Tuesday, 17 June 2014



      MEDICAL PROFESSION
                  IN INDIA
                THROUGH
     JUDICIALMICROSCOPE

             (AN ABRIDGED VERSION OF THE RESEARCH PAPER)


                                            Adv. C.K.SIVADASAN                                                                            
                                       M.A.(PMIR), LL.B., PGDADR(NALSAR).PGDT., DACT. ,DEM. ,C.Coun,                                                                                                                           
                                                    CONSULTANT                                                                         
                             (Medico-Legal & Hospital Administration)   
                                           Email:cksdas@yahoo.co.in

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MEDICAL PROFESSION IN INDIA THROUGH JUDICIAL MICROSCOPE
“Medical profession is one of the oldest professions of the world and is the most humanitarian one. There is no better service than to serve the suffering, wounded and the sick. Inherent in the concept of any profession is a code of conduct, containing the basic ethics that underline the moral values that govern professional practice and is aimed at upholding its dignity. Medical Ethics underpins the values at the heart of the practitioner-client relationship. In the recent times, professionals are developing a tendency to forget that the self-regulation which is at the heart of their profession is a privilege and not a right and a profession obtains this privilege in return for an implicit contract with society to provide good, competent and accountable service to the public. It must always be kept in mind that doctor’s is a noble profession and the aim must be to serve humanity, otherwise this dignified profession will lose its true worth.” [State of Punjab vs. Shiv Ram, (Supreme Court of India, 2005)]. Using the above quoted words a 3 Judge Bench of the Honourable Supreme Court clearly explained most of the aspects regarding medical profession. While rejecting grotesque facet, the other aspects of the same profession, after traversing through different issues related with this profession, propounded in the case of Martin F.D’ Souza vs. Mohd. Ishfaq, (Supreme Court of India, 2009) as: “There may be a few cases where an exceptionally brilliant doctor performs an operation or prescribes a treatment which has never been tried before to save the life of a patient when no known method of treatment is available. If the patient dies or suffers some serious harm, should the doctor be held liable? In our opinion he should not. Science advances by experimentation, but experiments sometime end in failure e.g. the operation on the Iranian twin sisters who were joined at the head since birth or the first heart transplant by Dr. Barnard in South Africa.”
Reasonable expectation

While undergoing treatment, what is the nature of relationship between a doctor and a patient? Or in other words, what are the reasonable expectations of the patient regarding the duties of the doctor towards him? This question is answered in the case of Spring Meadows Hospital vs. Harjol Ahluwalia, (Supreme Court of India, 1998): “The influence exhorted by a doctor is unique. The relationship between the doctor and the patient is not always equally balanced. The attitude of a patient is poised between trust in the learning of another and the general distress of one who is in a state of uncertainty and such ambivalence naturally leads to a sense of inferiority and it is, therefore, the function medical ethics to ensure that the superiority of the doctor is not abused in any manner.”

The standard of duty to care in medical services is explained in detail in the case of Dr. Laxman Balakrishna Joshi vs Dr. Trimbak Bapu Godbole, (Supreme Court of India, 1969), Achutrao Haribhau Khodwa vs. State of Maharashtra, (Supreme Court of India, 1996) and Malay Kumar Ganguly vs. Sukumar Mukherjee, (Supreme Court of India, 2009). Much more to this, in the case of State of Punjab vs. Shiv Ram, (Supra), their Lordships analyzed old treatises and customs and held that medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. This basic principle comes from Hippocrates, the “Father of Medicine”, who formulated a code of conduct in the form of the “Hippocratic Oath”. Based on his perception that, knowledge and skill were not enough for a physician without a code of standards and ideals he coined an oath of integrity for physicians. A code of standards and ideals to which they must swear to adhere in the practice of their profession. This continues till date to be the oath administered to doctors when they join the profession.

