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.

Peripheral arterial disease and diabetes: effects on endothelial progenitor cell differentiation and nitric oxide metabolism

In the recent years it is emerged that peripheral arterial disease (PAD) has become a growing health problem in Western countries. This is a progressive manifestation of atherothrombotic vascular disease, which results into the narrowing of the blood vessels of the lower limbs and, as final consequence, in critical leg ischemia. PAD often occurs along with other cardiovascular risk factors, including diabetes mellitus (DM), low-grade inflammation, hypertension, and lipid disorders. Patients with DM have an increased risk of developing PAD, and that risk increases with the duration of DM. Moreover, there is a growing population of patients identified with insulin resistance (IR), impaired glucose tolerance, and obesity, a pathological condition known as “metabolic syndrome”, which presents increased cardiovascular risk. Atherosclerosis is the earliest symptom of PAD and is a dynamic and progressive disease arising from the combination of endothelial dysfunction and inflammation. Endothelial dysfunction is a broad term that implies diminished production or availability of nitric oxide (NO) and/or an imbalance in the relative contribution of endothelium-derived relaxing factors. The secretion of these agents is considerably reduced in association with the major risks of atherosclerosis, especially hyperglycaemia and diabetes, and a reduced vascular repair has been observed in response to wound healing and to ischemia. Neovascularization does not only rely on the proliferation of local endothelial cells, but also involves bone marrow-derived stem cells, referred to as endothelial progenitor cells (EPCs), since they exhibit endothelial surface markers and properties. They can promote postnatal vasculogenesis by homing to, differentiating into an endothelial phenotype, proliferating and incorporating into new vessels. Consequently, EPCs are critical to endothelium maintenance and repair and their dysfunction contributes to vascular disease. The aim of this study has been the characterization of EPCs from healthy peripheral blood, in terms of proliferation, differentiation and function. Given the importance of NO in neovascularization and homing process, it has been investigated the expression of NO synthase (NOS) isoforms, eNOS, nNOS and iNOS, and the effects of their inhibition on EPC function. Moreover, it has been examined the expression of NADPH oxidase (Nox) isoforms which are the principal source of ROS in the cell. In fact, a number of evidences showed the correlation between ROS and NO metabolism, since oxidative stress causes NOS inactivation via enzyme uncoupling. In particular, it has been studied the expression of Nox2 and Nox4, constitutively expressed in endothelium, and Nox1. The second part of this research was focused on the study of EPCs under pathological conditions. Firstly, EPCs isolated from healthy subject were cultured in a hyperglycaemic medium, in order to evaluate the effects of high glucose concentration on EPCs. Secondly, EPCs were isolated from the peripheral blood of patients affected with PAD, both diabetic or not, and it was assessed their capacity to proliferate, differentiate, and to participate to neovasculogenesis. Furthermore, it was investigated the expression of NOS and Nox in these cells. Mononuclear cells isolated from peripheral blood of healthy patients, if cultured under differentiating conditions, differentiate into EPCs. These cells are not able to form capillary-like structures ex novo, but participate to vasculogenesis by incorporation into the new vessels formed by mature endothelial cells, such as HUVECs. With respect to NOS expression, these cells have high levels of iNOS, the inducible isoform of NOS, 3-4 fold higher than in HUVECs. While the endothelial isoform, eNOS, is poorly expressed in EPCs. The higher iNOS expression could be a form of compensation of lower eNOS levels. Under hyperglycaemic conditions, both iNOS and eNOS expression are enhanced compared to control EPCs, as resulted from experimental studies in animal models. In patients affected with PAD, the EPCs may act in different ways. Non-diabetic patients and diabetic patients with a higher vascular damage, evidenced by a higher number of circulating endothelial cells (CECs), show a reduced proliferation and ability to participate to vasculogenesis. On the other hand, diabetic patients with lower CEC number have proliferative and vasculogenic capacity more similar to healthy EPCs. eNOS levels in both patient types are equivalent to those of control, while iNOS expression is enhanced. Interestingly, nNOS is not detected in diabetic patients, analogously to other cell types in diabetics, which show a reduced or no nNOS expression. Concerning Nox expression, EPCs present higher levels of both Nox1 and Nox2, in comparison with HUVECs, while Nox4 is poorly expressed, probably because of uncompleted differentiation into an endothelial phenotype. Nox1 is more expressed in PAD patients, diabetic or not, than in controls, suggesting an increased ROS production. Nox2, instead, is lower in patients than in controls. Being Nox2 involved in cellular response to VEGF, its reduced expression can be referable to impaired vasculogenic potential of PAD patients.

