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.

Letteratura postmoderna e comunicazione pubblicitaria, problemi teorici e analisi testuali

Premise: In the literary works of our anthropological and cultural imagination, the various languages and the different discursive practices are not necessarily quoted, expressly alluded to or declared through clear expressive mechanisms; instead, they rather constitute a substratum, a background, now consolidated, which with irony and intertextuality shines through the thematic and formal elements of each text. The various contaminations, hybridizations and promptings that we find in the expressive forms, the rhetorical procedures and the linguistic and thematic choices of post-modern literary texts are shaped as fluid and familiar categories. Exchanges and passages are no longer only allowed but also inevitable; the post-modern imagination is made up of an agglomeration of discourses that are no longer really separable, built up from texts that blend and quote one another, composing, each with its own specificities, the great family of the cultural products of our social scenario. A literary work, therefore, is not only a whole phenomenon, delimited hic et nunc by a beginning and an ending, but is a fragment of that complex, dense and boundless network that is given by the continual interrelations between human forms of communication and symbolization. The research hypothesis: A vision is delineated of comparative literature as a discipline attentive to the social contexts in which texts take shape and move and to the media-type consistency that literary phenomena inevitably take on. Hence literature is seen as an open systematicity that chooses to be contaminated by other languages and other discursive practices of an imagination that is more than ever polymorphic and irregular. Inside this interpretative framework the aim is to focus the analysis on the relationship that postmodern literature establishes with advertising discourse. On one side post-modern literature is inserted in the world of communication, loudly asserting the blending and reciprocal contamination of literary modes with media ones, absorbing their languages and signification practices, translating them now into thematic nuclei, motifs and sub-motifs and now into formal expedients and new narrative choices; on the other side advertising is chosen as a signification practice of the media universe, which since the 1960s has actively contributed to shaping the dynamics of our socio-cultural scenarios, in terms which are just as important as those of other discursive practices. Advertising has always been a form of communication and symbolization that draws on the collective imagination – myths, actors and values – turning them into specific narrative programs for its own texts. Hence the aim is to interpret and analyze this relationship both from a strictly thematic perspective – and therefore trying to understand what literature speaks about when it speaks about advertising, and seeking advertising quotations in post-modern fiction – and from a formal perspective, with a search for parallels and discordances between the rhetorical procedures, the languages and the verifiable stylistic choices in the texts of the two different signification practices. The analysis method chosen, for the purpose of constructive multiplication of the perspectives, aims to approach the analytical processes of semiotics, applying, when possible, the instruments of the latter, in order to highlight the thematic and formal relationships between literature and advertising. The corpus: The corpus of the literary texts is made up of various novels and, although attention is focused on the post-modern period, there will also be ineludible quotations from essential authors that with their works prompted various reflections: H. De Balzac, Zola, Fitzgerald, Joyce, Calvino, etc… However, the analysis focuses the corpus on three authors: Don DeLillo, Martin Amis and Aldo Nove, and in particular the followings novels: “Americana” (1971) and “Underworld” (1999) by Don DeLillo, “Money” (1984) by Martin Amis and “Woobinda and other stories without a happy ending” (1996) and “Superwoobinda” (1998) by Aldo Nove. The corpus selection is restricted to these novels for two fundamental reasons: 1. assuming parameters of spatio-temporal evaluation, the texts are representative of different socio-cultural contexts and collective imaginations (from the masterly glimpses of American life by DeLillo, to the examples of contemporary Italian life by Nove, down to the English imagination of Amis) and of different historical moments (the 1970s of DeLillo’s Americana, the 1980s of Amis, down to the 1990s of Nove, decades often used as criteria of division of postmodernism into phases); 2. adopting a perspective of strictly thematic analysis, as mentioned in the research hypothesis, the variations and the constants in the novels (thematic nuclei, topoi, images and narrative developments) frequently speak of advertising and inside the narrative plot they affirm various expressions and realizations of it: value ones, thematic ones, textual ones, urban ones, etc… In these novels the themes and the processes of signification of advertising discourse pervade time, space and the relationships that the narrator character builds around him. We are looking at “particle-characters” whose endless facets attest the influence and contamination of advertising in a large part of the narrative developments of the plot: on everyday life, on the processes of acquisition and encoding of the reality, on ideological and cultural baggage, on the relationships and interchanges with the other characters, etc… Often the characters are victims of the implacable consequentiality of the advertising mechanism, since the latter gets the upper hand over the usual processes of communication, which are overwhelmed by it, wittingly or unwittingly (for example: disturbing openings in which the protagonist kills his or her parents on the basis of a spot, former advertisers that live life codifying it through the commercial mechanisms of products, sons and daughters of advertisers that as children instead of playing outside for whole nights saw tapes of spots.) Hence the analysis arises from the text and aims to show how much the developments and the narrative plots of the novels encode, elaborate and recount the myths, the values and the narrative programs of advertising discourse, transforming them into novel components in their own right. And also starting from the text a socio-cultural reference context is delineated, a collective imagination that is different, now geographically, now historically, and from comparison between them the aim is to deduce the constants, the similarities and the variations in the relationship between literature and advertising.

