Beginning with the seminal work by Williams and Nagel, moral philosophers have used auto accident hypotheticals to illustrate the phenomenon of moral luck. Moral luck is present in the hypotheticals because two equally careless drivers are assessed differently because only one of them caused an accident. This Article considers whether these philosophical discussions might contribute to the public policy debate over compensation for auto accidents. Using liability and insurance practices in the United States as an illustrative example, the (...) Article explains that auto liability insurance substantially mitigates moral luck and argues that, as a result, the moral luck literature is unlikely to make a significant contribution to this public policy debate. The debate would benefit more from philosophical analysis of victims’ luck, which is not as substantially mitigated by liability insurance. (shrink)

Tort law and liability insurance have a complex interaction in which each shapes the evolution and effects of the other. This interaction and its many forms and facets in different international contexts must be comprehended to understand fully the ethical responsibilities of liability insurers. This essay builds on previous scholarship on the tort law–liability insurance interaction through a series of observations from the perspective of a global reinsurer. It seeks in part to extend previous analyses (...) of this interaction by also considering issues in the developing world. It seeks to make some normative questions and stances explicit concerning this interaction, as well as to identify some empirical questions that still need to be answered. The responsibility of liability insurers includes ethically shaping the responsibility of others in interaction with tort law in countless diverse situations. (shrink)

As an important corporate governance mechanism, directors’ and officers’ liability insurance is theoretically associated with corporate financialization because it directly affects incentive constraints and risk preference of enterprise managers. However, whether there is a causal relationship in fact has not been sufficiently empirically investigated. Using a sample of Chinese non-financial listed companies in Shanghai and Shenzhen A-shares from 2008 to 2020, this paper empirically analyzes how corporate subscription to directors’ and officers’ liability insurance affects corporate financialization (...) and examines the mediating role played by risk-taking, financing constraints, and audit quality. The study finds that corporate subscription to D&O insurance increases corporate financialization. In terms of the influential mechanism, subscription to D&O insurance promotes financialization by increasing risk-taking, alleviating financing constraints, and improving audit quality. In addition, the results in the heterogeneity analysis suggest that the promotion of financialization by subscribing to D&O insurance is more significant in state-owned enterprises, growth and decline stage enterprises, and non-dual-employment enterprises. (shrink)

The deposit insurance makes the value of deposits independent from the behavior of other depositors or from the value of bank assets. Its existence induces a moral hazard which might threaten the stability of the banking system. The efficiency of the DI depends on the control of moral hazard, which means the agents’ responsibilisation, depositors included. There is a conflict between the DI principles and the present propositions improving this mechanism.The possible solutions in order to solve this paradox are (...) the restriction of the insurance coverage only for the demand deposits and the implementation of the double liability for the bank shareholders.The demand deposits insurance eliminates the incentive to bank runs caused by the fear of lack of liquidity, whereas the term deposits are exposed to losses which reduce the moral hazard induced by the demand deposit insurance.The double liability forces the shareholders of the defaulting banks to make supplementary payments limited to the nominal value of the owned shares. This combines the advantages of the limited liability and the unlimited liability.The efficiency of both propositions implies the enforcement of a closure rule of the banks whose net worth is close to zero.La garantie des dépôts rend la valeur des dépôts indépendante du comportement des autres déposa- nts ou de la valeur des actifs bancaires. Son instauration induit un aléa moral qui peut menacer la stabilité du système bancaire. L’efficacité de ce mécanisme dépend de la maîtrise de l’aléa moral. Cela suppose, entre autres, la responsabilisation des agents, y compris des déposants. Par conséquent, il existe un conflit entre le principe de la garantie des dépôts et les propositions courantes d’amélioration de ce dispositif.Les solutions envisagées dans cet article pour résoudre ce paradoxe sont la limitation de la garantie aux seuls dépôts à vue et l’instauration de la double responsabilité pour les actionnaires des banques.La garantie des dépôts à vue élimine l’incitation à la ruée due à la crainte de manque de liquidité, tandis que les dépôts à terme sont assortis d’une clause permettant à la banque de refuser tout retrait anticipé. Les titulaires des dépôts à terme s’exposent à des pertes, ce qui réduit l’aléa moral induit par la garantie des dépôts à vue.La double responsabilité oblige les actionnaires des banques défaillantes à effectuer des versements supplémentaires dans la limite de la valeur nominale des actions détenues. Cela réunit les avantages de la responsabilité limitée et de la responsabilité illimitée.L’efficacité des deux propositions suppose l’application d’une règle de fermeture des banques dont l’actif net avoisine zéro. (shrink)

Environmental politics needs more than piecemeal institutional efforts and more than calls for a set of 'new' values. It needs a realistic, comprehensive, and effective policy programme. Such a programme can be derived from a conjunction of Hardin's work on the 'tragedy of the commons' and Beck's analysis of the 'risk society', and involves exploiting the possibilities for the internalisation of risk provided by the insurance and reinsurance industries. Such exploitation requires tailored changes to the politico-legal environment, enforcing strict (...) liability for the production of risk, permitting any and all agents adversely effected by such negative externalities to initiate action for damages. The aim is not to clog up social and economic life with endless legal disputation, but through such a threat to ensure that environmentally significant investment and productive strategies are actively constrained by actuarially calculated strategies for risk internalisation. (shrink)

