Is it time to adopt a no-fault scheme to compensate injured patients?

• Author: Gibson, Elaine
• Position: 7th National Health Law Conference

THE TORT SYSTEM IS roundly indicted for its inadequacies in providing compensation in response to injury. More egregious is its response to injuries incurred due to negligence in the provision of healthcare services specifically. Despite numerous calls for reform, tort-based compensation has persisted as the norm to date. However, recent developments regarding physician malpractice lead to consideration of the possibility of a move to "no-fault" compensation for healthcare-related injuries. In this paper, I explore these developments, examine programs in various foreign jurisdictions which have adopted no-fault compensation for medical injury, and discuss the wisdom and feasibility of adopting an administratively-based compensation system for healthcare-related injury in Canada.

A number of jurisdictions around the world have created administrative bodies whose role is to assess and allocate appropriate compensation in response to healthcare-related injuries. The primary motivation has been either to accomplish greater justice or to deal with burgeoning costs of the medical malpractice system (often accompanied by threatened collapse of the major insurer). The administrative scheme adopted may replace tort completely vis-a-vis claims within its purview, or it may permit the claimant to select either to pursue the administrative route or to launch a civil lawsuit. The scheme may be comprehensive, i.e., attempting to cover all healthcare-related injury, or may be limited to a particular type or extent of injury. For example, three jurisdictions have adopted programs exclusively focused on serious neurological injury surrounding birth trauma.

Under these administrative schemes, an injured claimant must establish that the claimant fits within the program criteria, and therefore is entitled to compensation. The claimant is aided in the process by program administrative staff, and often by the complainant's health care provider. Thus, the adversarial relationship between plaintiff and defendant is replaced by a system wherein the care provider may provide assistance to the injured person in seeking compensation.

Numerous prominent individuals have argued in favour of reform of the Canadian tort-based medical malpractice, but governments have not been highly motivated to take action. However, the Canadian Medical Protective Association has recently sharply hiked the premiums paid for the defence of physicians and residents, in some cases an increase of close to 100 percent from 2014-15 to 2015-16. The lion's share of these premiums is funded by provincial governments, whose budgets are straining as a result. The question to be addressed in this paper is: Are events now such that governments will indeed be motivated to take on reform, perhaps radical reform? These recent price increases, combined with an enhanced focus on patient safety, may provide the stimulus for revision of our system's response to healthcare-related injury.

LE SYSTEME DE RESPONSABILITE civile delictuelle est generalement blame pour ses faiblesses a d'indemniser en cas de lesions. La plus remarquable est sa reponse aux lesions decoulant de la negligence dans la prestation de services de sante en particulier. Malgre de nombreuses demandes de reforme, l'indemnisation fondee sur la responsabilite civile delictuelle a continue d'etre la norme a ce jour. Cependant, de recents developpements concernant les fautes professionnelles des medecins ont mene a etudier la possibilite de passer a une indemnisation sans egard a la faute pour les lesions liees aux soins de sante. Dans notre article, nous explorons ces developpements, nous examinons les programmes de diverses competences etrangeres qui ont adopte une approche d'indemnisation sans egard a la faute pour les lesions liees aux soins medicaux, et nous discutons du bien-fonde et de la faisabilite d'adopter un regime d'indemnisation administratif sans egard a la faute pour les lesions liees aux soins medicaux au Canada.

Un certain nombre de ressorts ont, de par le monde, mis sur pied des organismes administratifs dont le rode est d'evaluer et de determiner l'indemnisation appropriee en cas de lesions attribuables aux soins medicaux. La motivation premiere pour la creation de tels organismes etait soit d'obtenir une plus grande justice, soit de juguler les couts croissants du systeme d'indemnisation des fautes professionnelles medicales qui, souvent, menacaient de faillite les principaux assureurs. Le modele administratif adopte pourrait remplacer completement la responsabilite civile delictuelle pour les cas relevant de sa competence, ou il pourrait permettre au demandeur de choisir la voie administrative ou d'intenter une poursuite au civil. Le modele pourrait etre exhaustif, c.-a-d. tenter de couvrir tous les cas de lesions decoulant de soins medicaux, ou se limiter a un type particulier ou a une etendue de lesions. Par exemple, trois ressorts ont adapte des programmes portant exclusivement sur les lesions neurologiques graves decoulant de traumatismes de naissance.

