Learn from the Libby Zion Case

The Libby Zion case is one of the foundational cases in the development of Health Law, particularly Medical Law worldwide. This case highlighted the weak legal protection for doctors undergoing educational programmes (both Internship and residency).

This case proved that negligence in medical actions is not only caused by a lack of understanding of medical science and experience in the medical field, but can also be caused by a lack of thoroughness and prudence when performing medical actions due to excessive workload (overload), resulting in burnout.

The formula is: patient safety will not be achieved in medical actions performed by doctors experiencing workload overload and burnout.

Libby Zion was an 18-year-old university student. On 4 March 1984, Libby Zion was brought by her parents to New York Hospital in a condition of high fever, excessive restlessness (agitation), and uncontrolled body movements resembling seizures. At the hospital, Libby Zion was handled by two resident doctors, Doctor Luise Weinstein and Doctor Gregg Stone.

Based on the examination results, the two doctors could not find the exact cause of Libby Zion’s condition and administered a sedative (Demerol) to address it. However, Libby Zion’s condition worsened. Therefore, the two resident doctors then instructed the nurse to administer additional sedatives and to attach bed restraints to Libby Zion.

Shortly thereafter, Libby Zion’s body temperature soared to 42°C, she suffered a heart attack, and subsequently died on the morning of 5 March 1984.

After her death, an investigation was conducted which later revealed the fact that before being brought to the hospital, Libby Zion had actually taken antidepressant medication. When the antidepressant interacted with the Demerol, a fatal reaction occurred. At first glance, this case appeared to be ordinary medical negligence.

However, Libby Zion’s father, Sidney Zion, saw that this case was not merely ordinary medical negligence but was systemic negligence within the doctor education programme. The resident doctors who handled Libby Zion had apparently been working for more than 36 hours without rest. The specialist doctor who was the supervisor of the resident doctors was positioned at home and could only be contacted by telephone.

In fact, the two resident doctors, who were experiencing overload and burnout, were left alone to handle a complex case without guidance and assistance from an authorised doctor (the supervising doctor).

Separated by distance and time, in March - April 2026, the Indonesian public (particularly medical personnel) mourned the loss of 4 (four) Internship doctors in various regions of Indonesia. These were in: Cianjur, West Java; Rembang, Central Java; Denpasar, Bali; and Kuala Tungkal, Jambi.

Medical facts state that the four doctors died due to illness, namely suspected measles infection, severe anaemia, Dengue Haemorrhagic Fever (DHF), and severe lung infection. Legal facts indicate a potential violation of the standards for doctor education in Indonesia, causing Internship doctors to experience workload overload.

The Internship programme is fundamentally regulated in Law of the Republic of Indonesia Number 17 of 2023 concerning Health, Government Regulation Number 28 of 2024 concerning Implementing Regulations for Law Number 17 of 2023 concerning Health, and Regulation of the Minister of Health of the Republic of Indonesia Number 13 of 2025 concerning Management of Health Human Resources.

The Internship programme is an obligation for every Indonesian citizen doctor or dentist who has graduated from a domestic or foreign doctor or dentist professional programme (Article 597 (1) PP 28/2024).

Internship programme participants must be accompanied by an Internship supervising doctor or dentist (Article 597 (2) PP 28/2024). The objectives of the Internship programme are: (1) Deepening understanding of competency standards, service standards, and professional standards (Article 599 (b) PP 28/2024 and Article 70 (3) (b) Permenkes 13/2025); (2) Integration of knowledge, skills, and attitudes (Article 599 (c) PP 28/2024 and Article 70 (3) (c) Permenkes 13/2025); (3) Development of medical practice skills for primary health services (Article 599 (d) PP 28/2024 and Article 70 (3) (d) Permenkes 13/2025); (4) Strengthening understanding of clinical authority, internal regulations of health service facilities, as well as legal and ethical provisions (Article 599 (e) PP 28/2024 and Article 70 (3) (e) Permenkes 13/2025);

Then implementing their knowledge by playing an active role in the health service team at health service facilities (Article 599 (f) PP 28/2024 and Article 70 (3) (f) Permenkes 13/2025); Improving the quality of health services (Article 602 (2) PP 28/2024); Strengthening proficiency and independence (Article 60 (2) Permenkes 13/2025); Developing clinical competence and professionalism (Article 60 (2) Permenkes 13/2025).

The implementation of the Internship programme should reflect the objectives of the Internship programme as mandated by these laws and regulations. The fundamental question is, has the implementation of the Internship programme in Indonesia implemented the mandate of these laws and regulations?

It is time for all of us (especially policymakers) to conduct deep introspection for the improvement of the Internship programme implementation in Indonesia.

Medical personnel participating in the Internship programme are legal subjects whose rights are recognised under the laws and regulations. Medical personnel participating in the Internship programme are entitled to receive: a. basic living cost assistance, transportation, and/or allowances (Article 600 (a) PP 28/2024); b. legal protection as long as they comply with professional standards and service standards (Article 600 (b) PP 28/2024); c. supervision from a doctor.