The liability regime for officers and directors of German companies combines strict and lenient elements. Officers and directors are liable for simple negligence, they bear the burden of proof for establishing diligent conduct, and they are liable for unlimited damages. These elements are worrisome for the reason that managers are confronted with the full downside risk of the enterprise even though they do not internalize the benefits of the corporate venture. This overly strict regime is balanced by other features (...) of the regime, namely comprehensive insurance and systematic under-enforcement. Even though the authority to enforce claims against the management is divided between three different actors - the supervisory board, the shareholders assembly, and individual shareholders - enforcement has remained the exception. Furthermore, under the current system of Directors’ and Officers’ liability insurance, board members do not feel the bite of liability as they are protected by an insurance cover that is contracted and paid for by the corporation. Thus, the current German system may combine the worst of two worlds, i.e., the threat of personal liability for excessively high amounts of damages in exceptional cases, and the practical irrelevance of the liability regime in run-of-the-mill cases. The present Article analyzes the shortcomings of the present regime and submits proposals for reform. (shrink)

Based on the findings of several research studies of professionals in both the property-liability insurance industry and the life insurance industry, the paper makes and supports several important points. First, ethical challenges in the insurance industry involve not only a series of ethical dilemmas frequently faced by those working in the business, but also a variety of factors that hinder those working in the industry as they seek to resolve the ethical dilemmas encountered in the course (...) of their work. Both of these two components of ethical challenges must be understood by those in the financial services industry who will deal with insurance operations in the future. Second, whereas the life insurance business and the property-liability insurance business have traditionally been viewed as being quite different from one another and still are in terms of operations and regulation, the research findings show that they are no longer very different in terms of the key ethical challenges faced by those working in the two segments of the industry. The paper shows how during the past decade the ethical challenges in the property-liability insurance industry have become quite similar to those in the more troubled life insurance industry. (shrink)

This paper explores, first, the common law principles of personal injury litigation explored through court decisions relating to sports injuries in (primarily) England and Wales and, second, the statutory schemes relating to concussion liability and young players in the United States. It explores the difficulties of using those strategies as a means of establishing liability for injuries arising from sports-related concussion (SRC) and explains why they are of such limited utility. While proposed class actions over historically acquired injuries (...) or individual litigation over recent catastrophic injury may have some merit, and while future amendments to the US laws might remove some of their inherent flaws, the difficulties in establishing liability for personal injury will always be exacerbated by the specific characteristics of SRC and the legal, factual and evidential issues that arise. For those reasons, the paper considers the potential benefits of other means of concussion prevention and mitigation, including no-fault compensation and mandatory insurance, the more widespread use of effective, nuanced concussion protocols, and inter-disciplinary research that engages with doctrinal legal research. (shrink)

Clinical Ethics Consultation (CEC) has grown significantly in the last decade, and efforts are being made to professionalize the practice. The American Society for Bioethics and Humanities (ASBH) has been instrumental in this process, having published the _Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants_ and founded and endorsed the creation of the _Healthcare Ethics Consultant Certified (HCEC) Certification Commission._ The ASBH also published “core competencies” for healthcare ethics consultants and has delineated a clear identity and role of (...) such consultants distinct from that other healthcare professionals. In addition, more enter the field armed with advanced degrees (MA and PhD) or certification in clinical ethics consultation. While some have questioned the trend toward professionalization, the momentum is clearly in its favor. This paper explores three questions: Does the professionalization of healthcare ethics consultation expose those engaged in the field to the types of liability claims faced by professionals in other fields? What specific liabilities could affect a healthcare ethics consultant? And finally, what should healthcare ethics consultants do to protect themselves against liability claims? We conclude that while the risk of liability remains low, those engaged in the field should accept that risk just as part of their status as professionals and, like those in allied professions, seek appropriate protection in the form of liability insurance. (shrink)

Theoretical arguments regarding the effect of corporate social responsibility (CSR) on firm liability risk are abundant; however, empirical evidence about this relationship is scarce. We investigate the relationship between CSR and the personal liability risk of a firm’s directors and officers. We argue that companies with better CSR performance represent a better underwriting risk for directors’ and officers’ (D&O) insurance providers and, therefore, have a lower cost of insurance. Our results show that firms with better CSR (...) performance are more likely to purchase D&O insurance and have a lower premium-to-coverage ratio, known as the insurance rate-on-line. We also show that this risk-reduction effect is stronger for firms that operate in a high-risk environment and have higher sales growth. These results provide evidence that CSR can be used as a risk management tool to mitigate liability risk and suggest which firms benefit most from this effect. (shrink)

In contrast to theoretical discussions about potential professional liability of clinical ethicists, this report gives the results of empirical data gathered in a national survey of clinical medical ethicists. The report assesses the types of activities of clinical ethicists, the extent and types of their professional liability coverage, and the influence that concerns about legal liability has on how they function as clinical ethicists. In addition demographic data on age, sex, educational background, etc. are reported. The results (...) show that while nearly one third (28.9%) of the ethicists regularly make recommendations about patient care, only 10.8% of them regularly make entries in the medical record; only approximately half (53.0%) of them are covered by professional liability (malpractice) insurance; and the vast majority (84.3%) of them say that concerns about legal liability do not influence the way they function as clinical ethicists. (shrink)

