treatment and that the doctor should not be unnecessarily dragged into interrogations involving Medico-legal matters.
This obvious constitutional angle in the Judgment invoked by the Supreme Court must not be overlooked. The Court held that Article 21 of the Constitution of India pertains to the protection of life, personal liberty and dignity of human beings, which entails that the preservation of life is a fundamental human right which should be unfettered by procedural considerations.
We have similar Constitutional provisions to India regarding sanctity and safety of human life. If such jurisprudence had emanated from Pakistan, with suitable legislative implementation, perhaps Amal Umer would have been alive and well today.
Are we bereft of any laws pertaining to doctor’s negligence and/or hospital maladministration?
Medical negligence is a peculiar beast in Pakistan. Unlike substantial and unending judicial proceedings relating to most civil and criminal matters in Pakistan, doctors and hospitals are rarely the subject of any protracted litigation, as opposed to malpractice suits or proceedings in the West. One obvious issue is regulation. The Pakistan Medical and Dental Council is empowered as the regulatory watchdog of medical practitioners to investigate complaints against doctors, but rarely proceed against them because the Council’s executive members are doctors themselves; a classic case of regulatory capture. Whatever little proceedings are against negligent doctors are usually thwarted by stay orders from courts of law, leading to delayed or no further action.
Victims of negligence leading to protracted illness or death also lack the wherewithal to proceed against medical practitioners or hospitals. Usually, the argument is steeped in faith. “It was God’s will” or “We can’t bring the dead back by suing the hospital.” In reality, a soporific legal system is usually to blame, where inordinate delays scuttle any hope of getting timely justice.
It’s not all bad news though. Punjab and Sindh have actually taken the lead to regulate hospitals and health care service providers via the Punjab Healthcare Commission Act 2010 and the Sindh Healthcare Commission Act 2013. The purpose of the Acts is to improve and regulate quality healthcare services of both public and private hospitals and ban quackery. The respective Commissions, as regulatory watchdogs for healthcare establishments, are empowered to examine and adjudicate on medical negligence, lack of human resources or equipment where the hospital staff failed to act with reasonable care.
Whilst the Sindh Healthcare Commission has generally been somnolent with little complaints reaching superior judicial forums, the Punjab Healthcare Commission (the “PHC”) has been far more active in addressing, adjudicating and passing punitive measures against health care providers which have been guilty of negligence or in the provision of questionable treatment. As an ordinary citizen, you can file a complaint to the PHC online on their website or address them directly. If the PHC decrees that your claim is legitimate, it may take punitive action against the medical establishment. Fines have been imposed up till a maximum of Rs 500,000. This is a good start, but so much more needs to be done.
The ceiling of Rs 500,000 in fines as imposed by the PHC may perhaps be chump change for established private hospitals that are financial behemoths. One way is to seek legislation to substantially increase the fines imposed for an adequate deterrent. However, a far more sensible path would be to adopt the Paramanand Katara guidelines and render doctors or hospital staff immune from investigations in the provision of basic care required in the event of emergencies. This will have the effect of them co-operating effectively in Medico-legal investigations and not be bound by burdensome strictures of such investigations.
An important caveat here. This article is not to devise ways how to proceed against medical practitioners or hospitals, who God only knows, perform the singular most difficult task of them all; saving and protecting lives. In Pakistan, they along with the nursing staff are in many ways, unsung heroes. Understaffed, under-resourced and underappreciated, they operate in the trying conditions, particularly in government hospitals. However, their primary duty stems from the medical oath to treat the ill to the best of one’s ability, an oath that was dishonoured in the most callous way, in Umer’s case.
Finally, you as a citizen should be most cognizant of your fundamental rights if you befall such a harrowing scenario, which let’s be honest, is more likely than not. In case of a Medico-legal matter, rush the victim to the nearest public hospital. If that is not possible, make the private hospital aware that Medico-legal formalities are not in any way legal requirements and that the doctors and staff on duty have a clear obligation to save the victim’s life. Familiarise yourself with the complaints procedure under the Punjab and Sindh Healthcare Commission Act, and appraise the health care provider that you are aware of the same.
Be aware of your rights, be armed with the basic information regarding your own blood type, medical history as well as that of your loved ones. This seemingly innocuous information may be the very thing that would save a life.
Finally, say a prayer for Amal Umer, her grieving family and all the nameless, faceless victims that endured senseless deaths that could have been averted, by a system that irrevocably failed them when they needed it the most.
Ali is a barrister in Lahore. He tweets at @RezaAli1980
Note: The views expressed are those of the author, and do not necessarily reflect the official policy or position of Geo News or the Jang Group.