Thesis (Ph. D.)--University of Hawaii at Manoa, 1991. / Includes bibliographical references (leaves 68-75) / Microfiche. / ix, 75 leaves, bound ill. 29 cm

This thesis focuses on infant and maternal health through the examination of different government regulated policy interventions. Specifically, this thesis comprises of three essays. First, I examine the effect of a reduction in coal-fired power plant emissions on infant health outcomes of downwind counties. Second, I analyze how limiting lawyers’ contingency fees affects physicians’ decision to perform C-sections on women and, ultimately, its effect on infant mortality. The third, and final, paper investigates whether or not medical malpractice tort reforms have altered physicians’ decision to take part in defensive medicine. Chapter 1 examines the Clean Air Interstate Rule (CAIR) which mandated the reduction of power plant emissions in the eastern United States. This policy improved air quality in neighbouring downwind counties, greatly reducing exposure to a specific form of pollution—fine particulate matter. I investigate the impact of this reduction exposure on birth outcomes using data from the U.S. Natality Detail Files. I find that female babies experience improvements in premature birth and low/very low birth weight status which are driven by the reduction in prematurity. I also focus on full-term babies to better isolate the impact of prematurity from fetal growth on birth weight. Consistent with recent work, I find that full-term male babies experience an increase in birth weight, demonstrating an improvement in intrauterine growth due to lower exposure to fine particulates. Finally, I find a reduction in infant mortality for babies whose mothers were categorized as “high-risk” pregnancies, suggesting that reduced exposure may lead to improved birth outcomes among those most at risk. Chapter 2 analyzes a limit on contingency fees for lawyers in medical malpractice cases enacted in Nevada. Generally, such limits are thought to change the composition of liability cases as they induce lawyers to drop more frivolous cases in favour of ones involving death and serious injury. Inadvertently, obstetricians faced a greater fear of litigation. Applying synthetic control methods, I find a 2.8 percentage point increase in the C-section rates of high school dropout patients, translating to a ten percent increase after the reform. There is no statistically significant difference in C-section rates after the enactment of the reform on patients with at least a college degree, and further, no statistically significant effect on infant mortality. Limiting contingency fees in medical malpractice cases induces obstetricians to engage in defensive medicine by performing more C-sections on low income patients, illustrating that tort reform can alter physician procedural patterns, albeit in heterogeneous ways. Chapter 3 continues with the theme of government regulated policy intervention by examining the effects of medical malpractice tort reform on maternal and infant health. Numerous papers examined the effects of tort reforms on physician behaviour using data from the 1990s. However, a medical malpractice “crisis” in the early 21st century saw many US states adopt tort reforms to alleviate this issue. Using data from 1995 to 2012 I observe that tort reforms are not as effective as they once were. However, I find evidence that physicians’ procedural choices are affected by tort reforms. Not only are C-section rates and “preventable” complications affected by tort reforms, but I also observe that tort reforms influence physicians’ decisions with non-risky patients. / Thesis / Doctor of Philosophy (PhD)

The criminal law has been critiqued as an unsuitable system to regulate adverse medical events (AME) because the unintentional nature of AME renders it incompatible with the penal objectives of the criminal law. This project uses an interpretivist approach to examine how blameworthiness is constructed in criminal cases involving AME. Situated within a contextual constructionist paradigm, and utilizing a theoretical framework that draws on legal pragmatism, symbolic interactionism, Habermasian thought, and Goffmanian frame analysis, this project employs a case study approach to explore how appellate courts construct AME as a product of fate or agency. The British case of Bawa-Garba v. R. (2016) and the Canadian case of R. v. Javanmardi (2019) are analysed using thematic analysis. It is concluded that the majority of the Supreme Court of Canada in Javanmardi constructed the AME within the realm of fate, contrasting the minority in Javanmardi and full panel of the England and Wales Court of Appeal in Bawa-Garba which constructed the AME within the realm of agency. It is also concluded that the majority in Javanmardi utilised pragmatic adjudication to determine blameworthiness. It is suggested that these findings could reduce fear of criminal liability among Canadian health care professionals. Future research is suggested to examine the legal cultures underlying this variation, critically explore the intersection of race and criminal prosecution of AME, and apply structural violence as a theoretical frame to further interrogate AME as a systemic failure.