Contemporary discussions of the relationship between negligence liability and the provision of services by both public and private organizations frequently suggest the emergence of a ‘compensation culture’. Despite empirical evidence that compensation culture claims are somewhat inflated, an anxiety persists that risks of tortious liability may still undermine the implementation of public policy. Concerns about the potential negative effects of liability on public administration frame the problem in various ways. First, there is an anxiety that public authorities (...) may overreact to liability risks by becoming excessively risk averse. Secondly, there is a fear that compensation claiming will divert financial resources away from service delivery and towards the payment of insurance premiums and compensation awards. Thirdly, there is the fear that insurance companies will, as ‘risk bullies’, curtail public service activities. And, finally, there is the suggestion that risk management, including legal risk management, is becoming the dominant mode of government decision-making to the exclusion of professional judgement. This article addresses these concerns through a set of empirical case studies about the management of liability risks associated with road maintenance services. Although our findings suggest that public authorities respond to liability risks in a variety of ways, we found only limited evidence of the above concerns. In general terms, it was a case of public authorities being risk aware and responsive as opposed to risk averse. (shrink)

To a large extent liability for ICT perils is still a grey area, even though an increasing number of information security researchers adopt economic approaches to highlight market mechanisms and externalities. That is why this article focuses on the need for increased awareness of externalities and liability among ICT professionals and their customers. This is critical to achieve in order to promote appropriate ICT technologies and services with comprehensible privacy and security protection. What is needed is a better (...) understanding of the consequences of externalities from ICT perils. This would benefit customers and increase trust in ICT products and services which in turn may even increase suppliers' profit margin; customers would be prepared to buy more services and products if contracts and service level agreements would accept more liability. Moreover, suppliers could sell guaranties and insurances on top of their products and services. The result would be a win-win situation and would benefit society at large. (shrink)

Abstract:This paper examines economic arguments employers sometimes use to justify restricting or excluding from employment those workers who are likely to incur high costs in health care insurance. We argue that, although profit-making is a legitimate goal for businesses, hiring practices based on non-job-related criteria violate principles of self determination, autonomy, discrimination, justice, and privacy. We conclude that hiring practices based on liability-driven ethics are not morally justified, but that as long as health care insurance and employment (...) are linked, businesses will continue to have an incentive to use liability-driven arguments. (shrink)

This paper deals with the claims of industrial operators and their insurers that expanding liability is being experienced in many legal systems in Europe and will lead to the uninsurability of certain risks. In this paper we address some aspects of this insurability problem by trying to identify precisely what might make an expanding liability risk uninsurable. Then we examine whether there are remedies for expanding liability that might result in certain risks remaining insurable. In that respect (...) we shall consider alternative compensation systems, financial caps, differentiation of risks, and the application of insurance policies over time, more specifically related to so-called ‘long-tail’ risks. Although each of these aspects might merit a separate paper, we prefer to discuss them in an integrated way by providing a balanced answer to current questions concerning the insurability of modem industrial hazards. (shrink)

In Campbell Soup Co. v. Allstate Insurance Co. ), the United States District Court for the Western District of Michigan, Southern Division, held that a health plan's coordination of benefits clause, covered under the Employee Retirement Income Security Act, does not preempt a similar no-fault automobile insurance clause in the absence of irreconcilable conflict. The court found that ERISA's policy of shielding plans from unanticipated claims could only be furthered when the plan had expressly disavowed such claims. Because (...) the ERISA plan in this case did not specifically subordinate itself to the no-fault policy, the district court found that the no-fault COB clause controlled. However, to escape this ruling, ERISA plans need only redraft their COB clauses specifically to disclaim liability in case of conflict with provisions of no-fault insurance policies. This caveat substantially limits the scope of the court's ruling. (shrink)

To achieve more cost-effective deterrence of unreasonable risktaking through civil liability, I propose and demonstrate previously unrecognized benefits of using simple random sampling to resolve multiple claims against a business or government defendant in the aggregate. I show that counter to intuition and prevailing assumptions and practice, simple sampling will enhance, not compromise, deterrent results regardless of the number of claims and the variety and significance of differences among them. Indeed, it can be used to resolve multiple claims that (...) bear no resemblance to one another except for targeting the same defendant. The proposal can thus be employed to increase the efficiency of resolving relatively similar claims in class and consolidated actions and, by extending the application of such collectivizing processes, lower the cost of resolving all other claims that would be adjudicated as separate actions. I close by sketching a design for a reformed civil liability system that fully integrates and exploits the law enforcement benefits of sampling to better achieve the primary social objectives of accident risk deterrence and insurance. (shrink)

Three major trends in American health policy are intersecting in a fascinating way. First, managed care has grown to become the most dominant form of health-care delivery, leading to reductions in health-care costs as insurers are able to influence health-care providers with financial incentives. Second, the present growth of managed care has slowed, almost to a standstill, largely on account of consumers questioning what effects these financial incentives are having on the care of patients — questioning that has been expressed (...) in particular through lawsuits against managed care companies.Third, we are experiencing a renewed interest in the existence of medical error and how it may be reduced as a result of the Institute of Medicine’s report, To Err Is Human: Building a Safer Health System. The most important aspect of this renaissance in error reduction has been its emphasis on health care as a system that can be made better through system-oriented change. The most frustrating aspect is that the IOM did not endorse change in malpractice liability, which consistently puts the impetus for reducing medical error on the individual provider rather than the system as a whole. (shrink)

Is the negligence standard in accident law acceptable to the egalitarian? The egalitarian - the egalitarian who would compensate only losses for which the actor was not responsible - cannot accept either a system of strict liability for all accidents or a system of social insurance for all accidents. A system of tort law acceptable to the responsibility - egalitarian must be a system based on negligence. But what will negligence mean? A negligence system in which the notion (...) of reasonableness is based on efficiency, I argue, is a system that redistributes wealth from the less well off to those better off. I consider alternative notions of reasonableness, ending up with a principle of proportional responsibility and distinguishing between commercial and non-commercial cases. (shrink)

