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Tort laws aim to deter risky medical practices and increase accountability for harm. This research examines their effects on deterrence of a high-risk obstetric practice in the United States: elective early-term (37-38 weeks gestation) induction of labor. Using birth certificate data from the Natality Detail Files and state-level data from publicly available sources, this study analyzes the effects of tort laws on labor induction with multilevel models (MLM) of 665,491 early-term births nested in states. Results reveal that caps on damages are associated with significantly higher odds of early-term induction and Proportionate Liability (PL) is associated with significantly lower odds compared to Joint and Several Liability (JSL). The findings suggest that clinicians are more likely to engage in practices that defy professional guidelines in tort environments with lower legal burdens. I discuss the implications of the findings for patient safety and the deterrence of high-risk practices.

o presente trabalho objetivou identificar e analisar as decisões jurídicas que se referem à responsabilidade médica, quanto à ocorrência de formação jurisprudencial relativa às faltas decorrentes de atos ou procedimentos técnicos, assim como das faltas contra o humanismo médico, nas esferas civil e penal. Pesquisou-se as decisões judiciais relativas à responsabilização da atividade médica, de 1960 a 1989, apresentadas na Revista dos Tribunais e Revista de Jurisprudência do Tribunal de Justiça do Estado de São Paulo. Foram estudados os casos relativos a faltas por erro de diagnóstico, determinação do tratamento, condução do tratamento e elaboração de falsos atestados médicos, classificados como faltas técnicas. Como faltas cometidas contra o humanismo médico foram estudadas as decisões concernentes ao direito ao consentimento, à informação, à liberdade, à privacidade, à segurança e o dever da solidariedade. Analisa-se e comenta-se as diversas tendências jurisprudenciais envolvendo a matéria pesquisada, através de abordagem que possa subsidiar os profissionais de saúde ao melhor conhecimento da realidade da interpretação jurídica da atividade médica. / The aim of this thesis was to identify and to analyse the juridical resolutions which refer to the medical responsibility for the ocurrence of the jurisprudence concerning failures due to performance or technical procedures, as well as failures against medical humanism, in civil or penal fields. The responsibility of medical activity, from 1960 to 1989, published by Revista dos Tribunais and Revista de Jurisprudência do Tribunal de Justiça do Estado de São Paulo, were searched. Ocurrences related to failures due to errors on diagnosis, instruction and conduction treatment, the filling out of wrong medical certificates, all of these, classified as technical failures, were inquired. As failures against medical humanism, resolutions regarding the right to consentment, to information, to liberty, to privacy and to security and the duty of solidarity were studied. A number of jurisprudential tendencies involving the searched matter were analysed and commented, through an approach which could give elements to health professionals for a better knowledge of the reality of juridical understanding of the medical activity.

o presente trabalho objetivou identificar e analisar as decisões jurídicas que se referem à responsabilidade médica, quanto à ocorrência de formação jurisprudencial relativa às faltas decorrentes de atos ou procedimentos técnicos, assim como das faltas contra o humanismo médico, nas esferas civil e penal. Pesquisou-se as decisões judiciais relativas à responsabilização da atividade médica, de 1960 a 1989, apresentadas na Revista dos Tribunais e Revista de Jurisprudência do Tribunal de Justiça do Estado de São Paulo. Foram estudados os casos relativos a faltas por erro de diagnóstico, determinação do tratamento, condução do tratamento e elaboração de falsos atestados médicos, classificados como faltas técnicas. Como faltas cometidas contra o humanismo médico foram estudadas as decisões concernentes ao direito ao consentimento, à informação, à liberdade, à privacidade, à segurança e o dever da solidariedade. Analisa-se e comenta-se as diversas tendências jurisprudenciais envolvendo a matéria pesquisada, através de abordagem que possa subsidiar os profissionais de saúde ao melhor conhecimento da realidade da interpretação jurídica da atividade médica. / The aim of this thesis was to identify and to analyse the juridical resolutions which refer to the medical responsibility for the ocurrence of the jurisprudence concerning failures due to performance or technical procedures, as well as failures against medical humanism, in civil or penal fields. The responsibility of medical activity, from 1960 to 1989, published by Revista dos Tribunais and Revista de Jurisprudência do Tribunal de Justiça do Estado de São Paulo, were searched. Ocurrences related to failures due to errors on diagnosis, instruction and conduction treatment, the filling out of wrong medical certificates, all of these, classified as technical failures, were inquired. As failures against medical humanism, resolutions regarding the right to consentment, to information, to liberty, to privacy and to security and the duty of solidarity were studied. A number of jurisprudential tendencies involving the searched matter were analysed and commented, through an approach which could give elements to health professionals for a better knowledge of the reality of juridical understanding of the medical activity.

