Quantifying the Economics of Medical Malpractice - A View from a Civil Law Perspective

Life is full of uncertainties. Legal rules should have a clear intention, motivation and purpose in order to diminish daily uncertainties. However, practice shows that their consequences are complex and hard to predict. For instance, tort law has the general objectives of deterring future negligent behavior and compensating the victims of someone else's negligence. Achieving these goals are particularly difficult in medical malpractice cases. To start with, when patients search for medical care they are typically sick in the first place. In case harm materializes during the treatment, it might be very hard to assess if it was due to substandard medical care or to the patient's poor health conditions. Moreover, the practice of medicine has a positive externality on the society, meaning that the design of legal rules is crucial: for instance, it should not result in physicians avoiding practicing their activity just because they are afraid of being sued even when they acted according to the standard level of care. The empirical literature on medical malpractice has been developing substantially in the past two decades, with the American case being the most studied one. Evidence from civil law tradition countries is more difficult to find. The aim of this thesis is to contribute to the empirical literature on medical malpractice, using two civil law countries as a case-study: Spain and Italy. The goal of this thesis is to investigate, in the first place, some of the consequences of having two separate sub-systems (administrative and civil) coexisting within the same legal system, which is common in civil law tradition countries with a public national health system (such as Spain, France and Portugal). When this holds, different procedures might apply depending on the type of hospital where the injury took place (essentially whether it is a public hospital or a private hospital). Therefore, a patient injured in a public hospital should file a claim in administrative courts while a patient suffering an identical medical accident should file a claim in civil courts. A natural question that the reader might pose is why should both administrative and civil courts decide medical malpractice cases? Moreover, can this specialization of courts influence how judges decide medical malpractice cases? In the past few years, there was a general concern with patient safety, which is currently on the agenda of several national governments. Some initiatives have been taken at the international level, with the aim of preventing harm to patients during treatment and care. A negligently injured patient might present a claim against the health care provider with the aim of being compensated for the economic loss and for pain and suffering. In several European countries, health care is mainly provided by a public national health system, which means that if a patient harmed in a public hospital succeeds in a claim against the hospital, public expenditures increase because the State takes part in the litigation process. This poses a problem in a context of increasing national health expenditures and public debt. In Italy, with the aim of increasing patient safety, some regions implemented a monitoring system on medical malpractice claims. However, if properly implemented, this reform shall also allow for a reduction in medical malpractice insurance costs. This thesis is organized as follows. Chapter 1 provides a review of the empirical literature on medical malpractice, where studies on outcomes and merit of claims, costs and defensive medicine are presented. Chapter 2 presents an empirical analysis of medical malpractice claims arriving to the Spanish Supreme Court. The focus is on reversal rates for civil and administrative decisions. Administrative decisions appealed by the plaintiff have the highest reversal rates. The results show a bias in lower administrative courts, which tend to focus on the State side. We provide a detailed explanation for these results, which can rely on the organization of administrative judges career. Chapter 3 assesses predictors of compensation in medical malpractice cases appealed to the Spanish Supreme Court and investigates the amount of damages attributed to patients. The results show horizontal equity between administrative and civil decisions (controlling for observable case characteristics) and vertical inequity (patients suffering more severe injuries tend to receive higher payouts). In order to execute these analyses, a database of medical malpractice decisions appealed to the Administrative and Civil Chambers of the Spanish Supreme Court from 2006 until 2009 (designated by the Spanish Supreme Court Medical Malpractice Dataset (SSCMMD)) has been created. A description of how the SSCMMD was built and of the Spanish legal system is presented as well. Chapter 4 includes an empirical investigation of the effect of a monitoring system for medical malpractice claims on insurance premiums. In Italy, some regions adopted this policy in different years, while others did not. The study uses data on insurance premiums from Italian public hospitals for the years 2001-2008. This is a significant difference as most of the studies use the insurance company as unit of analysis. Although insurance premiums have risen from 2001 to 2008, the increase was lower for regions adopting a monitoring system for medical claims. Possible implications of this system are also provided. Finally, Chapter 5 discusses the main findings, describes possible future research and concludes.

Birth, Development and Progressive Institutionalization of the Ombudsman in the Russian Legal and Political System

One of the current trends in governance and legal development in Russia is aimed at establishing a modern, efficient and internationally harmonised system of safeguards of human rights and civil liberties. A fairly recent addition to this system has been the institution of ombudsman as a public authority specialised in promoting and protecting human rights and civil liberties. The introduction of this institution as well as its formalisation at the constitutional and legislative levels has been increasingly relevant and important, as it raises the dealings between the state and the individual to a new level. As an independent public institution resolving conflicts between citizens and government authorities, the ombudsman makes steps, within the scope of his jurisdiction, to restitute individual rights, and helps to enhance the reputation of government. The present work describes and assesses the birth, development and institutionalization process of the Ombudsman Office in the Russian Federation, at federal and regional levels, with a particular emphasis on the role of international references and cooperation for institution building. Ombudsmen have done a magnificent job in demonstrating value with the resolution of individual and systemic complaints; subsequent improvements to government; and economic savings by mitigating litigation costs.

