State Objective Liability for Iatrogenesis versus Force MajeureResponsabilidad objetiva del Estado por iatrogenia frente a fuerza mayor

**IV.-** Within the dynamics of the Administration's preeminently objective liability system, the State is liable to an individual who has suffered an unlawful injury that they are not obligated to bear and that was caused by a public operation. The scope of coverage of the postulates that comprise it includes, in addition to material injuries, those of an non-economic (extrapatrimonial) nature. This type of liability is based on the damage itself, and not on other elements, such as willful misconduct (dolo) or fault (culpa). The foregoing finds support in Article 41 of the Political Constitution, which, in pertinent part, states: "Turning to the Laws, everyone shall find reparation for the injuries or damages they have received to their person, property, or moral interests." As well as in canon 197 of the General Public Administration Law (Ley General de la Administración Pública), according to which: "Liability shall apply for damage to purely moral assets, as well as for the moral suffering and physical pain caused by death or by the inflicted injury, respectively." For this criterion of imputation, it is not required that the analysis of the conduct focuses on whether there was willful misconduct (dolo) or fault (culpa) on the part of the person causing the injury. Such considerations become irrelevant, as other aspects come into play. It is essential that there be a causal link (nexo causal) between the conduct or situation causing the damage and that suffered by the victim, a link which is broken in the event of any exempting circumstance, namely: force majeure (fuerza mayor), fault of the victim (culpa de la víctima), or act of a third party (hecho de un tercero). This principle arises independently of the liability towards the administered party that its officials or agents may assume. Article 190 of the General Public Administration Law establishes: "1) The Administration shall be liable for all damages caused by its legitimate or illegitimate, normal or abnormal operation, except for force majeure (fuerza mayor), fault of the victim (culpa de la víctima), or act of a third party (hecho de un tercero). 2) The Administration shall be liable in accordance with this article, even when it cannot be by virtue of the following sections of this Chapter, but liability for a lawful act or normal operation shall only arise under the terms of the following Third Section." The imputation parameters are objective (normal or abnormal, lawful or unlawful operation) and the proof of the causal link can only be extinguished by the exempting circumstances expressed in the rule, without this conflicting with the possibility that, internally, the Administration itself determines the liability of its agents, where the rules are governed by the degree of participation and the concepts of willful misconduct (dolo) or gross fault (culpa grave). Therefore, the Administration shall be liable whenever its normal or abnormal operation causes damage that the victim is not obligated to bear, whether economic (patrimonial) or non-economic (extrapatrimonial), regardless of their subjective legal situation and the title or condition of power they hold.

**V.-** In the first place, the appellant alleges a break in the causal link (nexo causal) between the damage and the administrative conduct, as an exempting circumstance of liability for force majeure (fuerza mayor), called iatrogenesis (iatrogenia), was operative, which was unforeseeable and unavoidable. Regarding the error of fact in the assessment of the evidence claimed, specifically of the legal medical opinions and the testimonial evidence, it must be remembered that its valuation is governed by the rules of sound judgment (sana crítica), where its weighting is reflected in the proven facts that support the decision. In the present case, this Chamber does not observe that any infraction was committed regarding this point, for the points that have been taken as proven have adequate foundation in the evidentiary elements that are indicated as support in each one of them, without any evidence of the error of fact to which the appellant alludes and which, in the case of the testimonial evidence, is in any case not specified. The mere contrary opinion of the defendant is not sufficient reason to consider it otherwise. The Trial Court found it proven that Mr. Nombre11575 presented himself on June 27, 2000, at the Ebais Clinic of Lourdes de Agua Caliente de Cartago, for a bout of flu, and Doctor Olman Sanabria Araya applied an intramuscular injection of voltaren with dexamethasone to his left buttock. Immediately afterward, the patient lost mobility in his leg, from the knee down, later being diagnosed with peripheral neuritis. It analyzed legal medical report no. DML-382-2001, issued in the criminal jurisdiction, in the case for negligent bodily harm (lesiones culposas) brought against the Doctor, and medical opinions numbers DML 5622-04 and DML-2005-1271, processed in the present proceeding, concluding that "If the claimant suffered the injury after the intramuscular injection of voltaren with dexamethasone was applied, the only possible conclusion is that, despite the treating physician having used the proper technique, this was the cause of the injury. In any case, what is discussed here is the objective liability of the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social), and not the personal liability of the aforementioned physician. This being so, there is an adequate causal relationship (relación de causalidad) between the medical service provided and the damage claimed, which falls within the provisions of Articles 190 and 194 of the General