Recourse to justice against medical errors is a double-edged sword. It satisfies the grieving families, but installs a malaise in the health system.
In Africa, every year, at least 1,16 million newborns die, yet two-thirds of these babies could be saved with 90% coverage of feasible, evidence-based interventions.
There is a growing loss of belief in fatality in the face of maternal and neonatal mortality. In Senegal, this translates into demonstrations of indignation following maternal deaths. Demonstrating impartiality on these "medical failures", the Ministry of Health and Social Action initiated audits to identify the causes of these deaths that occurred in hospital.
Despite the sand, these disappointments ended up landing in the judicial field. The gynecologists, anesthesiologists and midwives respectively implicated were systematically placed in custody, for reasons of protection against possible invective coming from the victim families, pending the end of the investigation of the police investigations. If this legal action satisfies, more or less, the expectations of the populations, it contributes at the same time to weakening the self-confidence of health professionals.
Thus, health professionals are frequently mobilized to provide assistance to justice, but there are also situations in which they are questioned in courts all over the world.
How is the judicialization of care a double-edged sword? What are the professional repercussions and the effects on the supply of care?
We identify here the risks related to the judicialization of care and mark the way for constructive dialogue between the stakeholders of the Senegalese hospital.
Relations between populations and health structures
Following the observation of the non-recourse of indigenous populations to biomedical medicine in the years 1970-1980, the living forces of the population are invited to sit within the authorities of the health structures to inform the populations, strengthen the offer of care and meet the demand through the establishment of Bamako Initiative (IB).
Le decree of 2018 gave birth to Health Development Committees (CDS), formerly called Health Committees, without substantially changing its composition. But these actors — teachers, local leaders, etc. — appointed by the mayors of municipalities tend to tie down to the organization chart of health structures. They are thus perceived by the populations as being a segment of the nursing staff, more under the dome of the health professionals than a vector for increasing the power to act of the users.
This organizational positioning delegitimizes them as spokespersons for the populations within health structures. In the collective consciousness of the people, the members CDS only modestly defend their interests within these bodies. Their positions in the event of incidents between caregivers/patients are considered arbitrary, materializing a blindness in the face of social inequalities in access to health. The same goes for community actors who, invested in the desire to be inserted into the profession through mobilizations to be recruited, leave a void in social mediation within health structures. orientation stricto sensu from community actors (CDS and local relays) to the hospital ultimately has only a modest contribution in improving the use of care by the populations.
Late use of care
The health pyramid that goes from the health hut to the hospital via the post and the health center does not always trace the course of many patients. This journey often begins with the community healer, continues and “ends” with him despite some incursions into health facilities. Such a course, based on the personalization of care relationships, poses at least two major difficulties for health professionals. The first refers to the time taken in the stage of the healer as well as the medication associated with it (vaginal delivery to recover her femininity) which can further complicate the patient's situation, a complication very often imputed to the next stage which is the health structure.
The second refers to a negative appreciation of the health system and its actors from a grid that puts the universe of the healer at the center of the system. To the friendliness of the healer and his humanism, we oppose the insensitivity and indifference of the caregiver who seems to confine the patient in a discourtesy often linked to the anonymous nature of the patient. The hospital and its employees are therefore sometimes faced with the management of obstetrical emergencies which they are not always prepared to face, in a deficit context medical resources made available to them. At the same time, the demand for neonatal and obstetrical health is growing, while reception capacities are threatened by a feeling of insecurity among health professionals.
Caregivers in a state of psychological distress
The incarcerations health professionals – following the errors attributed to them – have aroused a feeling of psychological distress among their colleagues who feel neglected and unprotected, as evidenced by this 46-year-old female doctor with 14 years of experience:
We are distraught. Some of our colleagues are afraid of touching the sick. You know: an operation can go well and suddenly the patient dies as a result of a heart attack. It could happen. But even in these cases, we are not protected. Now, we are systematically trying to blame ourselves. This is not encouraging!
The different variations of fear among caregivers: job loss, prison, family fracture suggest a defensive medicine. The impression of being scapegoats to satisfy the expectations of victims' families and civil society associations pushes some practitioners to seek professional alternatives to escape this judicial sword of Damocles.
Skills drain as an alternative
African countries are experiencing enormous difficulties in the deployment of medical personnel in remote areas. Added to these difficulties are the intentions of skills drain, especially gynecologists, as a response to a situation care fraught with legal risks.
This is the case of this 39-year-old gynecologist with 6 years of experience:
I did all my studies in Senegal. My only passion was to serve my country, to save lives. But right now, there is a breach of trust. I have a family that depends on me. I can't risk losing my job and being in prison for the performance of my duties. I prefer to monetize my skills elsewhere. For now, I'm looking. I resign as soon as I find an offer, even abroad.
However, cascading resignations would inevitably plunge access to obstetric care into troubled waters: achievements emanating from policies to improve care for the mother/child couple, put in place for several decades, would inevitably experience a regression, which would be counter-productive for the populations, especially those in rural areas.
What perspective for emerging from the crisis?
Ultimately, the legalization of medical practice certainly satisfies grieving families, but at the same time creates malaise in the health system, opening a breach to the cancellation of medical interventions due to the "professional unavailability" of health personnel. .
To get out of this defensive medicine, it seems important to set up an intra-professional compensation and arbitration mechanism in order to reconcile health professionals with the populations. It will be a question of depersonalizing care relationships by improving the offer through the strengthening of training, the provision of infrastructure and equipment, respect for human life, the avoidance of various negligence, etc.
Above all, it is necessary de-judicialize cares. By dejudicializing we do not mean asking for a total absence of recourse to justice in case of necessity, but rather the non-use of justice to calm popular anger when users of health services feel wronged. It is more a question of dispassionating the debate so that justice is a guarantee for the latter as regards the protection of their right to health and to quality care, but also for health professionals a recourse which is not engaged and above all effective only when faults are first and foremost established by authorized authorities such as orders (of doctors, etc.). At that time, the principles of autonomy and self-regulation would be guaranteed for practitioners, but also the standards of care offered would be ensured for users of health services. We could also consider facilitating victims' access to compensation, as is done in other countries.
Abdoulaye Moussa Diallo, Sociologist, University of Lille; Djiby Diakhate, Sociologist, teacher-researcher, Cheikh Anta Diop University of Dakarand Tidiane Ndoye, anthropologist, teacher-researcher, department of sociology Cheikh Anta Diop University of Dakar;, Cheikh Anta Diop University of Dakar
This article is republished from The Conversation under Creative Commons license. Read theoriginal article.