L'univers féminin du picaresque

Les considérations sur le statut de la femme dans la littérature picaresque sont principalement limitées à la production littéraire espagnole. Nous ne pouvons que constater l’absence d’une étude comparatiste s’attachant aux personnages féminins qui peuplent le monde picaresque des pays où ce genre littéraire s’est majoritairement affirmé : l’Espagne, la France et l’Angleterre. Le but de cette analyse est de proposer une comparaison exhaustive entre les personnages féminins des romans picaresques européens de l’époque classique. Ceux-ci sont présentés selon les âges de la vie féminine : l’enfance, la jeunesse, l’âge d’épouse et de mère et la vieillesse. L’exploration de ces catégories d’âges dans lesquelles les rôles féminins se construisent met en évidence la place déterminante qu’ils occupent dans la narration. Leurs tâches, leurs comportements, leurs modes relationnels sont analysés dans les différents espaces et à l’intérieur d’un cadre temporel qui leur sont propres. Les représentations de la femme qui sont diffusées par les écrivains sont bien souvent marquées par une conduite désordonnée. Que les femmes soient victimes d’une société sexiste ou bien qu’elles fassent sciemment de mauvais choix, elles sont dans la majorité des cas, inexorablement condamnées à accepter la condition d’infériorité qui leur est imposée. Il est pourtant une catégorie d’entre elles qui ne s’en tient pas au rôle qui lui est dévolu à l’époque par la société et ses institutions et qui met en place toute une série de stratagèmes lui permettant de se frayer un chemin dans un monde dominé par la supériorité masculine

La tratta di donne a fini di sfruttamento sessuale: strumenti di contrasto e possibilità di intervento.

L’obiettivo della ricerca è, da un lato, quello di definire un quadro conoscitivo di sfondo rispetto al fenomeno della tratta e dello sfruttamento sessuale di donne che approdano nel contesto italiano, dall’altro quello di esaminare gli interventi politici e legislativi posti in essere per contrastare il fenomeno e per tutelarne le vittime. Dopo uno sguardo alle caratteristiche strutturali della tratta, alla normativa italiana, europea e internazionale connessa al suo contrasto e alla protezione delle vittime e ai modelli di intervento sociale nel settore posti in essere nel nostro Paese, l’analisi si è concretizzata prendendo in considerazione i risultati emersi dall’attività di ricerca. L’analisi delle storie di vita delle vittime, di nazionalità nigeriana, albanese e serba ha permesso, da un lato, di evidenziare la complessità dei loro percorsi di vita e dall’altro di tracciare un quadro delle modalità organizzative e di sfruttamento utilizzate dal racket nigeriano e da quello albanese. Sul versante legislativo, invece, le interviste ai ricercatori svedesi sono state volte a comprendere se la normativa che punisce l’acquisto di prestazioni sessuali potesse avere un potere deterrente e, quindi, se potesse rappresentare una risposta efficace per arginare il fenomeno della prostituzione schiavizzata. In ultimo, dal punto di vista processuale, l’analisi delle sentenze giudiziarie penali emesse dal Tribunale di Rimini è stata utile per individuare le principali dinamiche che caratterizzano il rapporto tra l’autore e la vittima di reato e, non di meno, per sottolineare l’importanza del ruolo della vittima nel processo penale.