Public Administration Law, for it is an injury derived from a normal functioning of the Administration, which is exceptional in its intensity." To arrive at the foregoing, it considered that it is not usual that, after the application of that medication, there is direct contact with the common peroneal nerve (nervio ciático poplíteo externo), it being possible for an injury to arise from an allergic reaction. Furthermore, it indicated, the consultation was for the flu, not for alcoholism, without finding alcoholic stigmata or grade; nor telangiectasias, collateral venous network, or hepatomegaly; so the site where the injection was placed was adequate, an iatrogenic situation arising, since the correct application adhering to the "Lex Artis" produces an unexpected and adverse result (no. DML-382-2001). It also stated, dysfunction of the sciatic nerve (nervio ciático) is a condition involving defective movement and/or sensation in the leg, caused by damage located in the posterior part of the leg, which innervates the muscles of the posterior part of the knee and the lower part of the leg. Among the usual causes, it cites direct trauma from an intramuscular injection in the buttocks or pressure on the nerve. The plaintiff, it stated, presents a dysfunction of the common peroneal nerve (nervio ciático poplíteo externo), which may be secondary to the intramuscular injection applied as part of the treatment indicated for the pathology he presented on June 27, 2000; however, from the physical examination, the study of the medical record and the consulted bibliography, there are no elements of judgment from a legal standpoint to support that the patient had inadequate or inopportune medical attention or treatment (no. DML 5622-04). Finally, it recorded, there are no documents to suppose that before the injection, he suffered from any type of sciatic nerve dysfunction and that it is possible for a patient to present extensions to it, even when using an adequate technique for its application (no. DML-2005-1271). Thus, this Chamber considers that, contrary to what the appellant stated, the final conclusion reached by the Ad quem court finds its basis in what the evidentiary elements report, in which, it is reiterated, the error accused does not occur. That is, despite the method practiced, which is the one accepted by medical science, and that the proper technique was used in applying it, the cause of the injury – defective movement and/or sensation in the leg due to damage to the sciatic nerve – was the application of an intramuscular injection of voltaren with dexamethasone in the left buttock. A circumstance that proves the existence of a cause-and-effect relationship between the provision of the medical service provided by Doctor Olman Sanabria Araya, at the Ebais of Lourdes de Agua Caliente de Cartago, and the deterioration in the physical integrity of Mr. Nombre11575. Given this, the appellant's argument that there is no causal link (nexo causal), specifically because the exempting circumstance of force majeure (fuerza mayor) concurs, as an unforeseeable, irresistible, and unavoidable situation occurred, which she calls iatrogenesis (iatrogenia), fails.

**VI.-** This last concept comes from the Greek "iatros": physician, and "genia": originated or caused by. From the standpoint of current legal regulations, there is no precise definition, so reference must be made generically. Thus, in a resolution of this Chamber no. 23 at 14:40 hours on April 21, 1993, a first approach to its definition and characteristics was attempted; however, it is appropriate to reframe the issue. Iatrogenesis (iatrogenia) consists of any alteration in the patient's state produced by the physician. Pathology produced by their intervention, so none would be free from producing it. It includes both positive and negative effects. An iatrogenic action can entail their liability and/or that of the institution providing the service, be it public or private. It occurs when the physician has generated, not just any new, banal and inconsequential fact, but has created, through an intervention with therapeutic intent, a new pathological situation. It can also be the result of treatments by other professionals linked to the health sciences, such as, for example, therapists, psychologists or psychiatrists, pharmacists, nurses, dentists, although it can also be caused by alternative medicines. The patient's own predisposition, constitution or sensitivity contribute to or can directly trigger it. Even under ideal conditions in which any medical act can be performed, iatrogenesis (iatrogenia) can exist, since medicine is not an exact science. Its forms are varied in their eventuality and circumstances, so, as stated, it can be classified into two types: positive and negative. In the first case, the alterations produced in the patient's state are innocuous. In the other, the patient's state suffers some damage from the medical action, which may be necessary or unnecessary. In the former, the physician has full knowledge of the risk of damage; it is an expected, foreseen risk, which does not cause surprise, and the specialist recognizes it as an inherent risk for the patient's benefit. In their decision, the benefit/damage ratio has been weighed, that is, the risk of producing an injury to achieve a result beneficial for the patient. The advisability of using resources that, on the one hand, will have beneficial effects but, on the other, will cause undesirable yet unavoidable effects to prevent a greater harm is evaluated. At no time has there been carelessness, mistake, or ignorance. The potential to generate impairment is inherent to the practice of medicine. For example, the radical removal of a malignant tumor can save the patient's life but in turn produce