Medical liability crisis: an international problem.

Developmental Medicine & Child Neurology 2003, 45: 363–363 363 ‘On the influence of abnormal parturition: difficult labours, premature birth, and asphyxia neonatorum, on the mental and physical condition of the child, especially in relation to deformities’. In the third paragraph he notes ‘the object of this communication is to show that the act of birth does occasionally imprint upon the nervous and muscular systems of the nascent infantile organism, very serious and peculiar evils’3 (italics mine). The impact of this description of ‘Little’s Disease’ has had a pernicious influence on the current understanding of the etiology of the heterogeneous conditions included under the term ‘cerebral palsy’. As Stanley et al. in their text Cerebral Palsies: Epidemiology and Causal Pathways state: ‘the litigation itself focuses attention on the intrapartum period, away from factors and events occurring earlier in development, where it is now believed that perhaps 80% of CP pathology is initiated’.4 To further delineate the limited influence of causation, an international consensus report entitled ‘A template for defining a causal relation between acute intrapartum events and cerebral palsy’ was published by the BMJ in 1999.5 Subsequent to this report, all clinicians should be aware of a recently published report by the collaboration of the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics entitled ‘Neonatal encephalopathy and cerebral palsy: defining the pathogenesis and pathophysiology’.6 The report lists criteria to define ‘an acute intrapartum hypoxic event sufficient to cause cerebral palsy’. The report clearly indicates that if any one of the listed factors is absent then intrapartum hypoxia is not the cause of CP. The very survival of individual clinical practices, the treating hospitals, and the wide spectrum of outpatient facility services depends upon reform of the current climate of litigation which endangers all of our current health care systems.