L’amministrazione della giustizia e le sue vittime: un’analisi comparativa a livello europeo

Il lavoro si propone di indagare, a livello europeo, il fenomeno della seconda vittimizzazione, attraverso l'analisi delle condizioni attuali dei sistemi giudiziari nei confronti delle vittime di reato, anche grazie allo spoglio della giurisprudenza della Corte Europea dei Diritti dell'Uomo di Strasburgo.

Uno studio sulla responsabilita' da reato degli enti

Il lavoro è suddiviso in due sezioni, che si compongono rispettivamente di tre e due capitoli. La prima sezione è dedicata all'esame dei principi fondamentali e della "parte generale" della disciplina della responsabilità amministrativa degli enti: il primo capitolo si concentra sull'evoluzione storica del principio Societas delinquere non potest nell'ordinamento giuridico italiano, prodromica all'analisi della natura della responsabilità amministrativa dipendente da reato degli enti. svolta nel secondo capitolo. Nel terzo capitolo della prima sezione si affronta la disciplina di "parte generale" del decreto 231, evidenziando, in particolare. i principi fondamentali che caratterizzano questo paradigma di illecito. La seconda sezione affronta invece due degli aspetti maggiormente problematici della "parte speciale" del decreto, ovvero la responsabilità degli enti per i delitti di omicidio e lesioni colpose (ai quali è dedicato il primo capitolo) e quella derivante dalla commissione di reati associativi (ai quali è dedicato il secondo capitolo).

Il consenso informato come strumento di esercizio del diritto alla salute per i pazienti stranieri?

L’elaborato propone una riflessione rispetto all’atto giuridico del consenso informato quale strumento garante dell’esercizio del diritto alla salute per i migranti. Attraverso una riflessione antropologica rispetto alla natura, alla costruzione e alla logica dei diritti universali, verranno analizzate le normative nazionali, europee ed internazionali a tutela del diritto alla salute per i migranti; l’obiettivo della ricerca è indagare l’eventuale scarto tra normative e politiche garantiste nei confronti della salute migrante e l’esistenza di barriere strutturali che impediscono un pieno esercizio del diritto alla salute. L’ipotesi di ricerca si basa sulla reale capacità performativa del consenso informato, proposto solitamente sia come strumento volto ad assicurare la piena professionalità dell’operatore sanitario nell’informare il paziente circa i rischi e i benefici di un determinato trattamento sanitario, sia come garante del principio di autonomia. La ricerca, attraverso un’analisi quanti-qualitativa, ha interrogato il proprio campo, rappresentato da un reparto di ginecologia ed ostetrica, rispetto alle modalità pratiche di porre in essere la firma nei moduli del consenso informato, con particolare attenzione alle specificità proprie delle pazienti migranti. Attraverso l’osservazione partecipante è stato quindi possibile riflettere su aspetti rilevanti, quali le dinamiche quotidiane che vengono a crearsi tra personale sanitario e pazienti, le caratteristiche e i limiti del servizio di mediazione sanitaria, le azioni pratiche della medicina difensiva. In questo senso il tema del “consenso informato”, indagato facendo interagire discipline quali l’antropologia, la bioetica, la filosofia e la sociologia, si è posto sia come lente di lettura privilegiata per comprendere le dinamiche relazionali ad oggi esistenti tra professionisti sanitari e popolazione migrante, ancora vittima di diseguaglianze strutturali, ma altresì come “innesco potenziale” di nuove modalità di intendere la relazione medico-paziente.