The general consensus is that reform of medical malpractice law should be part of the health care system's overhaul. Medical malpractice litigation results in the expenditure of tens of billions annually, largely paid out of health care insurance funds and mostly paid to defendants' and plaintiffs' lawyers. By all accounts, this tort law regime ill serves the basic deterrence and compensation goals of civil liability. The causes and magnitude of these failings are disputed, and many typical reform proposals (...) sidestep the basic problems and may do more harm than good. In contrast, we advance a straightforward way to improve both deterrence and compensation. Essentially, the proposal is to remove current legal limitations on the scope of insurance subrogation that bar private and public health care insurers from “buying” the whole of their insureds' potential medical malpractice claims in exchange for lower premiums and taxes and expanded insurance coverage. Our proposal’s benefits accrue regardless of the cause and magnitude of the failings of malpractice law or the further reforms that might be adopted. (shrink)

In this short paper, I shall answer the title’s question first in the context of criminal law and then in the context of tort law. In that latter section, I shall also mention in passing contractual and other forms of civil liability that are strict, although they will not be my principal focus. My conclusions will be that strict liability is never proper as the basis for retributive punishment; that it is a very crude device for achieving deterrence (...) through nonretributive penalties; and that with respect to tort liability, it is best justified as a means of defining insurance categories. (shrink)

With the great increase in litigation, insurance costs, and consumer prices, both managers and businesses should take a proactive position in avoiding liability. Legal liability may attach when a duty has been breached; many actions falling into this category are also considered unethical. Since much of business liability is caused by a breach of a duty by a business to either an individual, another business, or to society, this article asserts that the practice of liability (...) prevention is a practical business application of ethics. In today's highly litigious environment, it is appropriate for the concept of general liability prevention to be included in corporate codes of ethics. (shrink)

It is often assumed that science provides the most accurate knowledge about nature. This view not only collapses distinctions between different forms of knowing but also results in a paradox whereby understanding what it means to exist in the world is dictated by practioners of science. In this essay I argue for the relevance of an existential conception of nature via the philosophy of Martin Heidegger, and how his notions of thrownness and phusis enable us to recognize a certain ethical (...) bond to nature. I conclude with a critical analysis of liability insurance and actuarial science to demonstrate my points. (shrink)

Relevance of the article is determined that the effective functioning of the reinsurance market greatly depends on the development of its infrastructure because it creates opportunities for implementation of reinsurance services, mediates, accelerates and facilitates placement and execution of reinsurance contracts. Given the state of the domestic insurance market mediation necessary means to enhance its development and integration into the global reinsurance market. The article is a study of measures to enhance the role of mediation in the insurance (...) market of Ukraine. The article provided a critical assessment of the legal status of insurance mediation in Ukraine. Factors that determine its role in the insurance market of Ukraine. Established quantitative and cost indicators of intermediation of brokers in insurance and reinsurance, given their logical explanation. Suggestions to create appropriate conditions for the development of mediation in the insurance and reinsurance markets in Ukraine. Mediation plays an important role in the development of the insurance market of Ukraine since: helping the participants to choose the most optimal proposal for the establishment of additional guarantees of the insurance liabilities; strengthening partnerships and trust between the reinsurer and the reinsurer; improves the quality and dynamics of sales reinsurance services; supports a healthy competitive environment in the reinsurance market. It was established that the quantitative and cost indicators of intermediation of brokers in insurance and / or reinsurance in Ukraine do not match. By number of deals leadership position with insurers-residents, the cost - non-resident reinsurers. The most attractive segment for mediation turned provision of agreements with non-resident reinsurers for property insurance. To create the appropriate conditions for the development of mediation in the insurance and reinsurance markets of Ukraine should: increase transparency of brokers to introduce their professional liability insurance and the formation of guarantee funds. (shrink)

Many of the reforms being required or recommended to ensure that for-profit companies achieve greater transparency and more effective governance are similarly being promoted for adoption by nonprofit health care organizations. The demands are coming from a variety of sources - government officials, donors, business partners, companies that provide directors and officers (D&O) liability insurance, the media, and directors themselves. To meet these demands, nonprofit health care boards and executives need to assess whether they have the right number, (...) mix, and caliber of board members, and to modify their recruitment and/or retention strategies where they don't. -/- The following discussion is another in an ongoing Inquiry series called "Dialogue," a collaboration with the Alliance for Advancing Nonprofit Health Care to provide a variety of voices on current, major issues in the nonprofit health care sector. (shrink)

Whenever health care reform is debated, the state of the medical professional liability system in the United States re-emerges as an issue of importance. What exactly is broken with the MPL system and what the implications are is a point of contention among different stakeholder groups. Recent data demonstrate that medical liability premiums have been improving in recent years and the majority of premiums remained flat in 2010. General agreement still exists, however, that medical professional liability (...) class='Hi'>insurance premiums have become unaffordable for many physicians, and coverage has become less available, especially for certain medical specialties and in specific areas of the country.Multiple factors go into the determination of medical professional liability insurance premiums including return on investments, reinsurance costs, claims frequency, average amount paid out on malpractice claims, defense expenses, and administrative costs such as underwriting expense. (shrink)