mutilation or disability. This duality of effects is regulated under the "principle of double effect." According to this principle, it is lawful to perform an action in which the positive effect must be proportionate, that is, the final result must outweigh the unavoidable accidental harm. In unnecessary negative iatrogenesis (iatrogenia negativa innecesaria) (commonly just called "iatrogenesis" (iatrogenia)), damage occurs, despite the physician having adopted all the precautions of the case: they applied the general duty of prudence and diligence. They employed, correctly, in accordance with the conditions of manner, time, and place, their science, art, trade, and experience; but the particular situation of the patient – be it their immune system, their way of reacting, anatomical or physiological peculiarities different from the usual, or any unknown but evidently existent factor – causes a harmful or damaging pathology, unanticipated and unforeseeable. The above concepts should not be confused with malpractice (mala praxis), which is the detriment produced by negligent, imprudent, or unskillful conduct. It is the professional activity performed below the standards of good practice required. It is the physician's omission to properly provide the services they are obligated to in their professional relationship with the patient, and which causes harm. Malpractice (mala praxis) is the damage caused that the physician did not foresee, did not anticipate, and which was, however, foreseeable. Finally, it is important to understand that the medical act (acto médico) comprises every action or provision performed in the exercise of their profession, understood as such, those of diagnosis, therapy, among others, in the comprehensive care of the patient, as well as those directly derived from these. It is a complex act that implies scientific knowledge, to know the end sought and the possible consequences. The physicians' performance is limited to an obligation of means and not of results, which, it is known, can be negative, even when applying all available science, skill, dedication, or diligence. It must be governed by the "Lex Artis," which consists of an activity framed within the guidelines and rules that naturally and harmoniously derive from the current state of technical-scientific knowledge, also integrating norms of deontology. Its invocation supposes a reference not only to professional norms, but also to ethical criteria. The medical obligation is to place all knowledge at the patient's disposal in order to improve their health (obligation of means), and when these are insufficient, consultations must be made, working interdisciplinarily in order to seek what is appropriate for their benefit, but a total cure cannot be guaranteed (obligation of results). In this sense, the principle governs that the patient enters the hospital center to be cured, not to become more ill.

**VII.-** In accordance with the foregoing, and based on the above scheme, although the injury produced in Mr. Nombre11575's left leg was unforeseeable and unavoidable, which in principle rules out malpractice (mal praxis), it cannot be ignored that it occurred as a direct consequence of the provision of the medical service (Costa Rican Social Security Fund (Caja Costarricense de Seguro Social)). Thus, even though what happened falls within the classification of unnecessary negative iatrogenesis (iatrogenia negativa innecesaria), it was not due to an extraneous or external event – force majeure (fuerza mayor). What cannot be anticipated, because it is unknown or unknowable, cannot be avoided. Therefore, from the factual framework, it is not inferred that it constitutes an exempting cause of liability, as provided by Article 190, first paragraph, of the General Public Administration Law. In that line of thought, the Trial Court correctly assessed the evidence added to the file and properly applied the cited regulations, discarding the alleged cause of exemption.

**VIII.-** On the other hand, the appeal accuses that it was not demonstrated that the physician who applied the injection acted with negligence, imprudence, or lack of skill, so that, as his willful misconduct (dolo) or fault (culpa) was not proven, it is improper to grant the claimed compensation. In this sense, first of all, it is necessary to state that the cassation appeal is technical and its admissibility depends on compliance with certain requirements. Article 608 of the Civil Procedure Code contains a limitation aimed at ensuring that the questions submitted to the Chamber's examination have been timely raised and debated by the litigants. On this matter, this body's judgment no. 195 at 19:15 hours on February 20, 2002 may be consulted. This limitation constrains that the grievances submitted for examination must have been presented to the appellate court, in the appeal. Only then could it be considered that they are questions timely raised and debated by the litigants. From the study of the file, according to the brief on folios 343 to 353 of the file, when expressing grievances, the defendant's representative did not question that point. Consequently, the censure referring to that point must also be rejected. Furthermore, in recital VI of the appealed resolution, it was clear that, "In any case, what is discussed here is the objective liability of the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social), and not the personal responsibility of the aforementioned physician." A precision that conforms to the controversy under examination, as has been stated in this ruling. It being of no use to try to personally attribute blameworthy conduct to the treating physician, when the liability sought in the claim is of an objective type, attributable to the Public Administration.

