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.

For God'sake! Lift the embargo to Spain

Intorno alla metà degli anni trenta la Spagna diventò il centro dell’attenzione del mondo e tutte le grandi potenze internazionali, vecchie e nuove, vennero coinvolte, in misura diversa, nella guerra civile. Già nell’agosto del 1936, un mese dopo l’esplosione del conflitto, tutti gli Stati più rappresentativi caldeggiavano l’ipotesi di una politica comune di “non intervento”. Il ruolo guida in tal senso venne assunto dal governo inglese, capace di dissuadere, in tempi estremamente rapidi, il governo frontista francese di Leon Blum dall’intento di sostenere economicamente e militarmente il legittimo governo repubblicano spagnolo. La preoccupazione che il conflitto potesse degenerare in uno scontro più generale fu quindi la ragione principale per la quale qualche settimana dopo nacque il “Comitato di Non Intervento”, cui aderirono ben ventisette nazioni europee tra cui Francia, Inghilterra, URSS, Italia, Germania e Portogallo. Il mio progetto di ricerca dottorale esamina il ruolo, le scelte ed i relativi dibattiti in merito all’unica grande potenza, gli Stati Uniti d’America, che, pur scegliendo di rimanere neutrale, si astenne dal partecipare al suddetto Comitato. In ambito statunitense particolare rilievo assumono due aspetti del dibattito politico sulla Spagna: il primo maturato in seno all’Amministrazione Roosevelt, il secondo elaborato dalla componente Liberal della coalizione del New Deal attraverso i settimanali, “The Nation” e “The New Republic”. Il confronto pubblico acceso dalla guerra civile spagnola fu infatti l’occasione per la società civile americana per dibattere apertamente e francamente circa l’opportunità e la capacità della nazione di assumere o meno un ruolo internazionale corrispondente al prestigio socio-economico in via di acquisizione a livello mondiale. Approfondire ed esaminare il dibattito sulla guerra civile spagnola negli USA significa dunque andare alla ricerca delle radici culturali di quello che sarà uno dei più vasti ed articolati confronti politici e teorici del ventesimo secolo: l’internazionalismo americano.

Social inclusion of vulnerable groups through participatory and emancipatory approaches. Implementing active citizenship and socially innovative actions in the framework of civil & human rights model of disability

The research hypothesis of the thesis is that “an open participation in the co-creation of the services and environments, makes life easier for vulnerable groups”; assuming that the participatory and emancipatory approaches are processes of possible actions and changes aimed at facilitating people’s lives. The adoption of these approaches is put forward as the common denominator of social innovative practices that supporting inclusive processes allow a shift from a medical model to a civil and human rights approach to disability. The theoretical basis of this assumption finds support in many principles of Inclusive Education and the main focus of the hypothesis of research is on participation and emancipation as approaches aimed at facing emerging and existing problems related to inclusion. The framework of reference for the research is represented by the perspectives adopted by several international documents concerning policies and interventions to promote and support the leadership and participation of vulnerable groups. In the first part an in-depth analysis of the main academic publications on the central themes of the thesis has been carried out. After investigating the framework of reference, the analysis focuses on the main tools of participatory and emancipatory approaches, which are able to connect with the concepts of active citizenship and social innovation. In the second part two case studies concerning participatory and emancipatory approaches in the areas of concern are presented and analyzed as example of the improvement of inclusion, through the involvement and participation of persons with disability. The research has been developed using a holistic and interdisciplinary approach, aimed at providing a knowledge-base that fosters a shift from a situation of passivity and care towards a new scenario based on the person’s commitment in the elaboration of his/her own project of life.

Building Peace and/or Gender Equality. Changing Attitudes around Peace, Development and Security in International Cooperation in Rwanda.

The times following international or civil conflicts but also violent revolutions often come with unequal share of the peace dividend for men and women. Delusions for women who gained freedom of movement and of roles during conflict but had to step back during reconstruction and peace have been recorded in all regions of the world. The emergence of peacebuilding as a modality for the international community to ensure peace and security has slowly incorporated gender sensitivity at the level of legal and policy instruments. Focusing on Rwanda, a country that has obtained significant gender advancement in the years after the genocide while also obtaining to not relapse into conflict, this research explores to what extent the international community has contributed to this transformation. From a review of evaluations, findings are that many of the interventions did not purse gender equality, and overall the majority understood gender and designed actions is a quite superficial way which would hardly account for the significative advancement in combating gender discrimination that the Government, for its inner political will, is conducting. Then, after a critique from a feminist standpoint to the concept of human security, departing from the assumption (sustained by the Governemnt of Rwanda as well) that domestic violence is a variable influencing level of security relevant at the national level, a review of available secondary data on GBV is conducted an trends over the years analysed. The emerging trends signal a steep increase in prevalence of GBV and in domestic violence in particular. Although no conclusive interpretation can be formulated on these data, there are elements suggesting the increase might be due to augmented reporting. The research concludes outlining possible further research pathways to better understand the link in Rwanda between the changing gender norms and the GBV.