US Senate is considering legislation designed to immunize small businesses from lawsuits brought by customers alleging to have been infected with COVID-19 while on the premises. The legislation seeks to subsidize reopening small businesses by reducing their vulnerability to liability. I argue that the legislation produces worse public health outcomes than existing liability regimes, obliterates claims to redress supported by corrective justice, and unfairly burdens victims by forcing them to become de facto insurers of their injurers. In the (...) US, where health insurance is inextricably linked with employment, and during the pandemic with the consequent loss of employment, the legislation is cruel in addition to being ineffective, unjust, unfair and inappropriate. Since I first uploaded this manuscript to Philpapers, Senate Republicans have in fact introduced specific legislation that is marginally different than the one I discuss in the manuscript. Instead of offering blanket immunity, the current Republican proposal offers a series of substantial barriers both to filing lawsuits and to securing a successful verdict at trial. I discuss these as an addendum to the main paper. In short, though the changes impact some features of my argument, they do not alter any of the conclusions. The current proposal produces worse public health outcomes than would existing tort regime; it leaves the vast majority of those with legitimate claims to repair in corrective justice without a remedy, when providing the opportunity to secure a remedy for wrongs is in large measure, the essential nature of tort liability. Worse still, it continues to render victims the de facto insurers of those who have wronged them; it imposes the burden of spreading risks on victims who are considerably less efficient risk spreaders than are businesses and hospitals; it constitutes an inappropriate response to the challenge it seeks to address, i.e. subsidizing various sectors of the economy by reducing their overall costs; and given the fact that in the US health insurance is too closely linked to employment, it shifts the costs of the pandemic to those who are most at risk of losing their health insurance, rendering the proposal cruel in addition to inefficient, unjust, unfair and inappropriate. For those interested, I am considering a short op-ed piece assessing the particular legislative proposal. If I follow through I will let the readership know where that can be found. (shrink)

The legal environment -- Regulation of nursing practice -- Nurses in legal actions -- Standards of care -- Defenses to negligence or malpractice -- Prevention of malpractice -- Nurses as witnesses -- Professional liability insurance -- Accepting or refusing an assignment/patient abandonment -- Delegation to unlicensed assistive personnel -- Patients' rights and responsibilities -- Confidential communication -- Competency and guardianship -- Informed consent -- Refusal of treatment -- Pain control -- Patient teaching and health counseling -- Medication administration (...) -- Clients with AIDS and HIV testing -- Abusive situations -- Reproductive services -- Restraints -- Emergency psychiatric admissions -- Organ and tissue donation and transplantation -- Discharge against medical advice -- The medical record and documentation standards -- Electronic health information and communications -- Interdependent nursing functions: verbal orders and telenursing -- Event reporting and compliance -- Quality and safety in nursing practice -- Forensic issues -- Employer and employee rights -- Contracts -- Corporate liability -- Employment contracts and unionization -- Employment status liability -- Staffing issues and floating -- Americans with Disabilities Act -- Employees with AIDS/HIV infection and exposure to bloodborne pathogens -- Impaired nurses -- Sexual harassment in the workplace -- Violence in the workplace -- Intentional torts -- Environmental health and safety -- Ethical decision making -- Professional boundaries and patient relationships -- Moral courage and patient advocacy -- Social media and online professionalism -- Reporting illegal, unethical, or unsafe conduct -- Maternal versus fetal rights -- Futility of care -- Advance directives and end-of-life decisions -- Assisted suicide. (shrink)

The United States is in its fifth year of what is now widely referred to as “the new medical malpractice crisis.” Although some professional liability insurers have begun to report improvements in their overall financial margins, there are few signs that the trend toward higher costs is reversing itself - particularly for doctors and hospitals. In 2003-2004, the presidential election and tort reform proposals in Congress brought heightened public attention to the need for some type of policy intervention to (...) ease the effects of the crisis.The darling of tort reformers at both the federal and state levels has been legislation to limit, or “cap,” damages awarded to plaintiffs in malpractice cases. Health care provider groups, liability insurers, and the Bush Administration have all seized on the example of California's MICRA law, which since 1975 has capped noneconomic damages in malpractice cases at a flat $250,000, as the path to financial recovery. (shrink)

Merck suppressed data on harmful effects of its drug Vioxx, and Guidant suppressed data on electrical flaws in one of its heart-defibrillator models. Both cases reveal how financial conflicts of interest can skew biomedical research. Such conflicts also occur in electric-utility-related research. Attempting to show that increased atomic energy can help address climate change, some industry advocates claim nuclear power is an inexpensive way to generate low-carbon electricity. Surveying 30 recent nuclear analyses, this paper shows that industry-funded studies appear to (...) fall into conflicts of interest and to illegitimately trim cost data in several main ways. They exclude costs of full-liability insurance, underestimate interest rates and construction times by using overnight costs, and overestimate load factors and reactor lifetimes. If these trimmed costs are included, nuclear-generated electricity can be shown roughly 6 times more expensive than most studies claim. After answering four objections, the paper concludes that, although there may be reasons to use reactors to address climate change, economics does not appear to be one of them. (shrink)

It is sometimes argued that tort law is, or ought to be understood as, a system of personal responsibility and corrective justice. Moreover, it is often assumed that these notions are identical, or at least compatible. In fact, however, personal responsibility and corrective justice are very different concepts and they produce very different pictures of the law. The article demonstrates this by comparing the way in which personal responsibility and corrective justice deal with three important problems: the presence of non-subjective (...) standards in the law, the place of liability insurance, and the relationship between law and politics. (shrink)

