by Vivienne H. Harpwood. New York: Routledge-Cavendish, 2007. 240pp. Cloth. $170.00. ISBN: 9780415428071. Paper. $53.95. ISBN: 9780415428095.

Reviewed by Christopher A. Riddle, Department of Philosophy, Queen’s University, Canada. E-mail: 9car [at] queensu [dot] ca.


Vivienne Harpwood’s MEDICINE, MALPRACTICE, AND MISAPPREHENSIONS offers a thorough examination of the rising incidence of clinical negligence claims. Harpwood questions, in light of recent trends, whether there is in fact, a litigation crisis in healthcare. MEDICINE, MALPRACTICE, AND MISAPPREHENSIONS attempts to “put the debate about the so-called compensation culture on a sounder statistical, and hence, epistemological basis” (p.xiii). At its heart, MEDICINE, MALPRACTICE, AND MISAPPREHENSIONS argues that the current Governmental claims that are reluctant to acknowledge, or are skeptical of the existence of a compensation culture are “sadly, possibly deliberately, short of the mark in the healthcare context” (p.xiii). Harpwood is fair in her treatment of these questions, and often offers thorough support through both quantitative as well as qualitative analysis.

Harpwood’s introductory chapter presents the reader with a thorough understanding of the figures and trends surrounding clinical negligence claims. She then proceeds to examine the “myth” of the compensation culture and asks us who is to blame for the rise in incidents of malpractice, the role the media plays in such a culture, as well as the status doctors hold in contemporary UK culture. MEDICINE, MALPRACTICE, and MISAPPREHENSIONS ends with Harpwood’s attempt to “treat the affliction.” It is here she presents novel ideas and suggestions on the role of the courts, government intervention, as well as legal reform.

The first chapter, “Data, Accuracy, Compensation, and Error: What Should We Believe?” serves as an introduction to the statistical trends in clinical negligence claims. It examines the information available about the number of claims and errors that occur in healthcare. Harpwood proceeds by examining what these claims and errors cost the public, and ultimately, concludes that there is almost certainly what she refers to as “a culture of under-compensation” (p.xiv). This conclusion is not expressed without a fair amount of reluctance however. Harpwood navigates the reader through a maze of contradictory data and often stops to highlight briefly why she believes such discrepancies exist.

While this chapter serves as an excellent introduction to the complexities in understanding malpractice claims in the UK, it does have at least one shortcoming. MEDICINE, MALPRACTICE, AND MISAPPREHENSION is, by and large, [*839] written in a style that everyone can enjoy. It is clear, concise, and often speaks to the reader in a casual style, demystifying complex issues and figures. Harpwood’s first chapter however, focuses on quantitative analysis more than the rest of the book, and is perhaps overly thorough. She presents the reader with a tremendous amount of data, and I suspect, it will serve to overwhelm some. Tom Baker’s THE MEDICAL MALPRACTICE MYTH (2005) presents similar trends within the American context in a much more accessible style. What THE MEDICAL MALPRACTICE MYTH lacked in thoroughness, it made up through developing greater interest and lasting knowledge. I fear Harpwood has presented too much data to make a lasting impression in Chapter One, and as a result, could alienate some readers.

That said, providing too much data is hardly a complaint with which those engulfed in this debate would concern themselves. The more casual reader may gravitate more heavily towards Baker’s THE MEDICAL MALPRACTICE MYTH or perhaps William M. Sage and Rogan Kersh’s MEDICAL MALPRACTICE AND THE U.S. HEALTH CARE SYSTEM (2006).

The second chapter provides the reader with possible causes of the increase in clinical negligence claims. It is here Harpwood examines such phenomena as the impact of legal advertising, the rise of medical consumerism, as well as the new psychology of the doctor-patient relationship. Perhaps the most interesting section of this chapter is the timeline Harpwood provides us, outlining key events since 1984. She then associates these events to the number of claims reported in each corresponding year.

Harpwood then moves on to examine the potential reality of a compensation culture in the UK. In the third chapter, Harpwood focuses on the gap between myth and reality within the perceived contemporary culture of compensation, ending with a harsh critique of the government and other organizations that may “have an interest in promoting the idea that too many people, even those who deserve to be compensated, are making claims” (p.104).