Essays on geography and diseases

This dissertation explores how diseases contributed to shape historical institutions and how health and diseases are still affecting modern comparative development. The overarching goal of this investigation is to identify the channels linking geographic suitability to diseases and the emergence of historical and modern insitutions, while tackling the endogenenity problems that traditionally undermine this literature. I attempt to do so by taking advantage of the vast amount of newly available historical data and of the richness of data accessible through the geographic information system (GIS). The first chapter of my thesis, 'Side Effects of Immunities: The African Slave Trade', proposes and test a novel explanation for the origins of slavery in the tropical regions of the Americas. I argue that Africans were especially attractive for employment in tropical areas because they were immune to many of the diseases that were ravaging those regions. In particular, Africans' resistance to malaria increased the profitability of slaves coming from the most malarial parts of Africa. In the second chapter of my thesis, 'Caste Systems and Technology in Pre-Modern Societies', I advance and test the hypothesis that caste systems, generally viewed as a hindrance to social mobility and development, had been comparatively advantageous at an early stage of economic development. In the third chapter, 'Malaria as Determinant of Modern Ethnolinguistic Diversity', I conjecture that in highly malarious areas the necessity to adapt and develop immunities specific to the local disease environment historically reduced mobility and increased isolation, thus leading to the formation of a higher number of different ethnolinguistic groups. In the final chapter, 'Malaria Risk and Civil Violence: A Disaggregated Analysis for Africa', I explore the relationship between malaria and violent conflicts. Using georeferenced data for Africa, the article shows that violent events are more frequent in areas where malaria risk is higher.

Studio e sviluppo di un motore a 2 tempi diesel veloce di nuova concezione per applicazioni automobilistiche

The Department of Mechanical and Civil Engineering (DIMeC) of the University of Modena and Reggio Emilia is developing a new type of small capacity HSDI 2-Stroke Diesel engine (called HSD2), featuring a specifically designed combustion system, aimed to reduce weight, size and manufacturing costs, and improving pollutant emissions at partial load. The present work is focused on the analysis of the combustion and the scavenging process, investigated by means of a version of the KIVA-3V code customized by the University of Chalmers and modified by DIMeC. The customization of the KIVA-3V code includes a detailed combustion chemistry approach, coupled with a comprehensive oxidation mechanism for diesel oil surrogate and the modeling of turbulence/chemistry interaction through the PaSR (Partially Stirred Reactor) model. A four stroke automobile Diesel engine featuring a very close bore size is taken as a reference, for both the numerical models calibration and for a comparison with the 2-Stroke engine. Analysis is carried out trough a comparison between HSD2 and FIAT 1300 MultiJet in several operating conditions, at full and partial load. Such a comparison clearly demonstrates the effectiveness of the two stroke concept in terms of emissions reduction and high power density. However, HSD2 is still a virtual engine, and experimental results are needed to assume the reliability of numerical results.

Politiche di sviluppo e questione etnica. La cooperazione italiana IN Bosnia Erzegovina

The globalization process of the last twenty years has changed the world through international flows of people, policies and practices. International cooperation to development is a part of that process and brought International Organizations (IOs) and Non Governmental Organizations (NGOs) from the West to the rest of the world. In my thesis I analyze the Italian NGOs that worked in Bosnia Herzegovina (BH) to understand which development projects they realized and how they faced the ethnic issue that characterized BH. I consider the relation shaped between Italian NGOs and Bosnian civil society as an object of ethnic interests. In BH, once part of former Yugoslavia, the transition from the communist regime to a democratic country has not been completed. BH’s social conditions are characterized by strong ethnic divisions. The legacy of the early 1990s crisis was a phenomenon of ethnic identities created before the war and that still endure today. The Dayton Peace Agreement signed in 1995 granted the peace and reinforced the inter-ethnic hate between the newly recognized three principal ethnicities: Serbs, Croats and Bosniak. Through the new constitution, the institutions were characterized by division at every level, from the top to the bottom of society. Besides it was the first constitution ever written and signed outside the own country; that was the root of the state of exception that characterized BH. Thus ethnic identities culture survived through the international political involvement. At the same time ethnic groups that dominated the political debate clashed with the international organization’s democratic purpose to build a multicultural and democratic state. Ethnic and also religious differences were the instruments for a national statement that might cause the transition and development projects failure. Fifteen years later social fragmentation was still present and it established an atmosphere of daily cultural violence. Civil society suffered this condition and attended to recreate the ethnic fragmentation in every day life. Some cities became physically divided and other cities don’t tolerated the minority presence. In rural areas, the division was more explicit, from village to village, without integration. In my speech, the anthropology for development – the derivative study from applied anthropology – constitutes the point of view that I used to understand how ethnic identities still influenced the development process in BH. I done ethnographic research about the Italian cooperation for development projects that were working there in 2007. The target of research were the Italian NGOs that created a relation with Bosnian civil society; they were almost twenty divided in four main field of competences: institutional building, education, agriculture and democratization. I assumed that NGOs work needed a deep study because the bottom of society is the place where people could really change their representation and behavior. Italian NGOs operated in BH with the aim of creating sustainable development. They found cultural barricade that both institutions and civil society erected when development projects have been applied. Ethnic and religious differences were stressed to maintain boundaries and fragmented power. Thus NGOs tried to negotiate development projects by social integration. I found that NGOs worked among ethnic groups by pursuing a new integration. They often gained success among people; civil society was ready to accept development projects and overcome differences. On the other hand NGOs have been limited by political level that sustained the ethnic talk and by their representation of Bosnian issue. Thus development policies have been impeded by ethnic issue and by cooperation practices established on a top down perspective. Paradoxically, since international community has approved the political ethnic division within DPA, then the willing of development followed by funding NGOs cooperation projects was not completely successful.