La déjudiciarisation des litiges est un sujet actuel et fondamental pour les pouvoirs publics au regard de l’engorgement des juridictions françaises. Il s’agit d’une préoccupation que partage l’assureur en responsabilité civile médicale pour lequel faciliter le règlement amiable des conflits signifie diminuer ses coûts de gestion internes, avoir une meilleure maîtrise des sommes allouées au titre la réparation des dommages résultant de soins et valoriser son image d’expert de l’indemnisation auprès de ses assurés. Aujourd’hui, le monde de l’assurance du risque médical s’engage publiquement en faveur de la recherche d’une solution négociée des litiges. Il présente cette dernière comme étant un mode opératoire bénéficiant à toute la société et particulièrement aux patients (ou à leurs ayants-droit), lesquels peuvent obtenir une indemnisation plus rapidement que devant les juridictions et en limitant leurs frais. Pour mettre en œuvre cette démarche, l’assureur se dote de processus internes afin d’optimiser les chances de succès des réclamations présentées dans un cadre amiable. Il s’appuie également sur l’action des pouvoirs publics, lesquels ont, notamment, créé les commissions (régionales) de conciliation et d’indemnisation des accidents médicaux, affections iatrogènes et infections nosocomiales, qui permettent de faciliter les solutions négociées aux litiges. Pour autant, force est de constater qu’il existe des limites à cette entreprise. En effet, outre le fait que la victime demeure la principale décisionnaire du choix du mode opératoire de l’examen de sa demande, d’autres acteurs directs et indirects voire le professionnel de l’assurance du risque médical lui-même, peuvent être à l’origine de la judiciarisation du différend. En tout état de cause, le recours aux juges ne doit pas être entendu uniquement comme un échec de la solution négociée dans la mesure où la jurisprudence peut se révéler être un atout pour faciliter la déjudiciarisation des litiges ultérieurs. / Solving disputes outside of the judicial system is a contemporary and a fundamental challenge for public authorities given the current congested workload of Courts. Medical liability insurers obviously share that concern. Indeed, facilitating amicable settlements is a way to decrease internal administration costs, to have better control over the damages awarded, and to enhance their image as Experts in their field. Nowadays, medical risk insurance companies are publicly committed to negotiated solutions. According to them, the out of Court approach can benefit the entire society and particularly the patients (or their beneficiaries), who can reach compensation more quickly than they would in front of a court, while limiting their fees. In order to implement this procedure, the insurance companies provide themselves with new internal processes, to optimize the chances of finding amicable settlements for the claims they receive. The success of this strategy also relies on the action of public authorities, whose decision to create the C(R)CI (Commissions of conciliation and compensation for medical accidents, iatrogenic disorders and nosocomial infections), has eased access to negotiated solutions.Nevertheless, this approach cannot always lead to a successfull outcome. As a matter of fact, the victims remain the last to decide on the way they want the litigation to be settled. Some other direct or indirect actors, or even the medical liability insurer itself, can bring the action before the Court. Either way, recourse to a Judge does not have to be only seen as a failure, since it allows jurisdictions to give orientations that will help parties position themselves in the event of further cases.