Fighting corruption with pyramids: A Law and Economics approach to combating corruption in post-socialist countries

Corruption is, in the last two decades, considered as one of the biggest problems within the international community, which harms not only a particular state or society but the whole world. The discussion on corruption in law and economics approach is mainly run under the veil of Public choice theory and principal-agent model. Based on this approach the strong international initiatives taken by the UN, the OECD and the Council of Europe, provided various measures and tools in order to support and guide countries in their combat against corruption. These anti-corruption policies created a repression -prevention-transparency model for corruption combat. Applying this model, countries around the world adopted anti-corruption strategies as part of their legal rules. Nevertheless, the recent researches on the effects of this move show non impressive results. Critics argue that “one size does not fit all” because the institutional setting of countries around the world varies. Among the countries which experience problems of corruption, even though they follow the dominant anti-corruption trends, are transitional, post-socialist countries. To this group belong the countries which are emerging from centrally planned to an open market economy. The socialist past left traces on institutional setting, mentality of the individuals and their interrelation, particularly in the domain of public administration. If the idiosyncrasy of these countries is taken into account the suggestion in this thesis is that in public administration in post-socialist countries, instead of dominant anti-corruption scheme repression-prevention-transparency, corruption combat should be improved through the implementation of a new one, structure-conduct-performance. The implementation of this model is based on three regulatory pyramids: anti-corruption, disciplinary anti-corruption and criminal anti-corruption pyramid. This approach asks public administration itself to engage in corruption combat, leaving criminal justice system as the ultimate weapon, used only for the very harmful misdeeds.

Cooperation after war: International development in Bosnia, 1995 to 1999

This paper discusses how predispositions, incentives, the number and heterogeneity of participants, and leadership (Faerman et al. 2001) jointly influenced the international effort to develop Bosnia and Herzegovina. International coalitions, task forces, and advisory groups are increasingly charged with implementing reforms following civil conflict. This requires a complex web of interorganizational relationships among NGOS, donors and host nations at both global and ‘ground’ levels. To better understand development assistance, attention must be paid to the relationships between these varied players. We find that four factors influenced relationships between policy, donor, and implementing organizations; and those strained relationships, in turn, affected development success. The paper draws on interviews, conducted in Bosnia, with 43 development professionals, observation of development meetings in Tuzla and Sarajevo, and review of related documents from international development programs.

International Service-Learning and the Development of Civic Identity: Understanding the Role of Short-Term International Service-Learning and its Influence on the Development of Civic Identity in College Students Using a Mixed Methodological Approach

Higher education has a responsibility to educate a democratic citizenry and recent research indicates civic engagement is on the decline in the United States. Through a mixed methodological approach, I demonstrate that the potential exists for well structured short-term international service-learning programming to develop college students’ civic identities. Quantitative analysis of questionnaire data, collected from American college students immediately prior to their participation in a short-term service-learning experience in Northern Ireland and again upon their return to the United States, revealed increases in civic accountability, political efficacy, justice oriented citizenship, and service-learning. Subsequent qualitative analysis of interview transcripts, student journals, and field notes suggested that facilitated critical reflection before, during, and after the experience promoted transformational learning. Emergent themes included: (a) responsibilities to others, (b) the value of international service-learning, (c) crosspollination of ideas, (d) stepping outside the daily routine to facilitate divergent thinking, and (e) the necessity of precursory thinking for sustaining transformations in thinking. The first theme, responsibilities to others, was further divided into subthemes of thinking beyond oneself, raising awareness of responsibility to others, and voting responsibly.

Changes in volumetric BMD of radius and tibia upon antidepressant drug administration in young depressive patients

To determine longitudinal changes in trabecular volumetric BMD (vBMD) at tibia and radius in young depressive patients under antidepressants using pQCT.

Ocular toxicity during adjuvant chemoendocrine therapy for early breast cancer: results from International Breast Cancer Study Group trials

BACKGROUND: Others have reported ocular toxicity after adjuvant chemoendocrine therapy, but this study looked at ocular toxicity in similarly treated patients from large randomized clinical trials. METHODS: Information was retrieved on incidence and timing of ocular toxicity from the International Breast Cancer Study Group (IBCSG) database of 4948 eligible patients randomized to receive tamoxifen or toremifene alone or in combination with chemotherapy (either concurrently or sequentially). Case reports of patients with ocular toxicity were evaluated to determine whether ocular toxicity occurred during chemotherapy and/or hormonal therapy. Additional information was obtained from participating institutions for patients in whom ocular toxicity occurred after chemotherapy but during administration of tamoxifen or toremifene. RESULTS: Ocular toxicity was reported in 538 of 4948 (10.9%) patients during adjuvant treatment, mainly during chemotherapy. Forty-five of 4948 (0.9%) patients had ocular toxicity during hormone therapy alone, but only 30 (0.6%) patients had ocular toxicity reported either without receiving any chemotherapy or beyond 3 months after completing chemotherapy and, thus, possibly related to tamoxifen or toremifene. In 3 cases, retinal alterations, without typical aspects of tamoxifen toxicity, were reported; 4 patients had cataract (2 bilateral), 12 impaired visual acuity, 10 ocular irritation, 1 optical neuritis, and the rest had other symptoms. CONCLUSION: Ocular toxicity during adjuvant therapy is a common side effect mainly represented by irritative symptoms due to chemotherapy. By contrast, ocular toxicity during hormonal therapy is rare and does not appear to justify a regular program of ocular examination. However, patients should be informed of this rare side effect so that they may seek prompt ophthalmic evaluation for ocular complaints.

Nordic Film Series: "To My Son in Spain: Finnish Canadians in the Spanish Civil War"

Finlandia University's Nordic Film Series, a free event open to the public, will feature two viewings of "To My Son in Spain: Finnish Canadians in the Spanish Civil War," with writer Dr. Saku Pinta available for questions. This documentary features the story of Jules Päiviö (1916-2013), who was the last surviving Canadian volunteer of the Mackenzie-Papineau Battallion of the “International Brigades”.

Nordic Film Series: "To My Son in Spain: Finnish Canadians in the Spanish Civil War"

Finlandia University's Nordic Film Series, a free event open to the public, will feature two viewings of "To My Son in Spain: Finnish Canadians in the Spanish Civil War," with writer Dr. Saku Pinta available for questions. This documentary features the story of Jules Päiviö (1916-2013), who was the last surviving Canadian volunteer of the Mackenzie-Papineau Battallion of the “International Brigades”.