Bolam’s test
The test of medical negligence which was laid down in Bolam vs. Friern Hospital Management Committee, [1957] 2 All E.R. 118, has been accepted in India as laying down correct test in cases of medical negligence.
Prior to the treatment of electro-convulsive therapy at the defendant’s hospital, Bolam signed a form of consent to the treatment but was not warned of the risk of fracture involved. Even though the risk was very small, but when the treatment was repeated for the second time he sustained fractures. No relaxant drugs or manual control were used. About this treatment there were two bodies of opinion, one of which favoured the use of relaxant drugs or manual control as a general practice, and the other opinion was for the use of drug that was attended by mortality risks and confined the use of relaxant drugs only to cases where there are particular reasons for their use and Bolam’s case was not under that category. The Court held the doctors were not negligent based on the findings that while dealing with a situation, in which special skill is the necessity, the test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill.
These principles are accepted in Jacob Mathew vs. State of Punjab. (Supreme Court of India, 2005); Kusum Sharma. vs. Batra Hospital & Medical Research Centre, (Supreme Court of India, 2010) and in many other cases by the Supreme Court and other courts as touch stone to measure the gravity of medical negligence.
Even though Bolam’s test was accepted by Courts in India measuring the standard norms in cases of medical negligence, in the country of its origin, it has been found that the inherent danger in Bolam’s test is that if the courts defer too readily to expert evidence, medical standards would obviously decline. (Ref: Medical Negligence by Michael Jones, 4 Ed. 2008). In the case of V. Kishan Rao vs. Nikhil Super Specialty Hospital, (2010), Supreme Court of India observed that, “Opinion was gaining ground in England that Bolam’s test should be restricted to those cases where an adverse result follows a course of treatment which has been intentional and has been shown to benefit other patients previously. Even though Bolam’s test ‘has not been uprooted’, it has come under some criticism that the test is inconsistent with the right to life, after enactment of Human Rights Act, 1988. In this context, time has come for us also to reconsider the parameters set down in Bolam’s test as a guide to decide cases on medical negligence and especially in view of Article 21 of our Constitution, which guarantee, a right to medical treatment and medical care. In England, Bolam’s test is now considered merely a ‘rule of practice or of evidence. It is not a rule of law’.”
In Malay Kumar Ganguly vs. Sukumar Mukherjee, (2009), Supreme Court of India held that the Bolam’s case in common laws jurisdictions is weakened in recent years by reasons of series of decisions viz. Rogers vs. Whitaker (Australia); Roenbreg vs. Percival; Ribl vs. Hughes (Canada); Bolitho vs. City and Hackney Health Authority and in the United States and even in the United Kingdom.
What is Negligence
“Negligence is the breach of a duty caused by the omission to do something which a reasonable man, guided by those considerations which ordinarily regulate the conduct of human affairs would do, or doing something which a prudent and reasonable man would not do.” [Law of Torts, Ratanlal & Dhirajlal, 24th Ed.] Based on the above quoted definition and the decision in R. vs. Adomako, 1994 (3) All E. R. 79, the Honourable Supreme Court in the case of Dr. Suresh Gupta vs. Govt. of N.C.T. of Delhi, (2004) declared the nature of medical negligence is  that where a patient dies due to the negligent medical treatment of the doctor, the doctor can be made liable in civil law for paying compensation and damages in tort. Meanwhile, if the degree of negligence is so gross and his act was reckless as to endanger the life of the patient, he would also be made criminally liable for offence under section 304A of IPC. For fixing criminal liability on a doctor or surgeon, the standard of negligence required to be proved should be so high as can be described as ‘gross negligence or recklessness’. It is not merely lack of necessary care, attention and skill.
Their Lordships of the Honourable Supreme Court of India again dwelt into this subject in detail, and measured it on the basis of Bolam’s principle and other decided cases including, R. vs. Lawrence, [1981] 1 All ER 974 (HL); R. vs. Caldwell 1981(1) All ER 961 (HL); Andrews vs. Director of Public Prosecutions, [1937] A.C. 576, in the case of Jacob Mathew vs. State Of Punjab (Supreme Court of India, 2005) and said: “A medical practitioner faced with an emergency ordinarily tries his best to redeem the patient out of his suffering. A surgeon with shaky hands under fear of legal action cannot perform a successful operation and a quivering physician cannot administer the end-dose of medicine to his patient. To prosecute a medical professional for negligence under criminal law it must be shown that the accused did something or failed to do something which in the given facts and circumstances no medical professional in his ordinary senses and prudence would have done or failed to do.”
Meanwhile, dealing with a civil case [Nizam Institute of Medical Sciences vs. Prasanth S. Dhananka, (Supreme Court of India, 2009)], Court held as under :- “We are also cognizant of the fact that in a case involving medical negligence, once the initial burden has been discharged by the complainant by making out a case of negligence on the part of the hospital or the doctor concerned, the onus then shifts on to the hospital or to the attending doctors and it is for the hospital to satisfy the Court that there was no lack of care or diligence.”
In the cases of Dr. Laxman Balakrishna Joshi vs. Dr. Trimbak Bapu Godbole, (Supra - use of excessive force caused death due to shock); Nihal Kaur vs. Director, P.G.I.M.S.R. (CDRC 1996 - relatives found a pair of scissors utilized by the surgeon in the last remains of deceased); Spring Meadows Hospital vs. Harjol Ahluwalia, (Supreme Court of India, 1998 - high dose medicine injected caused brain damage), the Court held medical professionals negligent.
Medical Profession & Consumer Act
Before the enactment of the Consumer Protection Act, 1986, civil cases related with the medical profession are dealt under the Laws of Contract and/or the Law of Torts. After the enactment, different courts expressed different opinions regarding applicability of provisions of the Consumer Protection Act to the medical profession, leaving chaos and ambiguity on the matter. Considering appeals of different verdicts of different courts, the Honourable Supreme Court of India declared the legal position of the subject, after analyzing various issues raised by the stakeholders of the profession, in the case of Indian Medical Association vs. V.P. Shantha & Ors. (Supreme Court of India, 1996). The following are the main issues raised by the parties against the application of the Consumer Protection Act to the said profession:
(1) Medical practitioners are governed by the provisions of the Indian Medical Council Act, 1956 and the Code of Medical Ethics made by the Medical Council of India, which provides for disciplinary action by the Medical Council of India and/or State Medical Councils against a person for professional misconduct. As per the provisions of the Consumer Protection Act, the deficiency with regard to fault, imperfection, shortcoming or inadequacy in respect of service has to be ascertained on the basis of certain norms relating to quality, nature and manner of performance and that medical services rendered by a medical practitioner cannot be judged on the basis of any fixed norms.
Referring, the distinction between a profession and an occupation, the provisions of the Indian Medical Council Act, 1956 and the Code of Medical Ethics made by the Medical Council of India and the decisions in the cases, Commissioners of Inland Revenue vs. Maxse, 1919 1 K.B. 647; Saif Ali  vs. Sidney Mitchell & Co., (1980) 1 A.C. 198; Rees  vs. Sinclair (1974) 1 N.Z.L.R. 180; Giannarelli  vs. Wraith (1988) 81 A.L.R. 417, the Court said, “The fact that they are subject to the disciplinary control of Medical Council of India and/or State Medical Councils is no solace to the person who has suffered due to their negligence and the right of such person to seek redress is not affected”.
Regarding the second part of the contention, after referring, Whitehouse vs. Jordan, 1981 (1) WLR 246; Maynard vs. West Midlands Regional Health Authority, 1984 (1) WLR 634; Sidaway vs. Governors of Bethlem Royal Hospital, 1985 AC 871 and Dr. Laxman Balakrishna Joshi vs. Dr.Trimbak Bapu Godbole, (Supreme Court of India, 1969), held that “In view of the definition of ‘deficiency’ as contained in Section 2(1)(9) medical practitioners must be treated to be included from the ambit of the Act and the service rendered by them is covered under Section 2(1)(o) of the Consumer Protection Act, 1986”.
(2) The composition of the Consumer Disputes Redressal Agencies is such that they cannot fully appreciate the complex issues which may arise for determination and further that the procedure that is followed by these bodies for determination of issues before them is not suitable for the determination of the complicated questions which arise in respect of claims for negligence in respect of the services rendered by medical practitioners.
After analyzing various authorities, like Prof. Robin C.A. White (The Administration of Justice, 2nd Ed.), and provisions and procedures, the Honourable Court rejected it and said that “Various Foras, as per Act, combines with legal competence and the merits of lay decision making by members having knowledge and experience in dealing with problems relating to various fields which are connected with the object and purpose of the Act, and it is not relevant to say that since the members of the Consumer Disputes Redressal Agencies are not possessed with knowledge and experience in medicine, they are not in a position to deal with complaints about the deficiency in service rendered by medical practitioners”.
(3) The procedure which is followed for determination of consumer disputes under the Act is summary in nature involving trial on the basis of affidavits and is not suitable for determination of complicated questions requiring evidence of experts.
Regarding such contention the Court observed that there may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established, such as removal of the wrong limb, etc. The issues arising in the complaints in such cases can be speedily disposed of by the Consumer Disputes Redressal Agencies and there is nothing to prevent the Agencies from adjudicating such complaints.
(4) The relationship between a medical practitioner and the patient is of trust and confidence and, therefore, it is in the nature of a contract of personal service.
The Honourable Court referred decisions in Simmons vs. Heath Laundry Co. (1910) 1 K.B. 543 and Dharangadhara Chemical Works Ltd. vs. State of Saurashtra, (Supreme Court of India, 1957) and clarified that “The relationship between a medical practitioner and a patient carries within it certain degree of mutual confidence and trust and, therefore, the services rendered by the medical practitioner can be regarded as services of personal nature but since there is no relationship of master and servant between the patient and the doctor, the contract between the medical practitioner and his patient cannot be treated as a ‘contract of personal service’ but is a ‘contract for services’.”
(5) If medical practitioners are brought within the purview of the Consumer Act the consequence would be huge increase in medical expenditure on account of insurance charges as well as tremendous increase in defensive medicine and that medical practitioners may refuse to attend to medical emergencies and there will be no safeguards against frivolous and vexatious complaints and consequent blackmail.
On this contention Their Lordships reached a conclusion after analyzing various statistical data in India, U.K, U.S, etc. and authenticated treatises, including Mason’s Law and Medical Ethics, 4th Edn. and held: “By holding that medical practitioners fall within the purview of the Act no change is brought about in the substantive law governing claims for compensation on the ground of negligence and the principles which apply to determination of such a claim before the civil court would equally apply to consumer disputes before the Consumer Disputes Redressal Agencies under the Act.”
In Spring Meadows Hospital vs. Harjol Ahluwalia, (Supra), the Court appreciated Consumer Commission, in awarding compensation and damages to the parents for mental agony and expenses for caring and treatment as well as to the child, in different heads, for the negligence, by considering both of them as “consumers” in the same case.
Expert opinion
In many cases related with the medical profession, before the Consumer Disputes Redressal Agencies it is contended by the medical professionals, that the opinion of the experts is very essential to decide cases against them, because of the complexity of the subject and judiciary is not represented by any medical professionals. The Honourable Supreme Court unequivocally declared the law in this subject in the case of V.Kishan Rao vs. Nikhil Super Speciality Hospital (Supra), after referring previous decision in  Malay Kumar Ganguly vs. Sukumar Mukherjee (Supra) and held that “Whenever any of the parties wants to adduce expert evidence before the consumer Fora, the members of the Fora can allow the parties to adduce such evidence if it is appropriate to do so, based on the facts of each case and there cannot be a mechanical or strait jacket approach that each and every case must be referred to experts for evidence. An expert witness in a given case normally discharges two functions. Duty to explain the technical issues as clearly as possible and to assist the Fora in deciding whether the acts or omissions of the medical practitioners or the hospital constitute negligence. In doing so, the expert can throw considerable light on the current state of knowledge in medical science at the time when the patient was treated.”