Le droit de la responsabilité médicale est sans doute l'un des domaines du droit ayant connu une évolution majeure à l'aune de ce XXIème siècle. Devenu un « véritable laboratoire des instruments de responsabilité civile », il a influé et sera influencé par différentes réformes intervenues très récemment. S'il est communément admis que l'essor des sciences et des techniques a influé sur les méthodes de prise en charge du malade, ces progrès ont également joué sur la manière d'appréhender la responsabilité du médecin que l'étude abordera à travers son activité de prévention, de diagnostic et de soins. L’art médical, dont la capacité de guérir trouvait initialement son essence dans un pouvoir divin, s’est progressivement doté de méthodes d’analyse et d’interprétation scientifiques. Envahi par la probabilité, l’exercice médical s’est technicisé mais s’est aussi systématisé, gagnant peu à peu précision et capacité de prévision. Dès lors, le médecin tente aujourd’hui de prévenir, de maîtriser, d’amoindrir ou d’éviter la survenance d’un événement dommageable, qu’il soit lié à l’état de santé initial du patient ou qu’il résulte du système de santé. Qu’il s’agisse de l’erreur ou de l’aléa, ce dernier est devenu probabilisable et c’est ainsi qu’il finira par être nommé « risque » ou plus exactement « risque résultant du système de santé ». L’idée est donc d’envisager le droit de la responsabilité médicale à l’épreuve de ce risque, étude qui conduira à en réviser les conditions de mise en œuvre à la poursuite d’un équilibre actuellement altéré / Medical liability law is undoubtedly one of the fields of law that has undergone major changes in the light of the 21st century. By becoming a true “civil liability treasure chest”, it has influenced and will in turn be influenced no doubt by various recent reforms. While it is generally agreed that the development of science and technology has strongly influenced patient management and care systems, it has clearly also played a vital role in grasping the physicists’ knowledge of such liability which has in turn been addressed accordingly through prevention, diagnosis and care. Originally based on divine power, the healing capacity of the medical skill has gradually adopted and advanced through analysis and scientific interpretation. With this increased and enhanced probability medical practice has progressively gained accuracy and therefore the capacity to subsequently predict possibilities purely by taking on board this newfound technology. As a result, physicians now aim to avoid, prevent, and lesson damaging situations that stem from the actual health of the patient or those from the health care system itself. Whether medical mistake or misfortune, the latter can therefore be subject to a simple assessment with the aim to highlight a “risk” or more specifically a “risk resulting from the actual health care structure in place”. The notion therefore is to determine this specific liability within medical responsibility, the application of which would then lead to the revision of conditions and the necessary balance

La thèse présentée est intitulée « Le principe d’autonomie de la volonté de la patiente enceinte avant l’accouchement: Modèle de communication hospitalière ». Le travail de recherche est essentiellement méthodologique. Il comporte également une partie d’étude empirique, des enquêtes sous forme de témoignages auprès de plus de 500 patientes ayant subi une IVG en Europe. Il contribue à un thème de recherche important, la mise en place des mécanismes juridiques nécessaires à l’évolution des stratégies de santé publique du droit à l’IVG. La thèse est structurée en deux grandes parties : I. La consécration de l’autonomie de la femme lors d’une grossesse indésirée II. Les atteintes à l’autonomie de la femme lors d’une grossesse indésirée (modèle de communication) Ce découpage met en évidence le développement juridique autour de la remise en cause de la procédure d’accès à l’IVG par un éclairage de l’autonomie de la patiente. La première partie est divisée en deux titres qui présentent le respect de l’autonomie et le recueil du consentement. Le travail de recherche se construit par une analyse des données nécessaires pour évaluer les impacts du consentement perverti par le profane et le milieu médical dans lequel il s’inscrit. La deuxième partie propose deux titres qui présentent la responsabilité médicale et l’effet relatif des responsabilités quant à l’autonomie de la femme enceinte, permettant d’analyser les limites à la détermination de la patiente, le préjudice subi de la perte d’autonomie et les inégalités qui découlent des traitements différents selon les législations en vigueur. Malgré l’impossibilité de conclure à priori sur l’autonomie du processus de décision médicale, des solutions juridiques sont néanmoins proposées dans le dernier chapitre : il s’agit d’une étude de cas pour le renforcement juridique du consentement de la patiente (2019) menée aux Hôpitaux de Genève (HUG) en Suisse permettant, notamment, une déconstruction du principe de « libre-choix » de la patiente. Loin d’entrer dans une logique critique et antinomique pro-IVG, la thèse propose d’analyser les failles procédurales (le paradoxe de la responsabilité médicale) dans