Infortuni sul lavoro e malattie professionali: danno e tutele

La tesi si occupa, con originalità e spunti di innovazione, del tema degli infortuni sul lavoro e tecnopatie, attraverso un'ottica del tutto nuova perchè attenta sia agli aspetti previdenziali (indennizzo Inail) e sia agli aspetti risarcitori (risarcimento dei danni differenziali e complementari). Lo studio, non scevro da analisi critiche, indaga in particolare sulla risarcibiità del danno c.d. differenziale e sperimenta le nuove poste risarcitorie applicabili, alla luce delle più recenti evoluzioni legislative e giurisprudenziali. L'Autore non trascura, infine, i complessi profili processuali a completamento delle tutele e le responsabilità sia del datore di lavoro (obbligato principale) e sia dei terzi.

Sustainability indicators for environmental management and decision making

The general objective of this research is to explore theories and methodologies of sustainability indicators, environmental management and decision making disciplines with the operational purpose of producing scientific, robust and relevant information for supporting system understanding and decision making in real case studies. Several tools have been applied in order to increase the understanding of socio-ecological systems as well as providing relevant information on the choice between alternatives. These tools have always been applied having in mind the complexity of the issues and the uncertainty tied to the partial knowledge of the systems under study. Two case studies with specific application to performances measurement (environmental performances in the case of the K8 approach and sustainable development performances in the case of the EU Sustainable Development Strategy) and a case study about the selection of sustainable development indicators amongst Municipalities in Scotland, are discussed in the first part of the work. In the second part of the work, the common denominator among subjects consists in the application of spatial indices and indicators to address operational problems in land use management within the territory of the Ravenna province (Italy). The main conclusion of the thesis is that a ‘perfect’ methodological approach which always produces the best results in assessing sustainability performances does not exist. Rather, there is a pool of correct approaches answering different evaluation questions, to be used when methodologies fit the purpose of the analysis. For this reason, methodological limits and conceptual assumptions as well as consistency and transparency of the assessment, become the key factors for assessing the quality of the analysis.

I materiali ceramici trasparenti: preparazione, caratterizzazione e correlazione microstruttura-proprietà

This thesis focuses on the ceramic process for the production of optical grade transparent materials to be used as laser hosts. In order to be transparent a ceramic material must exhibit a very low concentration of defects. Defects are mainly represented by secondary or grain boundary phases and by residual pores. The strict control of the stoichiometry is mandatory to avoid the formation of secondary phases, whereas residual pores need to be below 150 ppm. In order to fulfill these requirements specific experimental conditions must be combined together. In addition powders need to be nanometric or at least sub-micrometric and extremely pure. On the other hand, nanometric powders aggregate easily and this leads to a poor, not homogeneous packing during shaping by pressing and to the formation of residual pores during sintering. Very fine powders are also difficult to handle and tend to absorb water on the surface. Finally, the powder manipulation (weighting operations, solvent removal, spray drying, shaping, etc), easily introduces impurities. All these features must be fully controlled in order to avoid the formation of defects that work as scattering sources thus decreasing the transparency of the material. The important role played by the processing on the transparency of ceramic materials is often underestimated. In the literature a high level of transparency has been reported by many authors but the description of the experimental process, in particular of the powder treatment and shaping, is seldom extensively described and important information that are necessary to reproduce the described results are often missing. The main goal of the present study therefore is to give additional information on the way the experimental features affect the microstructural evolution of YAG-based ceramics and thus the final properties, in particular transparency. Commercial powders are used to prepare YAG materials doped with Nd or Yb by reactive sintering under high vacuum. These dopants have been selected as the more appropriate for high energy and high peak power lasers. As far as it concerns the powder treatment, the thesis focuses on the influence of the solvent removal technique (rotavapor versus spray drying of suspensions in ethanol), the ball milling duration and speed, suspension concentration, solvent ratio, type and amount of dispersant. The influence of the powder type and process on the powder packing as well as the pressure conditions during shaping by pressing are also described. Finally calcination, sintering under high vacuum and in clean atmosphere, and post sintering cycles are studied and related to the final microstructure analyzed by SEM-EDS and HR-TEM, and to the optical and laser properties.