Il Pluralismo tra Democrazia ed Autoritarismo: Il Caso Russo

The research explores the mechanisms in the formation and consolidation of a new regime which combines democratic and authoritarian features; it has emerged as result of democratization processes affecting different world areas in recent years. The study analyses a case of great international significance, post-communist Russia: here internal factors strongly prevail in front of the external variables of democratic imitation and contagion, thus showing to what extent Russia differs from other political contexts. The study intends to examine the strategies used by this regime to solve internal conflicts and become stable in spite of the democratizing pressures coming from outside. Indeed, the literature about political transformations has shown the problems in analyzing these polities together with the need to examine their peculiarities more in depth. In this perspective, the first section focuses on the dynamics of State-building in Russia as a fundamental process in tracing the specific characteristics of the current regime: particularly, it is suggested that the State dimension comes out as crucial in determining the level of political and social pluralism accepted in post-Soviet Russia. This argument is worked out in the second section, which analyses the main mechanisms used by the incumbents to limit and control pluralism within the two arenas of political competition and civil society, from where the major threats to the status quo are supposed to come. The main hypothesis is that the leadership interventions in these spheres during the last ten years have shaped a regime which can be characterized as a new type of authoritarianism: with respect to traditional authoritarian forms a certain degree of political contestation is accepted, visible in the presence of a multiparty system, semi-competitive elections and of the several representatives of civil society. Yet, this diversity is curbed basically in two different ways: from one hand the incumbents provide support to political and social actors who sponsor government politics (see the party of power and pro-Kremlin movements). From the other they use some non coercive forms of control and restriction (in legislation, in political elections) against those actors who promote values and priorities opposed to the official ones.

Reti socievoli: l’impatto dei social networks nella costruzione dello spazio pubblico

La tesi si è consolidata nell’analisi dell’impatto dei social networks nella costruzione dello spazio pubblico, nella sfera di osservazione che è la rete e il web2.0. Osservando che il paradigma della società civile si sia modificato. Ridefinendo immagini e immaginari e forme di autorappresentazione sui new media (Castells, 2010). Nel presupposto che lo spazio pubblico “non è mai una realtà precostituita” (Innerarity, 2008) ma si muove all’interno di reti che generano e garantiscono socievolezza. Nell’obiettivo di capire cosa è spazio pubblico. Civic engagement che si rafforza in spazi simbolici (Sassen, 2008), nodi d’incontro significativi. Ivi cittadini-consumatori avanzano corresponsabilmente le proprie istanze per la debacle nei governi.. Cultura partecipativa che prende mossa da un nuovo senso civico mediato che si esprime nelle “virtù” del consumo critico. Portando la politica sul mercato. Cultura civica autoattualizzata alla ricerca di soluzioni alle crisi degli ultimi anni. Potere di una comunicazione che riduce il mondo ad un “villaggio globale” e mettono in relazione i pubblici connessi in spazi e tempi differenti, dando origine ad azioni collettive come nel caso degli Indignados, di Occupy Wall Street o di Rai per una notte. Emerge un (ri)pensare la citizenship secondo due paradigmi (Bennett,2008): l’uno orientato al governo attraverso i partiti, modello “Dutiful Citizenship”; l’altro, modello “Self Actualizing Citizenship” per cui i pubblici attivi seguono news ed eventi, percepiscono un minor obbligo nel governo, il voto è meno significativo per (s)fiducia nei media e nei politici. Mercato e società civile si muovono per il bene comune e una nuova “felicità”. La partecipazione si costituisce in consumerismo politico all’interno di reti in cui si sviluppano azioni individuali attraverso il social networking e scelte di consumo responsabile. Partendo dall’etnografia digitale, si è definito il modello “4 C”: Conoscenza > Coadesione > Co-partecipazione > Corresposabilità (azioni collettive) > Cultura-bility.

