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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 gives a real headache. The damage that emerges in the process of treatment is influenced by various factors part of which are irrespective of doctors' will. Special knowledge is needed to properly evaluate various factors. The lack of the knowledge makes the evaluation of the factors that are irrespective of the doctors will inappropriate and makes the application of the doctors' liability based on the principle "all or nothing", that deviates from compensatory function of the civil liability. The doctrine of "lost chance" that is being applied by other states courts in cases of doctors' civil liability might be a better legal instrument to set up justice, that allows to individualize the scope of responsibility. The misapplication of the functions by the governmental institutions allows a whole system of inaccuracy in medicine and stops from providing qualified health services and implementing alternative device to recompense for damages such as insurance of civil liability. Considering the influence of actual circumstances for the damage to be done in some cases the application of state civil liability might be questioned.

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 gives a real headache. The damage that emerges in the process of treatment is influenced by various factors part of which are irrespective of doctors' will. Special knowledge is needed to properly evaluate various factors. The lack of the knowledge makes the evaluation of the factors that are irrespective of the doctors will inappropriate and makes the application of the doctors' liability based on the principle "all or nothing", that deviates from compensatory function of the civil liability. The doctrine of "lost chance" that is being applied by other states courts in cases of doctors' civil liability might be a better legal instrument to set up justice, that allows to individualize the scope of responsibility. The misapplication of the functions by the governmental institutions allows a whole system of inaccuracy in medicine and stops from providing qualified health services and implementing alternative device to recompense for damages such as insurance of civil liability. Considering the influence of actual circumstances for the damage to be done in some cases the application of state civil liability might be questioned.

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 gives a real headache. The damage that emerges in the process of treatment is influenced by various factors part of which are irrespective of doctors' will. Special knowledge is needed to properly evaluate various factors. The lack of the knowledge makes the evaluation of the factors that are irrespective of the doctors will inappropriate and makes the application of the doctors' liability based on the principle "all or nothing", that deviates from compensatory function of the civil liability. The doctrine of "lost chance" that is being applied by other states courts in cases of doctors' civil liability might be a better legal instrument to set up justice, that allows to individualize the scope of responsibility. The misapplication of the functions by the governmental institutions allows a whole system of inaccuracy in medicine and stops from providing qualified health services and implementing alternative device to recompense for damages such as insurance of civil liability. Considering the influence of actual circumstances for the damage to be done in some cases the application of state civil liability might be questioned.

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 gives a real headache. The damage that emerges in the process of treatment is influenced by various factors part of which are irrespective of doctors' will. Special knowledge is needed to properly evaluate various factors. The lack of the knowledge makes the evaluation of the factors that are irrespective of the doctors will inappropriate and makes the application of the doctors' liability based on the principle "all or nothing", that deviates from compensatory function of the civil liability. The doctrine of "lost chance" that is being applied by other states courts in cases of doctors' civil liability might be a better legal instrument to set up justice, that allows to individualize the scope of responsibility. The misapplication of the functions by the governmental institutions allows a whole system of inaccuracy in medicine and stops from providing qualified health services and implementing alternative device to recompense for damages such as insurance of civil liability. Considering the influence of actual circumstances for the damage to be done in some cases the application of state civil liability might be questioned.

This article reviews the empirical literature on the effects of damages caps and concludes that the better-designed studies show that damages caps reduce liability insurance premiums. The effects of damages caps on defensive medicine, physicians' location decisions, and the cost of health care to consumers are less clear. The only study of whether consumers benefit from lower health insurance premiums as a result of damages caps found no impact. Some state courts have based decisions declaring damages caps legislation unconstitutional on the lack of evidence of their effectiveness, thereby ignoring the findings of conflicting research studies or discounting their relevance. Although courts should be cautious in rejecting empirical evidence that caps are effective, legislators should consider whether they benefit consumers enough to justify limiting tort recoveries for those most seriously injured by malpractice.

Medical Malpractice claims are frequently asserted in the United States. At various time and places, an extraordinarily high number of claims and payouts led to what some have called medical malpractice crises. Consequently, in some geographical locations physicians either could not purchase malpractice insurance as carriers withdrew from the market, or, insurance became increasingly expensive and the overall costs associated with the delivery of health care continued to rise. Other undesirable consequences of these crises included a shortage of qualified physicians in certain parts of the country. Many of the states responded to these problems legislatively through a long series of tort reform measures. The health care industry itself has evolved in numerous ways. In particular, many health care providers have turned away from traditional private insurance models to self-insured models such as captives. Further, the industry has continued to consolidate, with fewer, but larger hospitals and clinics, and with an increasing number of physicians employed directly by hospitals and large clinics. The results of all of these changes have had mixed results.