In their decision, the benefit/harm ratio has been weighed, that is, the risk of producing an injury to achieve a convenient result for the patient. The convenience of using resources is evaluated, which, on the one hand, will have beneficial effects but, on the other, will cause undesirable yet unavoidable effects to avoid a greater evil. At no time has there been carelessness, mistake, or ignorance. The potential to generate harm is inherent to the practice of medicine. For example, the radical removal of a malignant tumor can save the patient's life but in turn produce mutilation or disability. This duality of effects is regulated under the “principle of double effect.” According to this principle, it is lawful to perform an action in which the positive effect must be proportionate, that is, the final result must outweigh the inevitable accidental evil. In unnecessary negative iatrogenesis (iatrogenia negativa innecesaria), (commonly called simply “iatrogenesis”), harm occurs, despite the fact that the physician adopted all the foreseen precautions for the case: they applied the general duty of prudence and diligence. They employed, correctly, in accordance with the conditions of manner, time, and place, their science, art, trade, and experience; but the particular situation of the patient—be it their immunological system, their manner of reacting, anatomical or physiological peculiarities different from the usual, or any unknown but evidently existing factor—causes a harmful or damaging pathology, unforeseen and unforeseeable. The previous concepts should not be confused with malpractice (mal praxis), which is the detriment produced by negligent, imprudent, or unskilled conduct. It is professional activity performed below the required good practice standards. It is the physician's omission to appropriately provide the services to which they are obligated in their professional relationship with the patient, and which causes harm. Malpractice is the caused harm that the physician did not foresee, did not anticipate, and which, however, was foreseeable. Finally, it is important to understand that the medical act encompasses every action or disposition carried out in the exercise of their profession, understood as such to include diagnosis, therapy, among others, in the comprehensive care of the patient, as well as those directly derived from these. It is a complex act that implies scientific knowledge, to know the end sought and the possible consequences.

The performance of physicians is limited to an obligation of means and not of results, which, it is known, can be negative, even when applying all available science, expertise, dedication, or diligence. It must be governed by the "Lex Artis", which consists of an activity framed within the guidelines and rules that naturally and harmoniously derive from the current state of technical-scientific knowledge, also integrating norms of deontology. Invoking it supposes a reference not only to professional norms but also to ethical criteria. The medical obligation is to place all knowledge at the patient's disposal for the purpose of improving their health (obligation of means) and when this is insufficient, interconsultations must be carried out, working interdisciplinarily to seek what is adequate for their benefit, but total cure cannot be guaranteed (obligation of results). In this sense, the principle applies that the patient enters the hospital to be cured, not to become sicker.

**VII.-** In accordance with the foregoing, and based on the preceding framework, although the injury produced in the left leg of Mr. Nombre11575 was unforeseeable and inevitable, which in principle rules out malpractice, it cannot be ignored that it occurred as a direct consequence of the provision of medical service (Caja Costarricense de Seguro Social). Thus, despite the fact that what happened is placed within the so-called unnecessary negative iatrogenesis (iatrogenia negativa innecesaria), it was not due to a strange or external event—force majeure (fuerza mayor). What cannot be anticipated, because it is unknown or unknowable, cannot be avoided. In such a way that, from the factual scenario, it is not inferred that a cause for exemption from liability is constituted, pursuant to the provisions of numeral 190, first paragraph, of the Ley General de la Administración Pública. In that line of reasoning, the Court correctly assessed the evidence attached to the case file and properly applied the cited regulations, dismissing the alleged cause for exemption.

**VIII.-** On the other hand, the appeal alleges that it was not proven that the physician who gave the injection acted with negligence, imprudence, or lack of skill, such that, since their intent (dolo) or fault (culpa) was not proven, it is improper to grant the compensation sought.

In this regard, first of all, it is necessary to state that the cassation appeal is technical and its admissibility depends on compliance with certain requirements. Article 608 of the Código Procesal Civil contains a limitation intended to ensure that the issues submitted for the Chamber's examination have been timely proposed and debated by the litigants. On this matter, ruling no. 195 of this body, issued at 7:15 p.m. on February 20, 2002, may be consulted.

