Is there an acceptable answer to rising medical malpractice premiums?

This article explores the key issues involved in the attempts at reform of the present medical malpractice system. Investigating the effects that federal tort reform legislation would have on physicians, patients, lawyers, and the medical malpractice insurers, Dr. Gunnar succinctly outlines the issues surrounding the present "crisis in healthcare" and explores the separate interests involved. The article examines the economic forces influencing the medical malpractice insurance industry, reviews previous tort reform, and predicts the future of federal tort reform legislation. Dr. Gunnar concludes by proposing alternatives for malpractice reform.     

Relationships between the deinstitutionalization of healthcare for patients with mental disorder, substance abuse, and isolated death

Isolated death (ID) (i.e., dying alone without anyone noticing for several days) has been suggested to be related to social isolation, mental disorder, and alcohol and/or drug abuse. A major transfer of patients with a mental disorder and/or alcohol and/or drug abuse from institutionalized care to treatment as outpatients has been enacted in Sweden during the past decade. On the basis of the assumption that such deinstitutionalization is likely to result in increased social isolation, our working hypothesis was that the incidence of ID among patients belonging to these categories has increased in Sweden. The present study involved all deaths subjected to a medicolegal examination in Stockholm County (with a population of approximately 1.9 million people) during the period 1992-2000. The pattern of ID (defined as cases involving a postmortem delay between death and discovery of at least 1 week), as well as the incidence of fatalities subjected to medicolegal examination with a record of mental disorder and/or alcohol and/or drug abuse was evaluated. Throughout this period, the proportion of the deceased with a record of a mental disorder was high among all the cases examined and higher still among the cases of ID, especially among those younger than 65 years of age. There was a rather limited increase in the incidence of ID and a much more pronounced increase in the number of former psychiatric patients whose deaths were subjected to medicolegal examination, but did not satisfy the criteria for ID. A record of alcohol and/or drug abuse was more common than a diagnosis of mental disorder among both the males and females who died at an age of less than 65, with a clear difference between the cases of ID and non-ID in the case of men. There was no significant increase in incidence over the course of this study. Thus, this study reveals a slight increase in the number of IDs and a more pronounced increase in the number of medicolegal examination of non-IDs of individuals with a record of a mental disorder.     

Radiologically determined DMF index variations for forensic age estimation of young adults

The eruption and mineralization of third molars are the main criteria for dental age estimation of living people involved in criminal proceedings. Since the development of third molars is usually completed by the age of 19 or 20 years, this feature cannot be used to ascertain whether a person has attained the forensically relevant age of 21 years. This study examined whether the DMFT index or the third molar DFT index could supply reliable information enabling conclusions to be drawn about whether a person has reached the age of 21. To this end, 650 conventional orthopantomograms of German subjects aged 18 to 30 years were evaluated. The DMF index variations considered were found to be unsuitable for determining whether a person is over 21 because they displayed a weak correlation with age and considerable individual scatter. A high indicative value can only be attributed to a third molar DFT index of 4, although this is rarely observed in the relevant age group. An X-ray examination of the medial clavicular epiphyseal cartilage is, therefore, strongly recommended when assessing whether a person has attained 21 years of age.     

Analysis of carbohydrate-deficient transferrin (CDT) in vitreous humour as a forensic tool for detection of alcohol misuse

Analysis of carbohydrate-deficient transferrin concentration in vitreous humour (VH-CDT) has recently been demonstrated to be useful for diagnosis of pre-mortal alcohol misuse, but more knowledge considering possible methodological problems is warranted. In a forensic sample we examined the stability of VH-CDT during laboratory handling as well as the possible affection of time-dependent changes of total transferrin concentrations in vitreous humour (VH-Transferrin) in the dead body on VH-CDT as indicator of alcohol misuse. By use of a commercial assay designed for serum analysis (CDTect) it was possible to measure VH-CDT with high precision, and detectable amounts were found in 20 of 21 alcoholics and in two of seven controls. The compound was demonstrated to be stable in vitreous humour during laboratory handling, since the results of the first analysis were well reproducible after 4 months storage of the specimens (rs=0.86, P=0.0002). Transferrin concentrations in vitreous humour (VH-Transferrin) correlated to the estimated time since the individual last time had been alive before the forensic examination (rs=0.57, P<0.005). However, in this small sample the discriminating property of VH-CDT as indicator of alcohol misuse was not decisively affected, whether or not the variables "VH-Transferrin" and "estimated time since the individual last time had been alive" were considered in a multivariate logistic regression analysis (minor change in the beta-coefficient from 0.57 to 0.52, P=0.086). We conclude that CDT is stable in vitreous humour during proper laboratory handling and that detection of VH-CDT is primarily a marker of alcohol misuse before death. However, the results of this study do not exclude that time-dependent changes of VH-Transferrin, possibly affecting VH-CDT, may occur in the dead body. VH-CDT analysis should thus, at present, be restricted to cases with rather short post-mortal time interval.     