une étude nourrie de réflexions juridiques sur la notion d’autonomie et le statut de la femme lors de la décision IVG. / The thesis presented is entitled "The principle of autonomy of will of the pregnant patient before giving birth : a hospital communication model. The research work is essentially methodological. It also includes a part of empirical study, surveys in the form of testimonies with more than 500 patients having undergone a VTP care, in the 3 European countries determined in the study, in France, Poland and Switzerland. It contributes to an important research theme, the establishment of the legal mechanisms necessary for the evolution of public health strategies of the VTP right. The thesis is structured in two main parts : I. The recognition of women's autonomy when deciding on the use of the VTP care. II. Violations of women's autonomy when deciding on the use of the VTP care (hospital communication model). This division highlights the legal development around the questioning of the procedure of access to the VTP care by a lighting of the autonomy of the patient. The first part is divided into two titles that show respect for autonomy and the collection of consent. The research work is constructed by an analysis of the data needed to evaluate the impact of perverted consent by the lay person and the medical community in which he is enrolled. The second part proposes two titles that present the special medical responsibility and the relative effect of responsibilities on the autonomy of the pregnant woman, allowing to analyze the limits to the determination of the patient, the harm suffered from the loss of autonomy and the inequalities that result from different treatments according to the legislation in force. Despite the impossibility of concluding a priori on the autonomy of the medical decision-making process, legal solutions are nevertheless proposed in the last chapter : it is a case study for the legal strengthening of the patient's consent (2018) conducted at the Geneva Hospitals (HUG) in Switzerland allowing, in particular, a deconstruction of the principle of "free choice" of the patient. Far from entering a critical and antinomic pro-VTP logic, the thesis proposes to analyze the procedural flaws (the paradox of medical responsibility) in a study nourished by legal reflections on the notion of autonomy and the status of women during the decision IVG.

This dissertation studies the impact of Medicaid expansion on the liability insurance industry. Within the three chapters, the first two chapters focus on the medical liability insurance industry, and the third chapter focuses on the auto insurance industry. Chapter 1, “Medicaid Expansion and Medical Liability Costs”, examines the impact of health insurance expansion on medical liability costs using the case of the Affordable Care Act’s (ACA) Medicaid expansion. Medicaid expansion has increased the demand for medical services, but in doing so it may also have increased physicians’ liability in medical practice. By studying malpractice costs to insurers, medical practitioners, and hospitals in the U.S. for the period 2010–2018, we find insurers operating in states with Medicaid expansion experienced significantly higher medical liability costs than those in non-expansion states. While insurers in expansion states did increase premiums, the increase was not enough to fully offset rising costs. Moreover, we find that tort reforms did not mitigate ACA-induced malpractice liability costs. We show this is because Medicaid expansion increased malpractice costs mainly by increasing claim frequency while tort reforms generally focus on reducing claim severity. We further find little evidence that hospitals paid higher malpractice insurance premiums, self-insurance, or incurred higher out-of-pocket medical liability losses after Medicaid expansion. Taken together, our results imply that it is medical practitioners and malpractice insurers who bear the rising medical liability costs. Chapter 2, “Medicaid Expansion and Medical Liability Insurance Prices” extends the first chapter to study the impact of Medicaid expansion on medical liability insurance prices for three specialties, internal medicine, general surgery, and obstetrics-gynecology (OB-GYN). As Medicaid expansion increased medical liability costs to insurers, they may react by increasing medical malpractice insurance prices. By studying counties in expansion states and non-expansion states and bordering counties with different Medicaid expansion status over the years from 2010-2018, we find that Medicaid expansion leads to significantly higher medical liability insurance prices two years after the expansion on average and the impact is strongest for internal medicine and general medicine but less so for OB-GYN. Our finding suggests that the expansion of health insurance could increase liability costs to medical practitioners. Auto insurance provides coverage of healthcare for injured drivers even for those without traditional health insurance coverage. The expansion of public health insurance provides low-income injured drivers with an additional source of coverage for medical bills. This may change drivers’ incentives for using auto insurance and the ultimate