L'azione risarcitoria ex art. 2497 c.c.

Scopo della presente trattazione è quello di andare ad osservare in che modo il legislatore della riforma abbia cercato di offrire una disciplina ad un fenomeno sempre più in espansione nell’economia italiana: i gruppi di impresa. In particolare, l’elaborato è composto da 3 nuclei. Il primo analizza la disciplina, introdotta nel 2003, relativa all’attività di direzione e coordinamento (art. 2497 c.c. e ss) rintracciandone le regole generali e il rapporto con le norme del codice civile. Una seconda parte approfondisce gli elementi costitutivi dell'attivita' di direzione e coordinamento, i presupposti affinche' si possa configurare una responsabilita' da parte della societa' capogruppo e i soggetti conivolti all'interno di un gruppo. La terza parte e' invece dedicata allo studio delle problematiche legate all’azione risarcitoria introdotta con la disposizione di cui all’art. 2497 c.c., soprattutto confrontando la posizione dei soci di minoranza con quella dei creditori sociali. In particolare, vengono descritte le modalità con le quali i soci e i creditori sociali possono esercitare l’azione a tutela dei propri interessi e dunque tentare di trovare pieno ristoro ai danni sofferti; danni che in qualche modo risultano legati alle scelte operate dal gruppo di comando e, più tecnicamente, dalla società che esercita l’attività di direzione e coordinamento, la c.d. capogruppo.

La strage di Ustica nell'opinione pubblica italiana (1980-1992): analisi di un caso politico e mediatico

Questa ricerca indaga come il “caso Ustica” si è articolato nell’opinione pubblica italiana negli anni compresi tra il 1980 e il 1992. Con l'espressione “caso Ustica” ci si riferisce al problema politico determinato dalle vicende legate all’abbattimento dell’aereo civile DC-9 dell’Itavia, avvenuto il 27 giugno 1980 in circostanze che, come noto, furono chiarite solamente a distanza di molti anni dal fatto. L’analisi intende cogliere le specificità del processo che ha portato la vicenda di Ustica ad acquisire rilevanza politica nell’ambito della sfera pubblica italiana, in particolare prendendo in considerazione il ruolo svolto dall’opinione pubblica in un decennio, quale quello degli anni ’80 e dei primi anni ’90 italiani, caratterizzato da una nuova centralità dei media rispetto alla sfera politica. Attraverso l’analisi di un’ampia selezione di fonti a stampa (circa 1500 articoli dei principali quotidiani italiani e circa 700 articoli tratti dagli organi dei partiti politici italiani) si sono pertanto messe in luce le dinamiche mediatiche e politiche che hanno portato alla tematizzazione di una vicenda che era rimasta fino al 1986 totalmente assente dall’agenda politica nazionale. L’analisi delle fonti giudiziarie ha permesso inoltre di verificare come la politicizzazione del caso Ustica, costruita intorno alla tensione opacità/trasparenza del potere politico e all’efficace quanto banalizzante paradigma delle “stragi di Stato”, sia risultata funzionale al raggiungimento, dopo il 1990, dei primi elementi di verità sulla tragedia e all’ampiamento del caso a una dimensione internazionale.