The fourth chapter examines the role and influence of the media in informing the UK public of developments and incidents in healthcare litigation. Here Harpwood assesses how medical stories are reported, as well as the slant the media gives to accounts of clinical negligence. She notes how many of the reported errors or claims concern high awards of money to ensure the headlines are attention grabbing. However, despite this claim, Harpwood does present a well-balanced critique of the media and dedicates a good portion of this chapter to many examples of responsible media reporting. Ultimately, Harpwood does not present the reader with a strong conclusion, but throughout the chapter discusses many criticisms of media coverage in the healthcare context. These criticisms include, but are not limited to, the views of healthcare professionals, politicians, and lawyers.

Next, Harpwood attempts to draw some conclusions regarding how doctors are conceptualized in popular culture. “Over-paid, Out of Control, and Under-Regulated” examines how doctors are [*840] often depicted as over-regulated, out of control, practicing under pressure, and acting defensively. Again, Harpwood presents a well-balanced examination of the facts so as to ensure she is not perpetuating the myths she is attempting to demystify. For example, even though doctors in the UK earn well above their European counterparts, British doctors are also expected to achieve goals and meet Government targets and standards in a manner that represents significant departure from the remainder of Europe.

The primary shortcoming of this chapter is the overly-brief treatment of defensive medicine. Harpwood cites literature supporting the view that doctors practice defensively (meaning, they carry out procedures and treatments that are not clinically necessary, but because these measures are likely to prevent a legal claim of negligence). While she acknowledges the distinction between defensive medicine and risk management, Harpwood fails to thoroughly examine difficulties with defensive medicine arguments, as well as the positive and negative aspects of the practice.

Sandeep Jauhar (2008) recently penned an article for the NEW YORK TIMES addressing, amongst other topics, the reluctance of insurance companies to support what was perceived to be unnecessary tests or medication. He argues that practicing medicine was more difficult as a result of insurers “handcuffing” a selected course of treatment. He claims that insurance companies sometimes have more power over a patient’s course of treatment than the patient’s own doctor.

Additionally, despite the fact that most doctors admit to practicing defensive medicine, a postal questionnaire conducted in 1995 by Nicholas Summerton (1995) finds numerous positive outcomes of defensive medical practice. Some of these positive outcomes are more detailed note taking and explanation of procedures to patients, development of audit in practice, and increased patient satisfaction. Surely these outcomes are not of similar weight as many of the negative ones, but I believe that nevertheless, they deserve attention.

Finally, the sixth chapter concludes with Harpwood’s recommendations to progress to a better understanding of many of the misapprehensions about error and negligence claims in healthcare. These suggestions include improving statistical evidence, changing the culture, and developing the concept of primary liability, to name a few. Many of these suggestions are supported through conceptualization in previous chapters, but nevertheless, I believe the reader would benefit from more attention to these suggestions. Many of the suggestions are presented clearly and concisely, but some are relatively unsupported.

As a whole, Harpwood’s contribution is a large one. MEDICINE, MALPRACTICE, AND MISAPPREHENSIONS is a thorough examination of many of the nuances surrounding the contemporary culture of compensation in the UK. I suspect this monograph will be of primary interest to those working in healthcare litigation, it but would also benefit those interested in the politics of healthcare and bioethics. [*841]

Baker, Tom. 2005. THE MEDICAL MALPRACTICE MYTH. Chicago: The University of Chicago Press.

Jauhar, Sandeep. 2008. “Eyes Bloodshot, Doctors Vent Their Discontent.” July 18 2008 THE NEW YORK TIMES.

Sage, William M. and Rogan Kersh (eds.). 2006. MEDICAL MALPRACTICE AND THE U.S. HEALTH CARE SYSTEM. New York: Cambridge University Press.

Summerton, Nicholas. 1995. “Positive and Negative Factors in Defensive Medicine: A Questionnaire Study of General Practitioners.” 310 BRITISH MEDICAL JOURNAL 27-29.

© Copyright 2008 by the author, Christopher A. Riddle.