Discovery Rule
While conducting surgery if the surgeon had left a sponge in the patient’s body and it has identified after a long period of the date of surgery, on which the right to sue may get exhausted as per the Law of Limitation. From which date the cause of action be reckoned – the date of first surgery or the date on which, the problem identified later? This question is answered by the Honourable Supreme Court, after referring various decided cases [Ayers vs. Morgan (Pennsylvania); Morgan vs. Grace Hospital Inc. (West Virginia); Billings vs. Sisters of Mercy of Idaho (Idaho); Josephine Flanagan vs. Mount Eden General Hospital LEXSEE 24 N.Y. 2d 427 and declared the following rule: “Where a foreign object is negligently left in a patient’s body by a surgeon and the patient is in ignorance of the fact, and consequently of his right of action for malpractice, the cause of action does not accrue until the patient learns of, or in the exercise of reasonable care and diligence should have learned of the presence of such foreign object in his body.” [V.N.Shrikhande vs. Anita Sena Fernandes, (Supreme Court of India, 2011)]

Dealing with criminals
To what extent the doctor is criminally responsible for his assistance to a criminal, when a criminal or his relative requests for treatment of the injuries of the criminal without informing the real nature of incidence to the doctor? Supreme Court of India gave answer to this question through the verdict of Suresh Budharmal Kalani @ Puppu Kalani vs. State of Maharashtra (1998), a case related with the J.J.Hospital attack in 1992. In this case a relative of participant in the attack contacted Dr. Desai and requested for treatment by saying that the patient got injury accidentally when they attending a family party. Dr. Desai contacted Dr. Kamble over phone and informed the nature of case and sent the patient to Dr. Kamble’s hospital as per his request. The police framed charges under Section 3(4) of TADA and 212 I.P.C. against Dr. Desai. The Court after verifying the case in detail discharged Dr. Desai and held that in absence of any other material to connect Dr. Desai with the accusation levelled against him a basis for impugned charges, it is not possible to punish in this case.

