Forensic psychiatry and malpractice

This paper concerning the last 87 malpractice cases referred to the Department of Psychiatry and Law, Menninger Clinic, includes 57 suits against mental health practitioners and/or institutions, and 30 nonpsychiatric suits against general hospitals, surgeons, obstetricians, etc. A patient was available for interview in only 12 percent of the psychiatric cases; in 88 percent we reviewed medical records and consulted with attorneys. In the psychiatric cases the crucial question was whether a generally accepted standard of care was breached. The inherent problems of applying appropriate criteria to standards of care by practitioners and institutions are discussed. In half the psychiatric cases we found no significant deviation from acceptable clinical performance; in half we concluded that negligent practice had occurred. We did see a litigant for evaluation in 90 percent of the nonpsychiatric cases. The main issue involving them concerned harm or disability related to presumed negligence by medical personnel. How we evaluate such cases and apply disability criteria is discussed.     

The extent of aspartic acid racemization in dentin: a possible method for a more accurate determination of age at death?

In the current study the objective was to find to what extent a reliable determination of age at death is made possible by establishing the degree of aspartic acid racemization in the dentin of teeth. The results of the investigation of 46 teeth are in agreement with the values found by other authors. The method presented makes a reproducible and accurate estimation of age possible. We intend to elaborate and improve this promising method for determination of age at death. The relevant points are presented here.     

Sensitivity of various study technics in blood stains

Quadratic pieces of fleece measuring 16 mm2 were soaked with 10 different blood-samples in the dilution steps of 1:1, 1:10, 1:100, 1:1000, respectively, and were tested in blood group typing and identification tests of forensic serology. The above spezified dilutions correspond with 5 microliters, 0.5 microliter, 0.05 microliter and 0.005 microliter of blood, respectively. The detection limit of the microspectrometric test for blood was the dilution 1:10, of the porphyrine test a dilution above 1:100, whereas the preliminary test for blood (peroxidase) succeeded always up to a dilution of 1:1000 and the species determination by the radial immunodiffusion test in agar gels succeeded in most cases op to a dilution of 1:1000. The detection limit of the anti-human globulin inhibition test was between the dilution steps 1:10 and 1:100 when non-titrated and undiluted anti-human globulin serum was used. Gc- and ABO-grouping were possible up to a dilution of 1:100 and were thus the most sensitive grouping systems. Phenotyping of the enzyme-systems and the Gm/Km-system usually required stains with considerably higher blood concentrations i.e. stains of undiluted blood.     

Federal Reimbursement for Mandates on State and Local Governments

One of the remedies sought by state and local officials for the growing burden of federal mandates is a mandate reimbursement law. A major purpose of mandate reimbursement is to deter Congress from imposing excessive costs on state and local governments by making it fully accountable for its actions. The paper begins by extending the economic theory of grants to mandates and reimbursed mandates. It goes on to assess the benefits and costs of mandate reimbursement, and to distinguish mandates that should be reimbursed, should a reimbursement program prove desirable, from those that should not. Then, using the economic theory of grants and mandates, the paper compares reimbursed mandates with two alternatives for accomplishing the same objective, compensating grants and procedural rules. It concludes that the latter are more promising than mandate reimbursement.     

NETWORK REGULATION: THE MANY FACES OF ACCESS

Telecommunications regulation has experienced a fundamentalshift from rate regulation to increased reliance on compelledaccess, perhaps best exemplified by the Telecommunications Actof 1996's imposition of no fewer than four new access requirements.Unfortunately, each access requirement is governed by a separateset of rules for determining both the scope and the price ofaccess. The resulting ad hoc regime has created difficult definitionalproblems and opportunities for regulatory arbitrage. In thisarticle we propose a system inspired by the discipline of mathematicsknown as graph theory that integrates all of the different formsof access into a single analytical framework. This system separatesdifferent access regimes into five categories: (1) retail access,(2) wholesale access, (3) interconnection access, (4) platformaccess, and (5) unbundled access. It also provides insightsinto how each type of access complicates the already difficultproblems of network configuration and management and introducesinefficient biases into decisions about network capacity anddesign. The approach we propose also provides insights intothe transaction cost implications of the different types ofaccess. Drawing on the Coasean theory of the firm, our approachexamines the tradeoffs between internal governance costs andthe external transaction costs of providing access to offera theory of network boundaries. This framework shows how accessregulation distorts networks' natural boundaries and providesa basis for evaluating whether private ordering through marketswould lead to more efficient network design.     

DOES ECONOMICS PROVIDE A RELIABLE GUIDE TO REGULATING COMMODITY BUNDLING BY FIRMS? A SURVEY OF THE ECONOMIC LITERATURE

This article surveys the voluminous economic literature on commoditybundling. While bundling has been widely studied, the vast majorityof the literature has focused on theoretical treatments of bundlingthat demonstrate a wide range of reasons why firms might engagein bundling. These papers generally contain restrictive assumptions,including assumptions regarding the existence of monopoly insome markets, and the nature of rivalry in others. The modelscontained in these papers also generally suppress the more obviousand ubiquitous reasons firms may use bundling. Moreover, thesemodels have not been subject to robustness checks, nor havetheir assumptions been tested empirically. This review of theeconomic literature generally confirms the US Solicitor General'sview in 3M v. LePage's regarding the underdeveloped state ofthe economics literature and its position that the US SupremeCourt should defer promulgation of antitrust standards for bundling.While the literature has demonstrated the possibility that bundlingcan generate anticompetitive harm, it does not provide a reliableway to gauge whether the potential for harm would outweigh anydemonstrable benefits from the practice. As a result, the widespreadapplication of the antitrust laws to bundling by firms can generatesignificant error costs by erroneously condemning or deterringefficient business practices. In the future, economists shouldseek to expand their understanding of both the anticompetitiveand procompetitive reasons firms engage in bundling. This willentail studying the reasons why bundling is adopted by firmswithout market power, relaxing the assumption of monopoly intheoretical models, and generating testable hypotheses and thedata to test them.     

Proficiency testing (external quality assessment) of drug detection in oral fluid

Eighteen external quality assessment (proficiency testing) samples were prepared from client specimens collected with the Intercept^® oral fluid collection device and by spiking drug-free oral fluid. Samples were circulated in pairs at quarterly intervals to 13 UK and USA based laboratories for analysis by a panel of OraSure micro-plate Intercept^® enzyme immunoassay kits and hyphenated mass spectrophotometric techniques. During the survey, there was a single case of non-specificity in a false report for methadone. The major errors were of lack of sensitivity relative to the concentration thresholds specified for the immunoassays. The sensitivity for overall ‘present’/‘not found’ reports calculated as true positives/(true positives + false negatives) were for the amfetamine specific assay 50%, methyl-amfetamines 93%, barbiturates 64%, cannabinoids 73%, cocaine and metabolites 100%, benzodiazepines 69%, methadone 95%, opiates 79% (opiates excluding oxycodone 93%), phencyclidine 93% and human gamma-globulin 97%. A small number of the sensitivity errors were attributable to errors in chromatographic confirmation techniques.