payments made by auto insurers. In Chapter 3, “Public Health Insurance Expansion and Auto Insurance: The Case of Medicaid Expansion”, we first use a simple theoretical model to illustrate how obtaining public health insurance mitigates the incentive of insured drivers to engage in claims buildup. We then empirically test how the Affordable Care Act (ACA)’s Medicaid expansion changed the medical costs covered by auto insurance. By studying private passenger auto insurers in expansion states and non-expansion states between 2010 and 2018, we find that Medicaid expansion led to significantly lower auto insurance losses and premiums. We further show that the results were driven by the decreasing losses and premiums for third-party liability insurers but not in the states with no-fault insurance. / Business Administration/Risk Management and Insurance

Le problème de la responsabilité médicale se pose avec acuité dans le monde. S'agissant de nos Etats comme le Sénégal nous observons une timide évolution de la responsabilité. Cette dernière est induite par le type d'offre de soins. Cette interdépendance s'exprime au niveau de la nature de la responsabilité et de son régime juridique. Dans le cadre d'une offre publique de soins, la responsabilité est administrative et relève de la compétence du juge administratif. Dans le cadre de l'offre privée de soins, la responsabilité est civile et est de la compétence du juge judiciaire. A travers cette étude, nous avons observé que l'offre de soins est diversifiée du fait des nombreux acteurs et déséquilibrée du fait de l'absence de couverture de santé généralisée. Nous avons également constaté que les mécanismes traditionnels d'engagement de la responsabilité sont surannés dans certains cas, ayant pour conséquence la difficulté d'indemnisation des victimes. Une amélioration de la réglementation des pratiques médicales, y compris de la médecine traditionnelle, et une meilleure prise en charge des dépenses de santé de la population sénégalaise seraient souhaitables. Au vu de ces constats, nous préconisons donc l'accélération de l'adoption du Code de la santé publique du Sénégal et la création d'une Commission Régionale d'Indemnisation des accidents médicaux et des infections nosocomiales dans l'espace de l'Union Economique Monétaire Ouest Africaine, comme il en existe une en France. / The problem of the medical liability arises with acuteness in the world. In Senegal, we observe a shy evolution of the liability. This last one is inferred by the type of healthcare services. This interdependence expresses at the level of the nature of the liability and its legal regime. Within the framework of public healthcare services, the liability is administrative and recovers from the competence of the administrative judge. Within the framework of the private healthcare services, the liability is civil and is the competence of the judicial judge. Through this study, we observed that the healthcare services are diversified because of the numerous actors and unbalanced because of the absence of cover of generalized health. We also noticed that the traditional mechanisms of commitment of the liability are outmoded in certain cases, having for consequence the difficulty of compensation of the victims. An improvement of the regulations of the medical practices, including the traditional medicine, and a better coverage of the expenses of health of the Senegalese population would be desirable. In view of these reports, we thus recommend the acceleration of the adoption of the Public health code of Senegal and the creation of a Regional committee for Compensation of the medical accidents and the hospital-borne infections in the space of the Monetary Economic union the West African, as there is there one in France.

Du fait des progrès scientifiques modernes dans le domaine médical, ont été soulevés de nombreux problèmes concernant la responsabilité du service public hospitalier à cause de l'utilisation des méthodes scientifiques modernes en médecine. Le juge administratif français a été et est le moteur de l'évolution des règles en matière de responsabilité du service public hospitalier. Ce n'est pas le cas de la juridiction administrative au Liban. Mais plusieurs réformes législatives ont été adoptées au Liban depuis 1996. La thèse permet de confronter les solutions du droit positif français et du droit positif libanais et de rechercher les raisons d'une responsabilité médicale rarement mise en œuvre au Liban alors que les principes juridiques posés sont proches du système français. / Because of modern scientific progress in medical field, many problems, concerning the hospital public service liability, have been established as a consequence of the use of modern scientific methods in medicine. The French administrative judge has been and is a central point of rules evolutions in the field of hospital public service liability. This is not the situation of administrative jurisdiction in Lebanon. But several legislative reforms have been enacted in Lebanon since 1996. This research permit to discuss solutions of positive French and Lebanese laws, and to know why medical liability, in Lebanon, is rarely in service. Although Lebanon has the same rules and principles of France.