Medical Malpractice Allegations in Tunisia

Eight-year-old Aya smiles even when she is unable to play with her friends. Her mother believes medical error resulted in brain and nerve damage shortly after Aya was born, leaving her permanently disabled. The child twitches constantly and is unable to walk easily. 

Although Aya’s mother’s identity card says she is 30, she looks much older. She has devoted her life to her daughter, especially because her husband left immediately after the child became ill.

“The child was born normal, but the doctor did something that caused the disablement,” she said, adding that she was unable to take legal action because she was too busy caring for her daughter.

Another recent case of alleged malpractice involved, Elhem, a young married woman, who died as a result of what a relative described as medical error.

“She went into hospital a few months ago to give birth to a child, and doctors decided to give her a Caesarean section, but they left a bandage in her womb that caused her death,” said the relative, who did not want to be named.

Elhem’s family did not sue as they believed that medical staff and investigators would cover things up for their colleagues.

Sahbi Amri, a doctor at a public hospital, acknowledges that serious problems exist in the healthcare system.

“Medicine in Tunisia has become unethical and is dominated by materialistic practices and opportunism,” he said. “These factors generally influence the relationship of trust between patient and doctor. In addition, there is growing rivalry and competition among colleagues in the same profession. Such practices have weakened the doctor’s noble mission and have created a situation where the health of Tunisian citizens is at stake and doctors are exploiting their patients. It’s even worse when the patient becomes a victim of professional medical mistakes, crimes, negligence, fraud or extortion.”

Dr Amri says the prospect of an interminable legal process put people off taking claims to court.

“Cases that have been stuck in the courts for decades have made patients tired of pursuing a claim to obtain redress rights, and thus recorded medical mistakes remain locked in drawers at the health and justice ministries, with no accountability and no serious penalties,” he said. “Patients often pay for a doctor’s mistake, inexperience or lack of training with their health, possibly with their lives.”

Sonia Becheikh, a doctor who works for the health ministry, disagrees that malpractice is as widespread as many believe.

“Most medical errors that are talked about in the community fall into the category of medical complications, not mistakes,” she said. “Patients are unable to distinguish between medical error and complications caused by a specific medicine. In both cases, the doctor gets accused of negligence.”

Dr Becheikh cited the example of a patient who received medication for an ear problem which resulted in damage to his jawbone.

“He immediately accused the doctors of a mistake in the treatment, but was unaware that there is a nerve linking both organs, whose position differs from one patient to another so that it’s hard to locate with certainty,” the doctor said.

Boubaker Amidi, who heads the health ministry department responsible for arbitrating in disputes, insisted that medical staff were subject to the law.

“The doctor is first and foremost a civil servant, in the sense that he or she is subject to the Civil Service Act. In a case where serious medical error is proven, it is up to the judiciary to deal with the case and to issue a ruling. The doctor can be dismissed and sued in line with current legal procedure.”

“The victim is compensated according to the scale of the error,” Amidi said. At the same time, he acknowledge that Tunisia’s legal system was still grappling with the “complexity, ramifications and detail of these issues”, but he did not address the reasons why people were so reluctant to bring legal action.

Overall, Amidi argues that things are getting better, not worse.

“There hasn’t been a rise in the number of serious medical errors in Tunisia; in fact they have declined compared with previous years, as the level of medical competence in public hospitals is improving,” he said. “For about two years, we have recorded no cases of gross medical negligence that resulted in complete paralysis, and which would have led to the doctor being formally dismissed.”

Dr Bouallégue, an inspector at the health ministry, said that between 600 and 700 complaints were currently under review.

“The process of proving medical error takes a long time because of the many complex matters which the experts look at, mainly re-examining the patient’s medical files from the onset of disease through hospitalisation until he or she leaves hospital, and determining his or her state of health after treatment,” he said.

The ministry defines medical error as a doctor’s failure to use all available means to diagnose disease, or the neglect of simple details that could help cure the patient.

The ministry says that when an individual or relatives bring a legal case, a doctor working in a government hospital is not personally liable to pay compensation, which can run to 80,000 dinars (50,000 US dollars). Instead, it is the hospital administration which is responsible. By contrast, in private hospitals the doctor assumes all liability and must pay compensation.

The Tunisian National Medical Association says it receives about 100 formal complaints a year relating to alleged malpractice. The association looks into some of them itself, while others are reviewed by the health ministry’s department for monitoring medical practice. The association has powers to issue warnings, dismiss doctors, and ultimately expel them from its ranks.

Ahlem Tamraoui produced this story after attending an IWPR training workshop in Tunis in August 2013.