I danni punitivi nel sistema della responsabilità civile

Il concetto di danno punitivo evoca una peculiare forma di risarcimento del danno la cui funzione, lungi dal risolversi in una prospettiva meramente compensativa del soggetto danneggiato, si carica di una valenza punitiva e deterrente. L’obiettivo del presente lavoro è quello di indagare l’ammissibilità e la compatibilità dell’istituto con la sistematica della responsabilità da illecito aquiliano. Un piano di indagine sollecitato dal recente fervore pretorio sul tema, soprattutto in relazione alla verifica dialettica della compatibilità dell’istituto in parola con il concetto di ordine pubblico interno e internazionale: l’attuale impianto normativo dell’illecito aquiliano può legittimamente ambire ad una vocazione polifunzionale e dinamica in una più ampia prospettiva di effettività e completezza della tutela non solo interprivata ma anche superindividuale, nella consapevolezza, che “una responsabilità civile che non accarezzi la deterrenza non è una vera responsabilità civile”.

I mercati di crescita per le PMI

La tesi studia ed approfondisce la disciplina dei mercati di crescita per le PMI, indagando il regime normativo delle società ivi quotate. Considerata la struttura composita dell’architettura regolamentare (direttive e regolamenti europei, fonti primarie nazionali e regolamento del mercato) l’indagine adotta una prospettiva olistica sulla regolamentazione, al fine di individuare principii comuni e risolevere dubbi interpretativi. Inoltre, l’approfondimento in chiave storica e di economia politica, volto a ricostruire le ragioni per l’introduzione dei mercati di crescita e gli obiettivi perseguiti dal legislatore europeo, permette di identificare le rationes sottostanti alle disposizioni e di facilitarne l’interpretazione. Il primo capitolo approfondisce l’evoluzione storica e istituzionale dei mercati di crescita per le PMI e gli obiettivi che il legislatore europeo si prefigge di raggiungere. Il secondo capitolo affronta invece il processo di registrazione dei sistemi multilaterali di negoziazione come mercati di crescita. Il capitolo indaga quali siano i requisiti affinché un sistema multilaterale possa essere registrato come mercato di crescita, come si svolga il processo di registrazione e quale sia il ruolo dell’autorità di vigilanza. Il terzo capitolo approfondisce quali siano le disposizioni di diritto societario applicabili agli emittenti quotati sui mercati di crescita. Infatti, mentre la disciplina per gli emittenti quotati sui mercati regolamentati non è direttamente applicabile a queste società, non si può neppure escludere in via preliminare che determinate disposizioni non siano applicabili in via analogica, a causa delle specifiche caratteristiche conferite a questi emittenti ed ai titoli ammessi alla negoziazione dalla quotazione. Il quarto capitolo analizza diverse disposizioni relative all’informazione, intesa in senso ampio. Infine, il quinto capitolo affronta la disciplina dell’o.p.a. obbligatoria prevista dal regolamento del mercato di crescita AIM Italia.

High performance battery chargers for full electric and hybrid cars

This Doctoral Thesis aims to study and develop advanced and high-efficient battery chargers for full electric and plug-in electric cars. The document is strictly industry-oriented and relies on automotive standards and regulations. In the first part a general overview about wireless power transfer battery chargers (WPTBCs) and a deep investigation about international standards are carried out. Then, due to the highly increasing attention given to WPTBCs by the automotive industry and considering the need of minimizing weight, size and number of components this work focuses on those architectures that realize a single stage for on-board power conversion avoiding the implementation of the DC/DC converter upstream the battery. Based on the results of the state-of-the-art, the following sections focus on two stages of the architecture: the resonant tank and the primary DC/AC inverter. To reach the maximum transfer efficiency while minimizing weight and size of the vehicle assembly a coordinated system level design procedure for resonant tank along with an innovative control algorithm for the DC/AC primary inverter is proposed. The presented solutions are generalized and adapted for the best trade-off topologies of compensation networks: Series-Series and Series-Parallel. To assess the effectiveness of the above-mentioned objectives, validation and testing are performed through a simulation environment, while experimental test benches are carried out by the collaboration of Delft University of Technology (TU Delft).