Visam pasaulyje stebimos tendencijos ieškinių dėl gydymo metu patirtos žalos daugėjimo, kurios neabejotinai palies ir Lietuvą. Gydytojų ir paciento santykių institutas formavosi įtakojamas etikos, teisės ir medicinos mokslų. Šių mokslų specifikos nepakankamas įvertinimas, sprendžiant gydytojų civilinės atsakomybės klausimus, kaip ir netinkamas šių santykių teisinis reguliavimas ir teismų formuojama teisės normų aiškinimo praktika, žinomi, kaip svarbiausi veiksniai įtakojantys „gynybinės medicinos“ praktikavimą, darantį didelę žalą sveikatos priežiūros sistemos finansiniams ištekliams ir sukeliantį papildomos žalos riziką pacientams. Gynybinę mediciną nuo rūpestingo ir atidaus gydytojo pareigos vykdymo skiria labai plona ir lengvai peržengiama linija. Lietuvoje esantis sveikatos priežiūros paslaugų teisinio reguliavimo nenuoseklumas, vieningo gydytojų etikos kodekso nebuvimas, neįgyvendinta bendrų diagnostikos ir gydymo metodikų koncepcija, sukelia teorinį pavojų atsirasti naujoms civilinės atsakomybės taikymo problemoms. Teismų praktikoje įtvirtintas maksimaliai atidaus, rūpestingo ir kvalifikuoto gydytojo elgesio standartas, vertinant jį pasaulinės teismų praktikos ir medicinos specifikos požiūriu, turi būti keistinas, kaip nustatantis nerealius ir neįgyvendinamus kriterijus, galinčius tapti pagrindu neteisingam gydytojų civilinės atsakomybės taikymui. Skirtingai nuo aiškių kriterijų vertinant paciento informavimo institutą, priežastinio ryšio nustatymas, bylose dėl gydytojų... [toliau žr. visą tekstą] / All over the world we observe a tendency for the increase of claims for damages of treatment that will with no doubt come to Lithuania. The establishment of the institute of doctor and patient was influenced by the science of ethics, law and medicine. The fact that these sciences were underestimated when discussing doctors’ liability as well as improper legal regulation and explanation of normative legal acts formed by courts are the main factors that brought “defensive medicine” in practice, that makes a lot of harm to the formation of the health care system financial recourses and puts the patients in the risk of getting additional damage. Thoughtful and attentive doctors’ duties and “defensive medicine” is separated by a hairline which is easy to trespass. The incoherence of the health care legal regulations in Lithuania, the non-existence of united doctors’ ethic code, the unfulfilled concept of diagnosis and treatment bring a danger of emerging new problems in applying the civil liability. A standard of most attentive, careful and qualified doctor treatment is established in court practice. It has to change taking into consideration the worldwide court practice and particularities of medicine as that sets unrealistic and impracticable criteria, which makes base for misapplication of doctors’ civil liability. Differently from the clear criteria for the evaluation of the institute of patient information, the establishment of causality in cases of doctors’ civil liability... [to full text]

This research examines the experiences of Malaysian Neurosurgeons in managing communications with patients and their families in the aftermath of adverse medical events. These experiences were interpreted from a conflict avoidance and management perspective and the data from the research was analyzed using heuristic methodology. (Douglass and Moustakas 1985) The field of Neurosurgery in Malaysia was chosen firstly as a model of a high-risk medical specialty and secondly because of the researcher’s lived experience with the phenomenon being studied. Participants in the research were eleven Malaysian Neurosurgeons with at least ten years of independent clinical practice as specialists. Qualitative data was obtained through semi-structured in-depth interviews that were subsequently transcribed and analyzed heuristically, looking for different conflict management and patient-physician communication themes. The observations indicate that adverse medical events precipitate a major shift in the focus of tacit conflict management skill sets applied by the participants. The patient-Neurosurgeon relationship is abruptly transformed from one of high trust to one imbued with patient anxiety and suspicion of malpractice or medical error, and physician defensiveness. The observations also indicate that in multicultural Malaysia physician-family relationships were prioritized more than would be expected in a Western context. This may have implications for humanistic and interactive skills training for medical students and residents.