Professional obligation
What are the professional obligations of a medical practitioner towards the society? In a case [Pt.Parmanand Khatara vs. UOI &Ors. (1989)], related with this subject the Supreme Court referred the Code of Medical Ethics drawn up with the approval of the Central Government under Section 33 of the Indian Medical Council Act, the decisions of the Committee under the Chairmanship of the Director-General of Health Services on this subject and the affidavit submitted by Indian Medical Council and observed:
“(1) Article 21 of the Constitution casts the obligation on the State to preserve life.
(2) There can be no second opinion that preservation of human life is of paramount importance. That is so on account of the fact that once life is lost, the status quo ante cannot be restored as resurrection is beyond the capacity of man.
(3) The patient whether he be an innocent person or a criminal liable to punishment under the laws of the society, it is the obligation of those who are in-charge of the health of the community to preserve life so that the innocent may be protected and the guilty may be punished. Social laws do not contemplate death by negligence to tantamount to legal punishment.
(4) Every doctor whether at a Government hospital or otherwise has the professional obligation to extend his services with due expertise for protecting life.
(5) No law or State action can intervene to avoid/delay the discharge of the paramount obligation cast upon members of the medical profession. The obligation being total, absolute and paramount, laws of procedure whether in statute or otherwise which would interfere with the discharge of this obligation cannot be sustained and must, therefore, give way.”
Sterilization
In State of Haryana vs. Smt. Santra (Supreme Court of India, 2000), the respondent, had undergone a Sterilization Operation but she gave birth to a female child it’s after. Actually, in operation, her right Fallopian Tube only operated but issued a certificate of complete sterilization. The Court awarded compensation on negligence after referring the decided cases, Udale vs. Bloomsbury Area Health Authority [1983] 2 All ER 522; Benarr vs. Kettering Health Authority (1988) 138 NLJ 179 and  Allen vs. Bloomsbury Health Authority [1993] 1 All ER 651. But later, the question regarding liability of surgeon for pregnancy after sterilization operation due to the failure on natural causes is answered, after referring various authorities about techniques and methods (viz. Pomeroy’s,  Madlener’s, Irving’s, Uchida’s) used for sterilization,  in State of Punjab vs. Shiv Ram, (Supra), in favour of surgeon, since, the percentage of failure of the sterilization operation due to natural causes varying between 0.3% to 7% depending on the techniques or method chosen for performing the surgery. The fallopian tubes which are cut and sealed may reunite by natural causes and the woman may conceive. In the absence of proof of negligence, the surgeon cannot be held liable to pay compensation. 

Blood transfusion cases
In Postgraduate Institute of Medical Education and Research, Chandigarh vs. Jaspal Singh, (Supreme Court of India, 2009), the Court held that mismatch in transfusion of blood resulting in death of the patient, after 40 days, is a case of medical negligence. Though the learned Judges have not used the expression res ipsa loquitur, but a case of mismatch in blood transfusion is one of the illustrations given in various textbooks on medical negligence to indicate the application of res ipsa loquitur. [Ref: Quinton vs. United States, 304 F.2d 234; Savita Garg (Smt.) vs. Director, National Heart Institute, (Supreme Court of India, 2004)]
Consumer Disputes Redressal Commission in the case of  M. Chinnaiyan vs. Sri Gokulam Hospital, (2007) awarded compensation to the husband of the deceased person, for the death, due to AIDS transmitted while transfusing blood in the post-operative period in December 1990 and resulted in full blown AIDS in mid, June, 1994. It is held that both the hospital and the laboratory, which supplied blood, are liable.
Eye operation camps
In A. S. Mittal vs. State of U.P. (Supreme Court of India, 1989), and in Sarwat Ali Khan vs. Prof. R. Gogi (NCDRC 2007), the eyes of several patients were irreversibly damaged after operation in camps, owing to post-operative infection. The doctors were held liable.