Importance: The US Government Accountability Office has changed its estimate of the annual costs of defensive medicine, largely because it has been difficult to objectively measure its impact. Evaluating the association of malpractice claims rates with hospital admission rates and the costs of admitting patients with low-risk conditions would help to document the impact of defensive medicine. Although syncope is a concerning symptom, most patients with syncope have a low risk of adverse outcomes. However, many low-risk patients are still admitted to the hospital, with associated costs of more than $2.5 billion per year in the US. Objective: To assess whether hospital admission rates after emergency department visits among patients with lower-risk syncope are associated with state-level variations in malpractice claims rates. Design, Setting, and Participants: This cross-sectional study of emergency department visits among patients with lower-risk syncope used deidentified data from the Clinformatics Data Mart database (Optum). Lower-risk syncope visits were defined as those with a primary diagnosis of syncope and collapse based on International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 or International Classification of Diseases, Tenth Revision, Clinical Modification code R55 that did not include another major diagnostic code for a condition requiring hospital admission (such as heart disease, cancer, or medical shock) or an inpatient hospital stay of more than 3 days. These data were linked to publicly available data from the National Practitioner Data Bank pertaining to physician malpractice claims between January 1, 2008, and December 31, 2017. The 2 data sets were linked at the state-year level. Data were analyzed from October 2, 2019, to September 12, 2020. Main Outcomes and Measures: The association between the rate of hospital admission after emergency department visits among patients with lower-risk syncope and the rate of physician malpractice claims was assessed at the state-year level using a state-level fixed-effects model. Standardized costs obtained from the Clinformatics Data Mart database were adjusted for inflation and expressed in 2017 US dollars using the Consumer Price Index. Results: Among 40 482 813 emergency department visits between 2008 and 2017, 519 724 visits (1.3%) were associated with syncope. Of those, 234 750 visits (45.2%) met the criteria for lower-risk syncope. The mean (SD) age of patients in the lower-risk cohort was 71.8 (13.5) years; 141 050 patients (60.1%) were female, and 44 115 patients (18.8%) were admitted to the hospital, representing an extra cost of $6542 per admission. The mean rate of physician malpractice claims varied from 0.27 claims per 100 000 people to 8.63 claims per 100 000 people across states and across years within states. A state-level fixed-effects regression model indicated that, for every 1 in 100 000-person increase in the physician malpractice claims rate, there was an absolute increase of 6.70% (95% CI, 4.65%-8.75%) or a relative increase of 35.6% in the hospital admission rate, which represented an additional $102 million in costs associated with this lower-risk cohort. Conclusions and Relevance: In this study, increases in physician malpractice claims rates were associated with increases in hospital admission rates and substantial health care costs for patients with lower-risk syncope, and these increases are likely associated with the practice of defensive medicine.

This chapter argues that covenantal thought and practice has the capacity to discipline marketisation processes in service of an ethos of gracious compassion in healthcare. It engages critically with the analyses of Diagnosis Related Groups, Personal Budgets and Defensive Medicine offered by Feiler, Herring, Papanikitas and Jani in the preceding three chapters, showing that the key themes of 'care' and 'work' can be illumined by a covenantal approach which works judiciously with healthcare marketisation. Constructively, it draws on parallels in the Armed Services to argue for five required characteristics of a written and institutionalised Healthcare Covenant between health and care workers and the public. Drawing on traditions of pastoral and political theology to explore the psychological and social influences of marketisation, this chapter provides the bridge between the systemic issues of Part I, the policy concerns of Part II and the questions of professional ethics considered in Part III.

Medical accidents and litigation can have a profound and long lasting effect on both doctors and patients. Research has shown that for doctors, working in a profession which is intrinsically stressful, the added stress of litigation and accidents is leading to considerable strain and sometimes to maladaptive and inappropriate behaviors on the part of some doctors. For many it is leading to the practice of defensive medicine. For patients the picture is not better. Some are left with no clear idea of what has happened or why they have been injured by their medical treatment. Many are left needing further remedial treatment and for some the psychological effects are akin to those suffered by victims of major disasters. In this paper we have looked at these issues and have put forward proposals to suggest how things can be improved for both doctors and patients.