It could be argued that tort law is failing, and arguably an example of this failure is the recent public liability and insurance (‘PL&I’) crisis. A number of solutions have been proposed, but ultimately the chosen solution should address whatever we take to be the cause of this failure. On one account, the PL&I crisis is a result of an unwarranted expansion of the scope of tort law. Proponents of this position sometimes argue that the duty of care (...) owed by defendants to plaintiffs has expanded beyond reasonable levels, such that parties who were not really responsible for another’s misfortune are successfully sued, while those who really were to blame get away without taking any responsibility. However people should take responsibility for their actions, and the only likely consequence of allowing them to shirk it is that they and others will be less likely to exercise due care in the future, since the deterrents of liability and of no compensation for accidentally self-imposed losses will not be there. Others also argue that this expansion is not warranted because it is inappropriately fueled by ‘deep pocket’ considerations rather than by considerations of fault. They argue that the presence of liability insurance sways the judiciary to award damages against defendants since they know that insurers, and not the defendant personally, will pay for it in the end anyway. But although it may seem that no real person has to bear these burdens when they are imposed onto insurers, in reality all of society bears them collectively when insurers are forced to hike their premiums to cover these increasing damages payments. In any case, it seems unfair to force insurers to cover these costs simply because they can afford to do so. If such an expansion is indeed the cause of the PL&I crisis, then a contraction of the scope of tort liability, and a pious return to the fault principle, might remedy the situation. However it could also be argued that inadequate deterrence is the cause of this crisis. On this account the problem would lie not with the tort system’s continued unwarranted expansion, but in the fact that defendants really have been too careless. If prospective injurers were appropriately deterred from engaging in unnecessarily risky activities, then fewer accidents would ever occur in the first place, and this would reduce the need for litigation at its very source. If we take this to be the cause of tort law’s failure then our solution should aim to improve deterrence. Glen Robinson has argued that improved deterrence could be achieved if plaintiffs were allowed to sue defendants for wrongful exposure to ongoing risks of future harm, even in the absence of currently materialized losses. He argues that at least in toxic injury type cases the tortious creation of risk [should be seen as] an appropriate basis of liability, with damages being assessed according to the value of the risk, as an alternative to forcing risk victims to abide the outcome of the event and seek damages only if and when harm materializes. In a sense, Robinson wishes to treat newly-acquired wrongful risks as de-facto wrongful losses, and these are what would be compensated in liability for risk creation (‘LFRC’) cases. Robinson argues that if the extent of damages were fixed to the extent of risk exposure, all detected unreasonable risk creators would be forced to bear the costs of their activities, rather than only those who could be found responsible for another’s injuries ‘on the balance of probabilities’. The incidence of accidents should decrease as a result of improved deterrence, reduce the ‘suing fest’, and so resolve the PL&I crisis. So whilst the first solution involves contracting the scope of tort liability, Robinson’s solution involves an expansion of its scope. However Robinson acknowledges that LFRC seems prima facie incompatible with current tort principles which in the least require the presence of plaintiff losses, defendant fault, and causation to be established before making defendants liable for plaintiffs’ compensation. Since losses would be absent in LFRC cases by definition, the first evidentiary requirement would always be frustrated, and in its absence proof of defendant fault and causation would also seem scant. If such an expansion of tort liability were not supported by current tort principles then it would be no better than proposals to switch accident law across to no-fault, since both solutions would require comprehensive legal reform. However Robinson argues that the above three evidentiary requirements could be met in LFRC cases to the same extent that they are met in other currently accepted cases, and hence that his solution would therefore be preferable to no-fault solutions as it would only require incremental but not comprehensive legal reform. Although I believe that actual losses should be present before allowing plaintiffs to seek compensation, I will not present a positive argument for this conclusion. My aim in this paper is not to debate the relative merits of Robinson’s solution as compared to no-fault solutions, nor to determine which account of the cause of the PL&I crisis is closer to the truth, but rather to find out whether Robinson’s solution would indeed require less radical legal reform than, for example, proposed no-fault solutions. I will argue that Robinson fails to show that current tort principles would support his proposed solution, and hence that his solution is at best on an even footing with no-fault solutions since both would require comprehensive legal reform. (shrink)

Medical indemnity is not usually the stuff of high political and social drama in Australia. When the biggest medical defense organization went into voluntary liquidation in 2002, this all changed. Newspapers carried stories on an almost daily basis about the actual or possible negative impact of the “crisis” on doctors, hospitals, and communities. Doctors became increasingly vocal in their criticisms and expansive in their claims. Their political organization, the Australian Medical Association, lobbied powerfully and successfully for government intervention to address (...) the problem of dramatically escalating premiums for some doctors. This, combined with a broader public relations campaign about public liability insurance, resulted in significant changes in the law at both the federal and state level - not just in the area of medical negligence but in relation to most personal injury litigation.The genesis of and reasons for current medical indemnity problems in Australia have been the subject of much speculation and little rigorous analysis. (shrink)