Essays on risk-taking in corporate finance

This thesis consists of three independent essays on risk-taking in corporate finance. The first essay explores how community-level social capital (CSC), framed as a cultural characteristic of individuals born in different provinces of Italy, affects investment behavior in equity crowdfunding. Results show that investors born in high-CSC provinces invest more money in ventures characterized by an enhanced risk profile. Observed risk-taking is theoretically linked to higher generalized trust endowed to people born in high-CSC areas. The second essay focuses on how convexity of Chief Financial Officers’ stock options affects their hedging decisions in the oil and gas industry. Highly convex CFOs hedge less commodity price risk, even if the Chief Executive Officer’s incentives are consistent with a more conservative hedging strategy. Finally, the third essay is a systematic literature review on how different sources of compensation-based risk-taking incentives of Chief Executive Officers affect decision-making in corporate finance.

The right to explanation

This research investigates the use of Artificial Intelligence (AI) systems for profiling and decision-making, and the consequences that it poses to rights and freedoms of individuals. In particular, the research considers that automated decision-making systems (ADMs) are opaque, can be biased, and their logic is correlation-based. For these reasons, ADMs do not take decisions as human beings do. Against this background, the risks for the rights of individuals combined with the demand for transparency of algorithms have created a debate on the need for a new 'right to explanation'. Assuming that, except in cases provided for by law, a decision made by a human does not entitle to a right to explanation, the question has been raised as to whether – if the decision is made by an algorithm – it is necessary to configure a right to explanation for the decision-subject. Therefore, the research addresses a right to explanation of automated decision-making, examining the relation between today’s technology and legal concepts of explanation, reasoning, and transparency. In particular, it focuses on the existence and scope of the right to explanation, considering legal and technical issues surrounding the use of ADMs. The research analyses the use of AI and the problems arising from it from a legal perspective, studying the EU legal framework – especially in the data protection field. In this context, a part of the research is focused on transparency requirements under the GDPR (namely, Articles 13–15, 22, as well as Recital 71). The research aims to outline an interpretative framework of such a right and make recommendations about its development, aiming to provide guidelines for an adequate explanation of automated decisions. Hence, the thesis analyses what an explanation might consist of, and the benefits of explainable AI – examined from legal and technical perspectives.

Distributed ledger technologies between anonymity and transparency: AML/CFT regulation of cryptocurrency ecosystems in the EU

The advent of Bitcoin suggested a disintermediated economy in which Internet users can take part directly. The conceptual disruption brought about by this Internet of Money (IoM) mirrors the cross-industry impacts of blockchain and distributed ledger technologies (DLTs). While related instances of non-centralisation thwart regulatory efforts to establish accountability, in the financial domain further challenges arise from the presence in the IoM of two seemingly opposing traits: anonymity and transparency. Indeed, DLTs are often described as architecturally transparent, but the perceived level of anonymity of cryptocurrency transfers fuels fears of illicit exploitation. This is a primary concern for the framework to prevent money laundering and the financing of terrorism and proliferation (AML/CFT/CPF), and a top priority both globally and at the EU level. Nevertheless, the anonymous and transparent features of the IoM are far from clear-cut, and the same is true for its levels of disintermediation and non-centralisation. Almost fifteen years after the first Bitcoin transaction, the IoM today comprises a diverse set of socio-technical ecosystems. Building on an analysis of their phenomenology, this dissertation shows how there is more to their traits of anonymity and transparency than it may seem, and how these features range across a spectrum of combinations and degrees. In this context, trade-offs can be evaluated by referring to techno-legal benchmarks, established through socio-technical assessments grounded on teleological interpretation. Against this backdrop, this work provides framework-level recommendations for the EU to respond to the twofold nature of the IoM legitimately and effectively. The methodology cherishes the mutual interaction between regulation and technology when drafting regulation whose compliance can be eased by design. This approach mitigates the risk of overfitting in a fast-changing environment, while acknowledging specificities in compliance with the risk-based approach that sits at the core of the AML/CFT/CPF regime.