Introduction
No-fault medical accidents involve adverse medical outcomes that occur without gross negligence or intentional misconduct by physicians. Given the inherent uncertainties and limitations of medical practice, such incidents are, to some extent, unavoidable. In South Korea, the high rate of criminal charges against physicians poses a substantial threat to workforce stability and deters physicians from entering high-risk or essential specialties. To address this issue, legal protections, and institutional safeguards must be strengthened, thereby enabling physicians to fulfill their clinical responsibilities without undue fear of legal reprisal. This is essential not only for protecting healthcare professionals but also for restoring trust and morale within the medical community [1].
Poor medical outcomes are inevitable even when lawful and appropriate treatments are provided. Holding physicians personally liable for such outcomes in no-fault cases contributes to the deterioration of essential healthcare services and encourages defensive medicine, which increases medical costs and compromises quality [2].
Compared to other countries, such as Japan, the United Kingdom, and Germany, South Korea has a disproportionately high rate of criminal sentencing for medical incidents. This punitive atmosphere has led to the avoidance of high-risk treatments and a growing tendency toward defensive medical practices. Furthermore, the increasing burden of legal risk has led to a decline in the number of medical trainees in high-risk departments [3].
This study assessed the perceived burden of no-fault compensation on physicians. For the healthcare system to remain sustainable and continuously improve quality, it is critical to consider and address this burden. The implementation of a patient-centered, no-fault compensation system could help protect both patients and healthcare providers, fostering a more supportive and effective clinical environment.
Methods
This study surveyed 199 physicians (male:female, 150 [75%]:49 [25%]; mean age, 45.8 [± 8.42]) from a city in South Korea using a structured questionnaire on the perceived burden caused by no-fault compensation. Of these, 190 (94.5%) were board-certified physicians and 9 (4.52%) were general practitioners (Table 1). Statistical analyses were performed using SPSS, version 29.0 (IBM Co.). Statistical significance was defined as a two-sided p-value of less than 0.05.
Results
Perceive burden in practice
A total of 72.4% of physicians conveyed that more than 40% of compensation judgments in no-fault medical accidents were unjust, and 44.7% reported that defensive practices increased healthcare costs by over 40%. A total of 26.9% of the respondents stated that excessive explanations of side effects and complications influenced more than half of their clinical encounters, primarily due to concerns about potential legal consequences. Additionally, over one-fifth of the respondents indicated that defensive practice made up more than half (40%) of their clinical duties (21.6%), and more than half of their clinical time was used for explanations (26.9%; Table 2, Fig. 1).
Perceived burden in education
Physicians also reported that residents’ training (46.7%) and medical student clerkship (77.2%) were disturbed due to the fear of no-fault compensation. The average frequency of disturbance among residents was 1.68 times per month. Additionally, more than 20% of resident clinical training time and 47.4% of medical clerkships were disturbed by the fear of no-fault compensation (Table 3).
Need for a no-fault compensation system
Most of the respondents indicated the need to implement a no-fault compensation system (90.7%; immediate adoption: 46.5%; gradual adoption: 44.2%), and an autonomous licensing body (83.9%; immediate adoption: 35.2%; gradual adoption: 48.7%; Table 4).
Discussion
In South Korea, the high incidence of criminal charges against physicians poses a serious threat to workforce stability and deters many physicians from entering high-risk medical specialties. However, no-fault medical accidents are inevitable owing to the inherent uncertainties and limitations of medicine [4]. The current legal framework is disproportionately accountable to physicians. This not only undermines essential healthcare services but also increases healthcare costs through the widespread adoption of defensive medical practice [5].
The current crisis in the supply and distribution of medical personnel can be attributed to high medical-legal risks. This study showed that 72.4% of physicians indicated that more than 40% of compensation judgments in no-fault medical accidents were unjust, and 44.7% reported that defensive practices increased healthcare costs by over 40%. These findings indicate a widespread perception among physicians that the legal system imposes excessive liability, even in the absence of professional negligence. Consequently, physicians experience undue elevated psychological stress and develop defensive clinical behaviors, ultimately undermining both the quality and efficiency of care.
Legal pressure relating to the duty of informed consent has also been found to significantly affect clinical decision-making. A total of 26.9% of the respondents stated that excessive explanations of side effects and complications influenced more than half of their clinical encounters, primarily due to concerns of potential legal consequences. This demand discourages physicians from pursuing high-risk or innovative treatments, hindering medical progress, and restricting patient access to optimal care. Furthermore, the demand for exhaustive explanations in every scenario, regardless of clinical urgency or context, places an undue burden on physicians and distorts the nature of shared decision-making.
The legal pressure extends beyond clinical practice into medical education and training. In this study, physicians reported that residents’ training (46.7%) and medical student clerkship (77.2%) were disturbed due to the fear of no-fault compensation. The average frequency of disturbance among residents was 1.68 times per month. Additionally, more than 20% of resident clinical training time and 47.4% of medical clerkships were disturbed by the fear of no-fault compensation.
These findings suggest not only a distributional issue in teaching responsibilities but also structural tensions in the current training system. The legal anxieties surrounding medical accidents, explanatory obligations, and defensive practices may inadvertently affect the quality of medical education, leading to excessive caution and emotional exhaustion among educators and trainees, thereby, reducing educational effectiveness.
Most physicians reported the need to implement a no-fault compensation system and an autonomous licensing body. These findings highlight the urgent need for institutional and legal reforms. A structured no-fault compensation system must be implemented to distinguish between unavoidable outcomes and genuine malpractice [6]. Furthermore, the physicians’ duty to explain and the scope of necessary clinical explanations must be legally clarified in the context of no-fault cases [7]. These strategies are paramount for reducing the pressure on excessive legal self-protection, supporting ethical and patient-centered care, and contributing to a more stable and innovative healthcare system. Physicians deserve adequate compensation for their expertise, responsibility, and societal values. Proper remuneration is critical for sustaining the healthcare system, ensuring the quality of care, and enabling ethical, patient-centered practices. A delay in addressing the current situation, workforce shortages and declining medical service quality, are inevitable.
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