Selon ees modeles, la partie demanderesse lesee doit etablir qu'elle repond aux criteres du programme et a done droit a une indemnisation. Le personnel administratif du programme vient en aide au demandeur/demanderesse dans le cadre du processus et, frequemment, le dispensateur de soins de sante en fait autant. Ainsi, les rapports fondes sur la contradiction entre le plaignant et le defendeur sont remplaces par un systeme dans lequel le dispensateur de soins peut aider la personne lesee a obtenir une indemnisation.

De nombreuses personnalites ont plaide en faveur d'une reforme du systeme canadien d'indemnisation des fautes professionnelles medicales fonde sur la responsabilite delictuelle, mais les gouvernements n'ont jusqu'a maintenant pas ete tres motives a agir. Cependant, l'Association canadienne de protection medicale a recemment augmente de facon considerable les primes a payer pour defendre les medecins et les residents; dans certains cas, l'augmentation atteint presque 100 p. 100 entre 2014-2015 et 2015-2016. La part du lion de ees primes est financee par les gouvernements provinciaux dont les budgets ecopent de facon consequente. La question a debattre dans cette presentation est la suivante: Les choses en sont-elles rendues a un point oil les gouvernements seront motives a entreprendre une reforme, peut-etre meme une reforme radicale? Ces recentes augmentations de couts venant s'ajouter a l'importance accrue accordee a la securite des patients pourraient bien etre l'incitation voulue pour une revision de notre systeme de reponse aux lesions decoulant de fautes medicales professionnelles.

CONTENTS I. Introduction II. Legal Response to Medical Malpractice in Canada A. Compensation Rates B. Role of the Canadian Medical Protective Association C. Calls for Reform III. No-Fault Compensation Schemes A. Administrative Structure B. Threshold Criteria to Qualify for Compensation C. Option to Sue in Negligence D. Damages E. Program Funding IV. Comparison between Canada's Fault-Based Approach and No-Fault A. Compensation B. Deterrence C. Corrective Justice D. Distributive Justice 1. Health Outcomes 2. Views of Participants 3. Health Expenditures 4. System Efficiencies V. Conclusion I. INTRODUCTION

The Canadian fault-based system of redress in law for injury due to medical malpractice functions poorly. An exceedingly small percentage of aggrieved patients ever commence legal action, and far fewer receive compensation as a result. A number of jurisdictions outside Canada have rejected a fault-based response to medical malpractice and instead have adopted a "no-fault" scheme to respond to medical mishaps. In this paper I explore some of the reasons for the low-functioning Canadian system, and examine whether or not a no-fault scheme of compensation for medical injury might perform in superior fashion.

A legal action commenced due to injury incurred while in receipt of healthcare services or treatment is commonly referred to as a medical malpractice lawsuit. This suit in civil negligence is brought by the plaintiff, who must establish that he or she was injured due to an action or failure to act on the part of the healthcare provider. The core of this action is proof on a balance of probabilities that the healthcare provider failed to meet the standard of care required in the circumstances, and that this failure caused injury to the plaintiff. Thus, we speak of the system being "fault-based" in that the plaintiff must establish that the injury resulted from the healthcare provider being "at fault," that is, having been negligent in falling below the requisite standard of care.

This paper commences with a discussion of the legal response to medical malpractice in Canada. I explore the low rates of compensation and reasons therefor. The prominent role of the Canadian Medical Protective Association (CMPA) is highlighted, and calls for reform are discussed. The need for reform is often said to be rooted in our fault-based system, and therefore some have argued that a no-fault system maybe preferable.

I then turn to an examination of the no-fault compensation schemes that have been adopted in ten jurisdictions around the world (Denmark, Finland, Iceland, Norway, Sweden, New Zealand, Virginia, Florida, Japan, and France). These schemes can be comprehensive--i.e., intended to replace the fault-based system entirely--or restricted to a particular type or severity of injury--e.g., solely covering obstetrically-induced brain injury. In particular, I examine their administrative structure, the threshold criteria to qualify for compensation, whether or not there remains an option to bring a lawsuit for negligence, what damages are available under the administrative scheme, and how the various schemes are subsidized.

Next, I undertake a comparison between Canada's fault-based response to medical malpractice and no-fault jurisdictions...