Sicurezza dei prodotti alimentari e la responsabilità civile nell'Unione europea e negli Stati Uniti: tecniche a confronto

Le profonde trasformazioni che hanno interessato l’industria alimentare, unitamente alle accresciute capacità delle scienze mediche ed epidemiologiche di individuare nessi causali tra il consumo di determinate sostanze e l’insorgere di patologie, hanno imposto al legislatore di intervenire nella materia della c.d. sicurezza alimentare mettendo in atto sistemi articolati e complessi tesi a tutelare la salute dei consociati. Quest’ultimo obiettivo viene perseguito, da un lato, mediante disposizioni di natura pubblicistica e di carattere preventivo e, dall’altro lato, dallo strumento della responsabilità civile. Le due prospettive di tutela della salute delle persone costituiscono parti distinte ma al tempo stesso fortemente integrate in una logica unitaria. Questa prospettiva emerge chiaramente nel sistema statunitense: in quel ordinamento la disciplina pubblicistica della sicurezza degli alimenti – definita dalla Food and Drug Administration – costituisce un punto di riferimento imprescindibile anche quando si tratta di stabilire se un prodotto alimentare è difettoso e se, di conseguenza, il produttore è chiamato a risarcire i danni che scaturiscono dal suo utilizzo. L’efficace sinergia che si instaura tra la dimensione pubblicistica del c.d. Public Enforcement e quella risarcitoria (Private Enforcement) viene ulteriormente valorizzata dalla presenza di efficaci strumenti di tutela collettiva tra i quali la class action assume una importanza fondamentale. Proprio muovendo dall’analisi del sistema statunitense, l’indagine si appunta in un primo momento sull’individuazione delle lacune e delle criticità che caratterizzano il sistema nazionale e, più in generale quello comunitario. In un secondo momento l’attenzione si focalizza sull’individuazione di soluzioni interpretative e de iure condendo che, anche ispirandosi agli strumenti di tutela propri del diritto statunitense, contribuiscano a rendere maggiormente efficace la sinergia tra regole preventive sulla sicurezza alimentare e regole risarcitorie in materia di responsabilità del produttore.

Legittimo affidamento nel diritto tributario: esperienze comparate di diritto italiano ed inglese

Il contributo di questo scritto è stato quello di delineare attraverso l’esame comparatistico del principio dell'affidamento quel particolare fil rouge che differenzia e che unisce, gli ordinamenti di common law e di civil law nell’approcciarsi a questo principio. In questo studio lo sviluppo del principio dell’affidamento nel diritto inglese,l’influenza della Corte di Giustizia, ed recepimento da parte dei giudici di common law di quei principi di armonizzazione indicati dalla Corte di Giustizia che ha estremamente modificato e razionalizzato il contenzioso inglese e quello italiano. Questa ricerca si propone di valutare in chiave comparatistica le possibili lesioni che possono aver tratto il contribuente in inganno attraverso comportamenti difformi dalla P.A. Rispetto a quanto promesso ed i possibili effetti risarcitori che potrebbero dare luogo nei confronti della Pubblica Amministrazione fiscale.

Profili civilistici della vendita giudiziale di beni immobili in Italia e in Spagna

La tesi di dottorato ha come oggetto di studio gli aspetti sostanziali della vendita giudiziale da un punto di vista comparatistico tra Spagna e Italia. Si tratta di un tema che non è stato analizzato profondamente dalle più recenti dottrine spagnola e italiana, che è caratterizzato da una notevole complessità tecnica visto il suo forte carattere interdisciplinare (in particolare, processuale-sostanziale) e la cui vigenza attuale è stata intensificata dalla grande quantità di processi di esecuzione che in questo periodo di instabilità economica sono una constante nei Tribunali spagnoli e italiani. Il fatto che costituisca un’istituzione giuridica inquadrata nell’ambito del processo di espropriazione forzata fa sì che questa possieda un accentuato carattere processuale e, infatti, è il legislatore processuale che si occupa per la maggior parte del suo regime giuridico. Tuttavia, al di là di questa sua natura evidentemente processuale, essa produce una serie di effetti sostanziali di enorme importanza, che sono proprio l’oggetto della tesi di dottorato, nello specifico ambito dei beni immobili (considerando la grande importanza economica e pratica dei diritti di questa natura nella nostra realtà socio-economica).