That limitation constrains the grievances submitted for examination to those that were raised before the appellate court in the appeal. Only thus could it be considered that they are issues timely proposed and debated by the litigants. Upon reviewing the case file, according to the brief at folios 343 to 353 of the file, when stating grievances, the representative of the defendant did not challenge that point. Consequently, the objection referring to that point must also be rejected. Furthermore, in Considerando VI of the appealed resolution, it was made clear that, “*In any case, what is being discussed here is the strict liability (responsabilidad objetiva) of the Caja Costarricense de Seguro Social, and not the personal liability of the aforementioned physician.*” A clarification that conforms to the controversy under examination, as has been set forth in this ruling. It is of no utility to attempt to personally attribute reprehensible conduct to the treating physician, when the liability sought in the claim is of a strict type (tipo objetivo), attributable to the Public Administration." In that line of reasoning, the Court correctly assessed the evidence brought into the case file and properly applied the cited regulations, discarding the alleged ground for exemption.</span><span> </span><span style=\"font-family:Tahoma; font-weight:bold\">VIII.-</span><span style=\"font-family:Tahoma\"> On the other hand, the appeal alleges that it was not demonstrated that the physician who administered the injection acted with negligence, imprudence, or lack of skill (impericia), such that, since his intent (dolo) or fault was not proven, granting the claimed compensation is improper.</span><span> </span><span style=\"font-family:Tahoma\">&#xa0;</span><span style=\"font-family:Tahoma\">In this regard, first of all, it is necessary to indicate that the cassation appeal is technical and its admissibility depends on compliance with certain requirements. Article 608 of the Civil Procedure Code contains a restriction intended to ensure that the questions submitted to the Chamber’s examination have been timely raised and debated by the litigants. On this point, see ruling no. 195 of this body, issued at 19:15 hours on February 20, 2002.</span><span> </span><span style=\"font-family:Tahoma\">&#xa0;</span><span style=\"font-family:Tahoma\">That restriction binds the grievances submitted for examination to have been set forth, to the appellate court, in the appeal. Only then could they be considered questions timely raised and debated by the litigants. From the study of the case file, according to the brief at folios 343 to 353 of the case file, when expressing grievances, the defendant’s representative did not challenge that point. Consequently, the objection referring to that point must also be rejected. Furthermore, in Considerando VI of the challenged decision, it was clear that, “</span><span style=\"font-family:Tahoma; font-style:italic\">In any event, what is at issue here is the objective liability of the Caja Costarricense de Seguro Social, and not the personal liability of the aforementioned physician.</span><span style=\"font-family:Tahoma\">” A clarification that matches the controversy under examination, just as has been set forth in this judgment. It is of no use to attempt to personally attribute reprehensible conduct to the treating physician, when the liability sought in the claim is of an objective type, attributable to the Public Administration.”</span><span> </span></p><p style=\"margin-top:0pt; margin-bottom:0pt; text-align:justify\"><span>&#xa0;</span></p></div></body></html>

“IV.- Dentro de la dinámica del sistema de responsabilidad preeminentemente objetiva de la Administración, el Estado es responsable frente a un particular que haya sufrido una lesión antijurídica que no tiene el deber de soportar y que haya sido provocada por un funcionamiento público. El ámbito de cobertura de los postulados que lo integran, incluye, además de las lesiones de naturaleza material, las de carácter extrapatrimonial. Este tipo de responsabilidad se sustenta en el daño propiamente, y no en otros elementos, como el dolo o la culpa. Lo anterior encuentra sustento en el artículo 41 de la Constitución Política, que en lo que interesa, señala: “Ocurriendo a las Leyes, todos han de encontrar reparación para las injurias o daños que hayan recibido en su persona, propiedad o intereses morales.”. Así como en el canon 197 de la Ley General de la Administración Pública, según el cual: “Cabrá responsabilidad por el daño de bienes puramente morales, lo mismo que por el padecimiento moral y el dolor físico causados por la muerte o por la lesión proferida, respectivamente.” Para este criterio de imputación no se requiere que el análisis de la conducta verse en si fue con dolo o culpa de quien causa la lesión. Ese tipo de consideraciones se tornan intrascendentes, por cuanto entran en juego otros aspectos. Es indispensable que exista un nexo causal entre la conducta o situación que motiva el daño y el que sufre la víctima, ligamen que se rompe en caso de mediar alguna eximente a saber: fuerza mayor, culpa de la víctima o hecho de un tercero. Este principio surge independientemente de la responsabilidad frente al administrado, que puedan asumir sus funcionarios o agentes. El numeral 190 de la Ley General de Administración Pública, establece: “1) La Administración responderá por todos los daños que cause su funcionamiento legítimo o ilegítimo, normal o anormal, salvo fuerza mayor, culpa de la víctima o hecho de un tercero. 