Cover -- Title -- Copyright -- Contents -- Acknowledgements -- Contributors -- Foreword -- Introduction -- PART I The place of the market -- 1 Why the economic calculation debate matters: the case for decentralisation in healthcare -- 2 The corruption of medical morality under advanced capitalism -- 3 Organisational ethics: a solution to the challenges of markets in healthcare? -- PART II The influence of the market -- 4 Encoding truths? Diagnosis-Related Groups and the fragility of the marketisation discourse -- 5 Personal budgets: holding onto the purse strings for fear of something worse -- 6 "More than my job is worth" – defensive medicine and the marketisation of healthcare -- 7 Covenant, compassion and marketisation in healthcare: the mastery of Mammon and the service of grace -- PART III The place of ethics -- 8 Commercialisation and the corrosion of the ideals of medical professionals -- 9 The virtuous professional and the marketplace -- 10 Empathy in healthcare: the limits and scope of empathy in public and private systems -- 11 Accounting for ethics: is there a market for morals in healthcare? -- What next? Editors' epilogue -- Index

Chemical weapons accounted for only 1 per cent of the 750,000 British troops killed in the First World War and yet caused disproportionate casualties (estimated at 180,100). The considerable investment in the development of new toxins and methods of delivery was designed to maintain the elements of surprise and uncertainty as these accentuated their psychological effect. Soldiers were continually challenged on the battlefield by combinations of different types of agent designed to undermine their confidence in respirators, disorientate them, and erode their morale. At first, army doctors practised defensive medicine, invaliding their patients for protracted periods to the UK or base hospitals. By 1917, progressive study of the physical and psychological effects of different types of toxin allowed physicians to design new management strategies. Borrowing ideas from shell shock, specialist units were set up closer to the front line and medical officers taught to identify crucial points in the course of illness to accelerate recovery times and forestall the accretion of psychosomatic symptoms.

Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.

[The guidelines in the new law reforming the medical liability]The increasing complexity of clinical practice has significantly strengthened the need for guidelines that provide physicians with clear professional standards for inspiration and, not infrequently, cling to withstand the wind of a sometimes excessive responsibility of their activities. Clinical guidelines are defined as «systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances».The fact that the guidelines indicate the rules of proper practice of the profession has led many doctors to hope that, according to them, they could avoid incurring liability. The doctrine has long held that the rules contained in the guidelines can have an abstract value, but the assessment of the behaviour of the physician must be conducted in the light of all the data of the individual and concrete clinical cases, which certainly can not be taken into consideration by the drafters of the guidelines. Although the medical-legal relevance of the guidelines was reduced by the Supreme Court in some cases, the legislature has decided to focus on guidelines to curb the phenomenon of defensive medicine and restoring tranquility to the doctors in the exercise of profession.Purpose of our article is to present a commentary on Article 3 of Decree Law no. 158/2012 (so-called "Decreto Balduzzi"), to highlight some critical points that are likely to frustrate the objective of the legislature.

[The guidelines in the new law reforming the medical liability]The increasing complexity of clinical practice has significantly strengthened the need for guidelines that provide physicians with clear professional standards for inspiration and, not infrequently, cling to withstand the wind of a sometimes excessive responsibility of their activities. Clinical guidelines are defined as «systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances».The fact that the guidelines indicate the rules of proper practice of the profession has led many doctors to hope that, according to them, they could avoid incurring liability. The doctrine has long held that the rules contained in the guidelines can have an abstract value, but the assessment of the behaviour of the physician must be conducted in the light of all the data of the individual and concrete clinical cases, which certainly can not be taken into consideration by the drafters of the guidelines. Although the medical-legal relevance of the guidelines was reduced by the Supreme Court in some cases, the legislature has decided to focus on guidelines to curb the phenomenon of defensive medicine and restoring tranquility to the doctors in the exercise of profession.Purpose of our article is to present a commentary on Article 3 of Decree Law no. 158/2012 (so-called "Decreto Balduzzi"), to highlight some critical points that are likely to frustrate the objective of the legislature.