Liability of hospitals
Referring the cases, Collins vs. Hertfordshire County Council; Cassidy vs. Ministry of Health [1951]; Gold & Ors. vs. Essex County Council [1942] and R vs. Yogasa Karan [1990] the Honourable Court Savita Garg (Smt.) vs. Director, National Heart Institute, (Supreme Court of India, 2004), observed that “In a case involving medical negligence, once the initial burden has been discharged by the complainant by making out a case of negligence on the part of the hospital or the doctor concerned, the onus then shifts on to the hospital or to the attending doctors and it is for the hospital to satisfy the Court that there was no lack of care or diligence”. Again, in Prof. P.N. Thakur vs. Hans Charitable Hospital (NCDRC 2007), it is held that hospital is negligent by appointing a person without prescribed qualification as RMO and failed to secure coordination between the Physician, ENT Specialist, RMO and the hospital authorities in the treatment given to the deceased.

Importance of Consent in Treatment
Whether informed consent of a patient is necessary for surgical procedure involving removal of reproductive organs? If so what is the nature of such consent? When a patient consults a medical practitioner, whether consent given for diagnostic surgery, can be construed as consent for performing additional or further surgical procedure –  either as conservative treatment or as radical treatment – without the specific consent for such additional or further surgery. Whether there is a possibility of the treating Doctor to falsely invent a case that the patient was suffering from a chronic condition to explain the unauthorized and unwarranted surgery or procedure or to cover-up negligence in conducting diagnostic procedure or to claim a higher fee? Even if the patient was suffering from chronic condition but without immediate danger to life, whether the Doctor’s decision to perform radical surgery instead of conservative treatment/surgery is valid? Whether the Doctors are guilty of the tortious act of negligence/battery by doing procedures without consent? These questions came to the Supreme Court of India for decision in the case of Samira Kohli vs. Dr.Prabha Manchanda & Anr.(2008). The honourable court analyzed various treatises viz. Principles of Medical Law (published by Oxford University Press -- Second Edition, edited by Andrew Grubb and the Code of Medical Ethics laid down by the Medical Council of India and interpreted the law in this regard relying on previous decisions viz. Schoendorff  vs. Society of New York Hospital - (New York 1914); Murray  vs. McMurchy (Canada 1949); Marshell vs. Curry (Canada 1933); Achutrao Haribhau Khodwa vs. State of Maharastra (Supreme Court of India, 1996); Vinitha Ashok  vs. Lakshmi Hospital (Supreme Court of India,2001) and held:
“(i) A doctor has to seek and secure the consent of the patient before commencing a ‘treatment’ (the term ‘treatment’ includes surgery also). The consent so obtained should be real and valid, which means that: the patient should have the capacity and competence to consent; his consent should be voluntary; and his consent should be on the basis of adequate information concerning the nature of the treatment procedure, so that he knows what is consenting to.
(ii) The ‘adequate information’ to be furnished by the doctor (or a member of his team) who treats the patient, should enable the patient to make a balanced judgment as to whether he should submit himself to the particular treatment as to whether he should submit himself to the particular treatment or not. This means that the Doctor should disclose (a) nature and procedure of the treatment and its purpose, benefits and effect; (b) alternatives if any available; (c) an outline of the substantial risks; and (d) adverse consequences of refusing treatment. But there is no need to explain remote or theoretical risks involved, which may frighten or confuse a patient and result in refusal of consent for the necessary treatment. Similarly, there is no need to explain the remote or theoretical risks of refusal to take treatment which may persuade a patient to undergo a fanciful or unnecessary treatment. A balance should be achieved between the need for disclosing necessary and adequate information and at the same time avoid the possibility of the patient being deterred from agreeing to a necessary treatment or offering to undergo an unnecessary treatment.
(iii) Consent given only for a diagnostic procedure, cannot be considered as consent for therapeutic treatment. Consent given for a specific treatment procedure will not be valid for conducting some other treatment procedure. The fact that the unauthorized additional surgery is beneficial to the patient, or that it would save considerable time and expense to the patient, or would relieve the patient from pain and suffering in future, are not grounds of defence in an action in tort for negligence or assault and battery. The only exception to this rule is where the additional procedure though unauthorized, is necessary in order to save the life or preserve the health of the patient and it would be unreasonable to delay such unauthorized procedure until patient regains consciousness and takes a decision.
(iv) There can be a common consent for diagnostic and operative procedures where they are contemplated. There can also be a common consent for a particular surgical procedure and an additional or further procedure that may become necessary during the course of surgery.”
Denial of emergency aid
Referring to Khatri (II) vs. State of Bihar, (Supreme Court of India, 1981); Rudul Shah vs. State of Bihar, (Supreme Court of India, 1983); Nilabati Behra vs. State of Orissa, (Supreme Court of India, 1993); Consumer Education and Rasearch Centre vs. Union of India (Supreme Court of India, 1995), the Supreme Court in Paschim Banga Khet Mazdoor Samity vs. State of West Bengal  (1996), held that “In the context of the constitutional obligation to provide free legal aid to a poor accused on account of financial constraints, the denial of emergency aid to the petitioner due to the non availability of bed in the Government Hospital amounts to the violation of the right to life under Article 21 of the Constitution and liable to pay compensation.”