Effect of hair care and hair cosmetics on the concentrations of fatty acid ethyl esters in hair as markers of chronically elevated alcohol consumption

Fatty acid ethyl esters (FAEE) can be used as alcohol markers in hair. It was investigated in this study whether this diagnostic method is disturbed by hair care and hair cosmetics. Traces of ethyl myristate, ethyl palmitate, ethyl oleate and ethyl stearate were detected in all of 49 frequently applied hair care products by headspace solid phase microextraction (HS-SPME) and gas chromatography-mass spectrometry (GC-MS). The highest concentration was 0.003% in a hair wax. From experiments with separated hair samples of alcoholics as well as from the evaluation of the FAEE concentrations and the data about hair care of 75 volunteers (alcoholics, social drinkers and teetotalers) follows that usual shampooing, permanent wave, dyeing, bleaching or shading are of minor importance as compared to the drinking amount and other individual features. However, false positive results were found after daily treatment with a hair lotion containing 62.5% ethanol, with a deodorant and with a hair spray. As an explanation, it is assumed that FAEE are formed in the sebum glands also after regular topical application of products with a higher ethanol content.     

The Benefit Equity Principle and Willingness to Pay for City Services

In 1991 and 1992, the City of Eugene, Oregon engaged in a citizen participation process to determine public support for a variety of spending and budget balancing alternatives. This process, called Eugene Decisions, employed an innovative combination of public forums, budget balancing exercises and representative surveys. Two of the surveys, which included questions about individual service use, are analyzed here in order to test whether the use of city services is related to willingness to pay taxes and fees. The concept of benefit equity is supported if service use is positively associated with willingness to pay.     

Should brands “nudge us for good”? Towards a critical assessment of neuro‐liberal corporate social responsibility

This article critically investigates the recent emergence of neuro‐liberal corporate social responsibility (CSR). Neuro‐liberal CSR is inspired by libertarian paternalism, a form of behavioural governance popularised by behavioural economist Richard Thaler and legal scholar Cass Sunstein in their bestseller Nudge (2008). Libertarian paternalism presumes humans to be “predictably irrational” due to hardwired cognitive biases and thus advocates the design of policy interventions that use human psychology for correcting these shortcomings in ways that benefit individuals and society. Although the use of “nudging” interventions has been critically scrutinised in the context of public policy, little attention has been paid to the adoption of libertarian paternalist principles in the corporate world. This paper uses Nudging for Good, an initiative by the European Brands Association (AIM), to illustrate how major corporations adopt and frame corporate nudging as a new and purportedly highly effective form of CSR. However, as this paper argues, neuro‐liberal CSR raises concerns regarding its effectiveness, transparency, and its individualisation and de‐politicisation of social ills.     

Sudden unexpected natural death in young persons

In a series of 1920 medico-legal autopsies, 78 cases fulfilled the criteria of sudden unexpected natural death in the age group 2-30 years. In 39 (50%) of these cases a health hazardous condition was known. A large group included epileptics, alcoholics, obstetric/gynecologic conditions, and drug addicts. For prophylactic reasons the medical intervention should focus on earlier detection, if possible, of acute myocarditis, better instruction to epileptics as to thorough medication and information of parents. Physicians should be reminded about the danger of inflammatory processes in the upper respiratory tract, especially acute tracheobronchitis and acute epiglottitis.