L'obstétrique est généralement présentée comme l'archétype des problèmes de la responsabilité médicale. La présente étude entreprend de dépasser ce constat afin de dévoiler l'appréhension imparfaite du risque obstétrical par la responsabilité médicale. La première partie de la thèse met en exergue les spécificités du risque obstétrical : elle soutient, d'une part, que ces spécificités ont des effets sur les systèmes d'indemnisation, et ; d'autre part, que ces spécificités atteignent également les mécanismes assurantiels. La seconde partie de l'étude s'intéresse à la judiciarisation du risque obstétrical. L'ouvrage constate en premier lieu que celle-ci à des incidences directes sur la pratique obstétricale et des incidences indirectes sur l'économie. La thèse envisage en second lieu d'utiliser les outils contractuels afin d'éviter les méfaits de cette judiciarisation. Entre la théorie et la pratique, la thèse propose de réécrire certaines dispositions législatives afin d'améliorer l'indemnisation des dommages obstétricaux, mais aussi de formaliser un contrat de naissance de nature à déjudiciariser le risque obstétrical. / Obstetrics is generally presented as the archetype of the issues related to medical liability. This study undertakes to go beyond that finding in order to cast light on the specific reasons for which medical liability hardly addresses issues related to obstetrics. The first part of the thesis highlights the specificities of the obstetrical risks: it argues on the one hand, that those specific characteristics have consequences as regards compensation systems; and on the other hand,, that those specific features also have an impact on the insurance mechanisms. The second part of the study deals with the judicialization of the obstetrical risks. The book notes, first, that judicialization has direct effects on obstetrical practice and indirect consequences on the Economy. Secondly, the study considers the use of contractual mechanisms as a way to prevent the effects of judicialization. Between theory and practice, the study proposes to rewrite certain legal provisions with a view to improve the compensation of obstetrics damages but also to formalise a birth contract in order to "de-judicialize" obstetrical risks.

隨著近年醫療糾紛日益增加，民刑事訴訟程序冗長，醫病雙方長時間煎熬，醫病關係日益惡化，導致防禦性醫療盛行。本研究從醫療責任切入，討論醫療爭議及現行處理途徑與方式，現行醫療責任保險之發展，簡介外國醫療責任保險概況。探討我國實施強制醫療責任保險之可能性。 本研究試圖以多階層醫療風險處理模式，以達有效處理醫療糾紛事件之目的。該模式將建立強制醫療責任保險以提供基本補償及簡化賠償機制，推動醫療機構責任保險以行政手段加強民眾保障，限定賠償金額避免高風險急重症專科無人從事，提倡醫師專業責任保險分散風險，引進醫事審議仲裁機制縮短醫療糾紛審查及賠償程序。 期以多面向分層處理醫療糾紛及其賠償問題，建構安全的醫療制度，避免防衛性醫療的盛行及司法資源的浪費。 / With the growing number of medical malpractice cases and the lengthy process of both civil and criminal litigation procedures in recent years, the torture has been agonizing and worsening the relationship between physicians and patients. The very situation results in the prevalence of defensive medical treatment. This research deals with the problem from the viewpoint of medical liability, discusses the current methods of handling medical disputes and explores the development of current medical liability insurance. An overview of the situation in other countries is presented to investigate the possibility of implementing mandatory medical liability insurance in Taiwan. This research attempts to establish a multi-level mode to effectively resolve medical risks. This mode will contribute to a lot of functions including enforcing mandatory medical liability insurance, supporting a fundamental compensation and simplifying the process of damages claiming. Furthermore, the mode will also serve to promote the medical liability insurance of medical institutions and in turn enhance the protection for the common public with administrative measures. In addition, the mode intends to restrict the upper limit of damages in order to remedy the serious phenomenon that no doctors are willing to practice in the high-risk medical departments, which is expected to distribute the medical risk of all the doctors. It will also introduce a medical arbitration mechanism to shorten and accelerate the procedure of medical reviewing and damages claiming in handling medical malpractice cases. We hope, with the establishment of such a multi-level mode, a sound and wholesome medical system can be constructed and the overflowing defensive medical treatment and waste of judicial resources can be avoided.