2) La Administración será responsable de conformidad con este artículo, aún cuando no pueda serlo en virtud de las secciones siguientes de este Capítulo, pero la responsabilidad por acto lícito o funcionamiento normal, se dará únicamente según los términos de la Sección Tercera siguiente.” Los parámetros de imputación son objetivos (funcionamiento normal o anormal, lícito o ilícito) y la acreditación del nexo de causal, sólo puede extinguirse por las eximentes expresadas en la norma, sin que ello riña con la posibilidad de que, a lo interno, la propia Administración determine la responsabilidad de sus agentes, en donde las reglas se rigen por el grado de participación y los conceptos de dolo o culpa grave. Por lo anterior, habrá responsabilidad de la Administración siempre que su funcionamiento normal o anormal, cause un daño que la víctima no tenga el deber de soportar, ya sea patrimonial o extrapatrimonial, con independencia de su situación jurídica subjetiva y la titularidad o condición de poder que ostente. V.- En primer término, alega la recurrente, quiebra del nexo causal entre el daño y la conducta administrativa, al operar una eximente de responsabilidad por fuerza mayor, llamada iatrogenia, el cual era imprevisible e inevitable. En cuanto a l error de hecho en la apreciación de la prueba que se reclama, en concreto, de los dictámenes médicos legales y la testimonial, debe recordarse que su valoración se rige por las reglas de la sana crítica, en donde su ponderación se refleja en los hechos probados que dan sustento a la decisión. En el presente caso, no observa la Sala que se haya cometido infracción en cuanto a este extremo, pues los extremos que se han tenido por acreditados tienen fundamento adecuado en los elementos probatorios que son señalados como soporte en cada uno de ellos, sin que en ello se evidencie el error de hecho a que alude la recurrente y que en el caso de la prueba testimonial de todas maneras no llega a precisar. La simple opinión contraria de la demandada no es resulte motivo suficiente para considerarlo de otra manera. El Tribunal, tuvo por demostrado que el señor Nombre11575 se presentó el 27 de junio del 2000 en la Clínica Ebais de Lourdes de Agua Caliente de Cartago, por un cuadro de gripe, y el doctor Olman Sanabria Araya le aplicó vía intramuscular una inyección de voltarén con dexamatasona en el glúteo izquierdo. Inmediatamente después, el paciente perdió movilidad en la pierna, de la rodilla hacia abajo, diagnosticándosele, luego, una neuritis periférica. Analizó el informe médico legal no. DML-382-2001, rendido en vía penal, en la causa por lesiones culposas que se siguió en contra del Doctor, y los dictámenes médicos números DML 5622-04 y DML-2005-1271, diligenciados en el presente proceso, concluyendo que “Si el demandante sufrió la lesión posteriormente a que se le aplicara la inyección de voltarén con dexametasona vía intramuscular, la única conclusión posible es que, a pesar de haberse utilizado el médico tratante la técnica adecuada, ésta fue la causa la (sic) lesión. En todo caso, lo que aquí se discute, es la responsabilidad objetiva de la Caja Costarricense de Seguro Social, y no la responsabilidad personal del citado galeno. Siendo así, existe una relación de causalidad adecuada entre el servicio médico que se prestó y el daño reclamado, que se enmarca dentro de lo establecido en los artículos 190 y 194 de la Ley General de la Administración Pública, pues una lesión derivada de un funcionamiento normal de la Administración, que reviste un carácter excepcional por su intensidad.” Para arribar a lo anterior, estimó que no es usual que posterior a la aplicación de ese medicamento, se tenga contacto directo con el nervio ciático poplíteo externo, siendo posible que una lesión surja por reacción alérgica. Además, indicó, la consulta fue por gripe, no por alcoholismo, sin encontrar estigmas alcohólicos ni el grado; tampoco telanguectacias, red venenosa colateral, ni hepatomegálias; por lo que el sitio donde se colocó la inyección fue el adecuado, surgiendo una situación iatrogénica, ya que la aplicación correcta y apegada al “Lex Artis” produce un resultado inesperado y adverso (no. DML-382-2001). También dijo, la disfunción del nervio ciático es una condición que implica movimiento y/o sensibilidad defectuosa en la pierna, causada por un daño localizado en la parte posterior de la pierna, que inerva los músculos de la parte posterior de la rodilla y de la parte inferior de la pierna. Entre las causas usuales, cita el trauma directo por una inyección intramuscular en los glúteos o la presión en el nervio. El actor, expuso, presenta una