Govt hospitals & Consumer Act
In Indian Medical Association  vs. V.P. Shantha (Supra), their Lordships have gone to the extent that even if the doctors are rendering services to the patients free of charge in the Government hospitals, the provisions of the Consumer Protection Act will apply, after analyzing, the definition of ‘service’ given in Section 2(1)(o) of the Consumer Protection Act, 1986, and have observed that the position related with the services provided in the Government hospitals as:
“Service rendered at a Government hospital/health centre/dispensary where no charge whatsoever is made from any person availing the services and all patients (rich and poor) are given free service - is outside the purview of the expression ‘service’ as defined in Section 2(1) (o) of the Act. The payment of a token amount for registration purpose only at the hospital/nursing home would not alter the position.
 Service rendered at a Government hospital/health centre/dispensary where services are rendered on payment of charges and also rendered free of charge to other persons availing such services would fall within the ambit of the expression ‘service’ as defined in Section 2(1) (o) of the Act irrespective of the fact that the service is rendered free of charge to persons who do not pay for such service. Free service would also be ‘service’ and the recipient a ‘consumer’ under the Act.”
ESI Corporation & Consumer Act
In Kishore Lal vs. Chairman, ESIC, (Supreme Court of India, 2007), the Court referred decisions in Indian Medical Association (supra); Spring Meadows Hospital vs. Harjol Ahluwalia, (Supra); State of Karnataka vs. Vishwabharathi House Building Co-op. Society, (Supreme Court of India, 2003); Secretary Thirumurugan Co-operative Agricultural Credit Society vs. M.Lalitha  (Supreme Court of India, 2004) and the provisions of the ESI Act, 1948, and held that “The service rendered by the medical practitioners of hospitals/nursing homes run by the ESI Corporation cannot be treated as gratuitous, because the charges for consultation, diagnosis and medical treatment are borne by the insurer and the claim for damages for negligence would not fall within the purview of the Employee’s Insurance Court, such service would fall within the ambit of ‘service’ as defined in Section 2(1)(o) of the Consumer Act.” 

Hospitals run by the employer
In the case of Laxman Thamappa Kotgiri vs. G.M. Central Railway, (Supreme Court of India, 2005), where an employee of the railways had filed a complaint on the ground that his wife had been negligently treated at a hospital of the Central Railway as a result of which she died. The Honourable Court held that “Since the medical treatment in the said Hospital is given to employees and their family members is part of the conditions of employment and that the Hospital is run and subsidised by the employer, the appellant’s case would fall within the parameters laid down in paragraph 55(12) of the judgment in V.P. Shantha’s case and in Section 2(1)(o) of the Consumer Act.”
While concluding this, even though it is inconclusive, we have to look into two important verdicts related with this subject. In State of Punjab vs. Shiv Ram, (Supra), their Lordships opined: “It cannot be denied that black sheep have entered the profession and that the profession has been unable to isolate them effectively. The need for external regulation to supplement professional self-regulation is constantly growing. The high costs and investments involved in the delivery of medical care have made it an entrepreneurial activity, wherein the professionals look to reaping maximum returns on such investment. Medical practice has always had a place of honour in society; currently the balance between service and business is shifting disturbingly towards business and this calls for improved and effective regulation, whether internal or external. There is need for introspection by doctors individually and collectively.”
 Again, their Lordships, in the case of Martin F.D’ Souza vs. Mohd. Ishfaq, (Supra), laid down Precautions which Doctors/Hospitals/Nursing Homes should take and held “It is true that the medical profession has to an extent become commercialized and there are many doctors who depart from their Hippocratic Oath for their selfish ends of making money. However, the entire medical fraternity cannot be blamed or branded as lacking in integrity or competence just because of some bad apples”