It was a simple surgery to fix a broken nose, doctor Naseer al-Sudani recalled. Although the procedure went well, weeks later the 35-year-old patient died from a blood clot, a condition deemed unrelated. Within hours, the dreaded phone calls began.

“They said, ‘Our brother is dead — we must negotiate,’ ” Sudani said, recounting the family’s initial demand of $40,000. If he refused, he knew he could be killed.

So he did what Iraqis do these days: He got himself a good sheik, who led a delegation to meet the family’s sheik, and weeks of distressing discussions began.

Eight years after the American invasion put Iraq on a path to a more modern, democratic society, people here are increasingly resorting to the ancient process of tribal negotiations — called fasels, and conducted by tribal leaders or sheiks — to demand compensation for alleged injustices.

While Iraqis have long joked about frivolous fasels, people say an especially degenerate version is now running amok, in which powerful sheiks are essentially extorting huge sums of money from professionals, especially doctors.

The problem is partly a result of Iraq’s weak legal system and the lack of official grievance processes, non-issues during Saddam Hussein’s autocratic rule, when a tyrannical order prevailed and malpractice complaints were handled through the courts. But many also blame a relic of the U.S. occupation: so-called “fake sheiks’’ — including “Condoleeza Rice sheiks,” named for the former secretary of state — who were paid by the United States to fight insurgents, a practice Prime Minister Nouri al-Maliki has continued.

While sheiks are generally respected in Iraqi society, many say that some of the newly-minted ones — often distinguished by flashy clothes and fancy sport-utility vehicles — are turning into a kind of fledgling Iraqi mafia.

“They are opportunists, like bullies,” said Ali Abbas Anbori, a Baghdad doctor who advocates for health care and legal reform. “It’s all about what kind of force does this person have — it has nothing to do with malpractice. If the doctor doesn’t pay, they may threaten his life, his family, kidnap his children.”

Officials at several Baghdad hospitals said tribal threats are so pervasive that many doctors are leaving the country as they did during the war.

“I don’t even know who my sheik is,” said an ophthalmologist who recently returned from Dubai, United Arab Emirates, to work in Baghdad and is considering leaving again. “My wife is an anesthesiologist and she wants to work [in Iraq,] but I’m telling her don’t. It’s too risky.”

Bargaining process

Of the many layers of identity in Iraq, tribe is among the most fundamental, although Iraqis embrace it to varying degrees. Many do not commit themselves to sheiks, a semi-formal process that brings economic and personal security but also obligations.

Though tribal law was officially banned in 1958 and mostly stifled during Hussein’s rule, it has begun to flourish again for a variety of reasons.

“After the ugly occupation, Iraq spent years with no authority, no government,” said Mohammad Ismaeel Almsuody, a respected sheik in Baghdad. “We’ve handled these matters responsibly.”

Sitting on an ornate velour couch in a handsome office, Almsuody described a recent case of a man who died during an operation.

As compensation for the dead man’s family, Almsuody initially demanded $50,000, which was subjected to various discounts according to tribal custom. Because the death was deemed accidental, the sheik agreed to cut the amount in half. Because the doctor confessed to an error quickly, it was reduced further. And because his delegation included a descendant of the prophet Muhammad, known as a Sayeed, there was another discount.

In the end, the doctor paid $5,000. To refuse would touch off a cycle of tribal retribution that could last years.

‘You have to pay’

While Almsuody considers himself a refined arbiter of tribal law, he and others lament the rise of those they consider “fake sheiks.” Instead of family pedigree, the authority of the nouveau sheiks derives from often huge sums money they received from the Americans to organize militias and fight insurgents during the worst days of the war.

More recently, many have struck political arrangements with Maliki, who has established quasi-political bodies called tribal support councils around the country.

Though he could not be certain, Sudani suspected the sheik who threatened him was one of these. Cautiously, the doctor described him as “impolite.”

“One of his delegates was boasting, ‘We’ve taken money from all the doctors in Nasiriyah!’ ’’ Sudani said, referring to the patient’s home town in southern Iraq, where the negotiations were held.

Sudani — whose own sheik assembled a formidable delegation — eventually paid about $8,000, which came out of his pocket because there is no liability insurance in Iraq.

“Even if it’s not your fault, you have to pay,” he said. “Otherwise, you will have problems.” He and others said that many doctors are declining to do more complex operations because of the new threats. Others are taking extra precautions.

‘Law of the jungle’

In the city of Fallujah, doctor Sabah al-Ani employs bodyguards to screen his waiting room for patients who might be dangerously litigious.

“There are certain bad signs,” said Ani, an orthopedic surgeon who has paid thousands in compensation in the past two years. “If a patient comes with his own bodyguard, or with a sheik. Or if he comes in talking on a cellphone, saying things like, ‘We are the responsible men here!’ In those cases, I will say I am tired, or send them to Baghdad.”

Sitting in his small clinic off a street of bullet-splashed buildings, Ani recalled a colleague who disputed a compensation demand. He was thrown in a trunk and held captive for weeks until his family agreed to pay.

Part of the problem, Ani said, is that patients often do not understand the possible complications of surgery. Mainly, though, when ordinary Iraqis get frustrated, they have “many newly powerful men” they might call into action,’’ he said. “It’s the law of the jungle.”

It was some blend of these factors that drove Ayad Hussein to target a doctor who failed to repair several fingers mangled by bullets during a firefight in Fallujah. After a year of unsuccessful operations, he said, “I visited my sheik.”

The doctor eventually paid Hussein about $2,000 — the cost of the operations, plus damages.

“We are from one of the biggest tribes,” said Hussein, an unemployed construction worker. “My sheik was pleased to accept this amount.”

Special correspondents Aziz Alwan and Ali Qeis contributed to this report.