disfunción del nervio ciático poplíteo externo, que puede ser secundaria a la inyección intramuscular que se aplicó como parte del tratamiento indicado para la patología que presentó el 27 de junio del 2000; sin embargo, del examen físico, el estudio del expediente médico y la bibliografía consultada, no existen elementos de juicio desde el punto de vista legal para sustentar que el paciente haya tenido una atención o tratamiento médico inadecuados o inoportunos (no. DML 5622-04). Finalmente, consignó, no existen documentos que supongan que antes de la inyección, padeciera de algún tipo de disfunción del nervio ciático y que es posible que un paciente presente extensiones en él, aún cuando se utilice una técnica adecuada para su aplicación (no. DML-2005-1271). De tal forma, estima esta Sala que, contrario a lo manifestado por la recurrente, la conclusión final a la que arribó el Ad quem, encuentra fundamento en lo que informan los elementos probatorios, en los que se reitera, no se da el error que se acusa. Esto es, no obstante el método practicado, que es el aceptado por la ciencia médica, y al aplicarlo se utilizara la técnica adecuada, la causa de la lesión -movimiento y/o sensibilidad defectuosa en la pierna por daño en el nervio ciático-, fue que se le aplicara una inyección de voltarén con dexametasona vía intramuscular en el glúteo izquierdo. Circunstancia que acredita la existencia de una relación causa efecto entre la prestación del servicio médico brindado por el doctor Olman Sanabria Araya, en el Ebais de Lourdes de Agua Caliente de Cartago, y el deterioro en la integridad física del señor Nombre11575. Ante ello, decae el argumento de la recurrente de que no existe nexo causal, específicamente por concurrir la eximente de fuerza mayor, al darse una situación imprevisible, irresistible e inevitable, que denomina, iatrogenia. VI.- Este último concepto, proviene del griego “iatros”: médico, y “genia”: originado o causado por. Desde el punto de vista de la normativa legal vigente, no existe una definición precisa, por lo que la remisión debe hacerse de forma genérica. Así en resolución de esta Sala n o. 23 de las 14 horas 40 minutos del 21 de abril de 1993, se intentó un primer acercamiento sobre su definición y características, sin embargo, convienen hacer un replanteamiento sobre el tema. La iatrogenia consiste en toda alteración del estado del paciente producida por el médico. Patología producida por su intervención, por lo que, ninguno estaría libre de producirla. En ella se incluyen tanto los efectos positivos como los negativos. La acción iatrogénica puede acarrear su responsabilidad y/o de la institución que presta el servicio, sea pública o privada. Es cuando el médico ha generado, no un hecho nuevo cualquiera, banal e intrascendente, sino que ha creado, con una intervención con pretensión terapéutica, una nueva situación patológica. También puede ser el resultado de tratamientos de otros profesionales vinculados a las ciencias de la salud, como por ejemplo terapeutas, psicólogos o psiquiatras, farmacéuticos, enfermeras, dentistas, aunque también ser provocada por las medicinas alternativas. La propia predisposición, constitución o sensibilidad del paciente contribuyen o pueden directamente desencadenarla. Aún en las condiciones ideales en que pueda efectuarse cualquier acto médico puede existir iatrogenia, desde el momento que la medicina no es una ciencia exacta. Sus formas son variadas en su eventualidad y circunstancias, por lo que, como se dijo, se puede clasificar en dos tipos: positiva y negativa. En el primer caso, las alteraciones producidas en el estado del paciente son inocuas. En el otro, el estado del paciente sufre algún daño por la acción médica, que puede ser necesaria o innecesaria. En aquella, el médico tiene pleno conocimiento del riesgo de daño, es un riesgo esperado, previsto, que no produce sorpresa y el especialista lo reconoce como un riesgo propio a favor del paciente. En su decisión se ha ponderado el cociente beneficio/daño, es decir, el riesgo de producir una lesión para alcanzar un resultado conveniente para el paciente. Se evalúa la conveniencia de usar recursos que, por una parte, tendrán efectos benéficos pero por otra causarán efectos indeseables aunque inevitables para evitar un mal mayor. En ningún momento ha existido descuido, equívoco o ignorancia. La potencialidad de generar un menoscabo es inherente a la práctica de la medicina. Por ejemplo, la extirpación radical de un tumor maligno puede salvar la vida del enfermo pero a su vez producir mutilación o discapacidad. Esta duplicidad de efectos se regula bajo el “principio del doble efecto”. Según este principio es lícito realizar una acción en la que el efecto positivo tiene que ser proporcionado, es decir, el resultado final debe superar el mal accidental inevitable. En la iatrogenia negativa innecesaria, (comúnmente llamada solo “iatrogenia”), se da un daño, pese a que el médico adoptó todas las previsiones del caso: aplicó el deber general de prudencia y diligencia. Empleó, de manera correcta, conforme a las condiciones de modo, tiempo y