The main indicators of assistance activity in the insurance market in Ukraine have been analyzed. Beneficial and negative trends of its development have been shown. The dynamics of the insurers' liquidation expenses structure and the payment of services expenses of the assistance establishments have been highlighted. Their structure has been shown due to the types of voluntary and compulsory insurance. The main problems hindering the effective development of the assistance services market have been characterized and the prospects of (...) its development have been offered. The aim of the research is to carry out comprehensive analysis of the current market of assistance services, to identify the main problems of their implementation and to point out the prospects of insurance market development. The dynamics of insurance bonuses and benefits including insurance compensation and services and the insurers' operating expenses concerning the payment of services of the assistance establishments has been analyzed on the basis of a sample survey of the main indicators of insurance market development due to the statistic data of National Committee of Financial Services. It has been revealed that majority of the insurance services provide settlement of insurance claims by offering assistance service. Alongside increasing of the share of insurance payment due to the contract providing the insurance service, allows the majority of insurance claims to be settled due to the payment of insurance compensation. Expenses on assistance services were the highest and the court expenses were the lowest in the structure of the insurer's liquidation expenses during 2011-2014. Expenses on services of the non-residential assistance establishments are low but they are increasing. It shows that emergency assistance to our citizens in the country and outside is being increased. Structure of assistance services in the voluntary and compulsory insurance market has been analyzed; main trends of assistance activity development according to the separate insurance services have been highlighted. In particular it was found out that the greatest amount of assistance services were provided due to the voluntary medical insurance, medical costs insurance, land transport insurance and compulsory insurance of civil liability of the owners of vehicles. On the basis of conducted analysis, we can draw a conclusion about the low level of assistance services market development. It is affected by negative trends of economic and political crisis, low solvency of insurers and the quality of insurance services, a lack of guaranties to provide emergency assistance in time, imperfect state regulation of assistance services provision, and a low level of institutional support. We offer to intensify the interaction between the insurers and assistance companies while providing insurance services including additional ones, insurance compensation, and settlement of insurance claims by ensuring emergency assistance in monetary and natural-material form. This will promote the increasing of quality of the insurance protection. (shrink)

SummaryI contend on both theoretical and historical grounds that quantitative risk assessment is relevant for policy determination only as a cost estimate. In particular, it provides a method for estimating the costs of a hypothetical insurance policy against the potential liabilities associated with a given course of action. It is not relevant to the question of rational choice under risk.RésuméJe montre, en partant d'arguments aussi bien théoriques qu'historiques, que le calcul quanti‐tatif des risques n'aide à la détermination d'une politique (...) à suivre qu'en tant qu'estimation des coûts. En particulier, il fournit une méthode pour estimer les primes d'une police hypothétique d'assurance contre les responsabilites potentielles associées à une suite donnée d'actions. 11 ne permet pas un choix rationnel dans des situations comportant des risques.ZusammenfassungIch argumentiere, sowohl aus theoretischen als auch aus historischen Gründen, dass eine quantitative Risikoberechnung für die Wahl einer Handlungsweise nur als Kostenschätzung relevant ist. Namentlich bietet sie eine Methode, um die Prämie einer Versicherungspolice gegen pot‐entielle Haftbarkeit, welche mit den Vorgängen eines Aktionsverlaufs verbunden ist, zu bestim‐men. Bei der Frage einer rationalen Wahl in einer Risikosituation ist sie nicht relevant. (shrink)

The law applicable to genomics in the United States is currently in transition and under debate. The rapid evolution of the science, burgeoning clinical research, and growing clinical application pose serious challenges for federal and state law. Although there has been some empirical work in this area, this is the first paper to survey and interview key scientific and legal stakeholders in the field of genomics to help ground identification of the most important legal problems that must be solved to (...) successfully integrate genomics into clinical care. The respondents in this study identified a wide range of interconnected issues, focusing specifically on the need for clear guidelines about how to use these data, fear of liability for those who use these data, and the need to protect patients from use of this information particularly by insurers, while endorsing data sharing. Developing legal strategies to support appropriate use of genomics now and in the future clearly will require making trade-offs, taking into account the full complexity of this legal ecosystem. (shrink)

A concise but informative overview of AI ethics and policy. -/- Artificial intelligence, or AI for short, has generated a staggering amount of hype in the past several years. Is it the game-changer it's been cracked up to be? If so, how is it changing the game? How is it likely to affect us as customers, tenants, aspiring homeowners, students, educators, patients, clients, prison inmates, members of ethnic and sexual minorities, and voters in liberal democracies? Authored by experts in fields (...) ranging from computer science and law to philosophy and cognitive science, this book offers a concise overview of moral, political, legal and economic implications of AI. It covers the basics of AI's latest permutation, machine learning, and considers issues such as transparency, bias, liability, privacy, and regulation. -/- Both business and government have integrated algorithmic decision support systems into their daily operations, and the book explores the implications for our lives as citizens. For example, do we take it on faith that a machine knows best in approving a patient's health insurance claim or a defendant's request for bail? What is the potential for manipulation by targeted political ads? How can the processes behind these technically sophisticated tools ever be transparent? The book discusses such issues as statistical definitions of fairness, legal and moral responsibility, the role of humans in machine learning decision systems, “nudging” algorithms and anonymized data, the effect of automation on the workplace, and AI as both regulatory tool and target. (shrink)

Individuals who become ill as a result of personal lifestyle choices often shift the monetary costs of their healthcare needs to the taxpaying public or to fellow members of a private insurance pool. Some argue that policies permitting such cost shifting are unfair. Arguments for this view may seem to draw support from luck egalitarian accounts of distributive justice. This essay argues that the luck egalitarian framework provides no such support. To allocate healthcare costs on the basis of personal (...) responsibility would arbitrarily and publicly burden socially detectable risk-takers while undetectable risk-takers continue to get a free ride. That problem is unavoidable even on the assumption that distributive institutions outside the healthcare sector are fully just. In actual, farfrom-just societies, imposing personal liability for the costs of voluntary risk taking would be wrong for an additional reason. Doing so would tend to magnify existing distributive injustices. These conclusions draw attention to two common ‘moral fallacies of the second best’ that can arise when applying ideal normative theory to matters of institutional design and in real-world policy contexts. (shrink)