lugar, su ciencia, arte, oficio y experiencia; pero la particular situación del enfermo -ya sea su sistema inmunológico, su forma de reaccionar, las particularidades anatómicas o fisiológicas diferentes a lo usual, o cualquier factor desconocido pero evidentemente existente-, causa una patología lesiva o dañina, imprevista e imprevisible. No deben confundirse los anteriores conceptos, con la mala práctica (mal praxis), que es el detrimento producido por una conducta negligente, imprudente o con impericia. Es la actividad profesional que se realiza por debajo de los estándares de la buena práctica exigida. Es la omisión del médico, de prestar apropiadamente los servicios a que está obligado en su relación profesional con el paciente, y que causa un perjuicio. La mal praxis, es el daño ocasionado que el médico no previó, no anticipó y que, sin embargo, era previsible. Por último, es importante entender que, e l acto médico, comprende toda acción o disposición que realiza en el ejercicio de su profesión, entendiéndose como tal, los de diagnóstico, terapéutica, entre otros, en la atención integral del paciente, así como los que se deriven directamente de éstos. Es un acto complejo que implica conocimiento científico, para saber el fin que se quiere lograr y las posibles consecuencias. La actuación de los médicos se contrae a una obligación de medios y no por resultados, que se sabe, pueden ser negativos, aún poniendo toda la ciencia disponible, pericia, dedicación o diligencia. Debe regirse por la “Lex Artis”, que consiste en una actividad encuadrada en las pautas y reglas que natural y armoniosamente derivan del estado del conocimiento técnico - científico actual, integrando también normas de la deontología. Su invocación supone una referencia no sólo a normas de carácter profesional, sino también a criterios éticos. La obligación médica es poner todos los conocimientos a la orden del paciente a los efectos de mejorar su salud (obligación de medios) y cuando son insuficientes, deben realizarse interconsultas, trabajando interdisciplinariamente a efectos de buscar lo adecuado para su beneficio, pero no puede asegurársele, la cura total (obligación de resultados). En este sentido, rige el principio de que el paciente ingresa al centro hospitalario para curarse, no para enfermarse más. VII.- De conformidad con lo expuesto, y partiendo del anterior esquema, si bien la lesión producida en la pierna izquierda del señor Nombre11575 era imprevisible e inevitable, lo que descarta en tesis de principio una mal praxis, no puede ignorarse que se produjo como consecuencia directa de la prestación del servicio médico (Caja Costarricense de Seguro Social). Así, a pesar de que lo sucedido se ubique dentro de la denominada iatrogenia negativa innecesaria, no se debió a un hecho extraño o exterior -fuerza mayor-. Lo que no se puede anticipar, por ser desconocido o inconocible, no se puede evitar. De tal forma que, del cuadro fáctico no se infiere que se constituya una causal eximente de responsabilidad, según lo dispuesto por el numeral 190, párrafo primero, de la Ley General de la Administración Pública. En ese orden de ideas, el Tribunal apreció de forma correcta las pruebas allegadas al expediente y aplicó adecuadamente la normativa citada, descartándose la causa de exención alegada. VIII.- Por otra parte, en el recurso se acusa, no fue demostrado que el médico que aplicó la inyección, actuara con negligencia, imprudencia o impericia, de modo tal que, al no acreditarse su dolo o culpa, es improcedente conceder la indemnización pretendida. En este sentido, en primer orden, es menester indicar que, el recurso de casación es técnico y su admisibilidad depende del cumplimiento de ciertas exigencias. El ordinal 608 del Código Procesal Civil, contiene una limitación tendiente a que las cuestiones sometidas al examen de la Sala hayan sido propuestas y debatidas oportunamente por los litigantes. Sobre el particular, puede consultarse la sentencia de este órgano no 195 de las 19 horas 15 minutos del 20 de febrero del 2002. Esa limitación constriñe a que los agravios sometidos a examen hayan sido expuestos, al tribunal de alzada, en el recurso de apelación. Sólo así podría considerarse que se trata de cuestiones oportunamente propuestas y debatidas por los litigantes. Del estudio del expediente, según el memorial de folio 343 a 353 del expediente, al expresar agravios, el representante del la demandada no cuestionó ese extremo. En consecuencia, la censura referida a ese punto, deberá también rechazarse. A mayor abundamiento, en el considerando VI de la resolución recurrida, quedó claro que, “En todo caso, lo que aquí se discute, es la responsabilidad objetiva de la Caja Costarricense de Seguro Social, y no la responsabilidad personal del citado galeno.” Precisión que se ajusta a la controversia bajo examen, tal y como se ha expuesto en este fallo. No teniendo ninguna utilidad intentar achacarle conductas reprochables de manera personal al médico tratante, cuando la responsabilidad solicitada en la pretensión, es de tipo objetivo, atribuible a la Administración Pública.”