The design of collaborative robotics, such as driver-assisted operations, engineer a potential automation of decision-making predicated on unobtrusive data gathering of human users. This form of ‘somatic surveillance’ increasingly relies on behavioural biometrics and sensory algorithms to verify the physiology of bodies in cabin interiors. Such processes secure cyber-physical space, but also register user capabilities for control that yield data as insured risk. In this technical re-formation of human–machine interactions for control and communication ‘a dissonance of attribution’ :7684, 2019. https://doi.org/10.1073/pnas.1805770115) (...) is created between perceptions of phenomena, materials and decision-making. This reconfigures relations not only between humans and machines, objects and subjects, but possibly disrupts attributive functions in the social system of Law. What it requires is shifting a legal accountability for action from a sovereignty of the human to a new materialist account based on a ‘cognitive assemblage’ between physiological data, computation and algorithmic sensing. This paper investigates the function of law as a guidance system to acknowledge this account of sensory and algorithmic computation as autonomous ‘sensing agents’ that may be accountable in situations of risk. This assemblage of robotic computation and sensory determination requires a clearer legal differentiation across the current static terminologies of person, property, liability and rights that maintain strict separations of object from subject. To neglect this, we argue, law will solely impute attributions of error to humans despite evidence of operation via mutual control. (shrink)

The aim of this paper is to evaluate the prevalence in the 27 member states of the European Union of a little discussed illicit wage arrangement in which formal employees are paid two wages by their formal employers – an official declared salary and an additional undeclared wage, thus allowing employers to evade their full social insurance and tax liabilities. Reporting the results of a 2007 Eurobarometer survey involving 26,659 face-to-face interviews, the finding is that one in 18 formal (...) employees received such an envelope wage from their formal employer and that envelope wage payments are more prevalent in member states with lower (rather than higher) levels of state intervention. The tentative conclusion is that illicit envelope wage payments are a product of under-regulation, rather than over-regulation, and that further research is now required to test the validity analysis of this thesis in other global regions. (shrink)

Those found liable for negligently injuring others are required to compensate them, but current practices permit most tort feasors to spread the costs of their liability burdens through the purchase of insurance. Those found guilty of criminal offences, however, are not allowed to shift the burdens of their sentences onto others. Yet the reasons for not allowing criminal offenders to shift such burdens – harm reduction, retribution, and moral education – also appear to retain some force in relation (...) to negligent tort feasors. Arguments for and against limiting the abilities of negligent tort feasors to spread such costs, thus imposing a penalty on them, are discussed. The conclusion reached is that further consideration of such a penalty is warranted. (shrink)

Autonomous AI agents present transformative opportunities and significant governance challenges. Existing frameworks, such as the EU AI Act and the NIST AI Risk Management Framework, fall short of addressing the complexities of these agents, which are capable of independent decision-making, learning, and adaptation. To bridge these gaps, we propose the ETHOS (Ethical Technology and Holistic Oversight System) framework—a decentralized governance (DeGov) model leveraging Web3 technologies, including blockchain, smart contracts, and decentralized autonomous organizations (DAOs). ETHOS establishes a global registry for AI (...) agents, enabling dynamic risk classification, proportional oversight, and automated compliance monitoring through tools like soulbound tokens and zero-knowledge proofs. Furthermore, the framework incorporates decentralized justice systems for transparent dispute resolution and introduces AI-specific legal entities to manage limited liability, supported by mandatory insurance to ensure financial accountability and incentivize ethical design. By integrating philosophical principles of rationality, ethical grounding, and goal alignment, ETHOS aims to create a robust research agenda for promoting trust, transparency, and participatory governance. This innovative framework offers a scalable and inclusive strategy for regulating AI agents, balancing innovation with ethical responsibility to meet the demands of an AI-driven future. (shrink)

The purpose of the paper is to discover a rationale for the practice of attaching excuses to criminal responsibility. I do this by criticizing the theory of h l a hart that we adopt this practice largely because it gives persons more power to predict and determine their liability to punishment than would a system of "strict" liability. I extract from my criticisms of hart the alternative theory that we adopt the institution of excuses because it insures that (...) persons do not assume burdens beyond what it is necessary to assume for the benefits of the legal system to accrue to all. (shrink)

The paper reviews the basics of development and implementation of the debt policy of Ukraine, outlines its formation principles and establishes requirements to normative legal documents which specify administrative measures in the field of the public debt. The research conducted shows that the main normative legal documents which govern activities of state administration bodies responsible for the debt policy implementation are the State Budget and the Program for State Debt Management of the Ministry of Finance of Ukraine. An analysis of (...) the structure of the above documents and ensuing governmental regulations of Ukraine indicates that the national debt policy is not a separate link of the public financial administration, it is shaped subsequent to the results of managerial decisions in the field of monetary relations, changes in the taxation system, operation of the efficiency control system of national taxes, the government deficit level, impacts of foreign economic factors etc. It is proved that debt operations in Ukraine are becoming a factor of economic risk for the state budget whereas the debt budget itself is becoming a destabilization factor. The budgetary policy of Ukraine, which is primarily aimed at maximization of tax collection, results in distortion of the public finance system and aggravates the economic status of numerous industries. The public debt service expenses are however still increasing and require public borrowings which keep growing year by year. The author indicates that the most unsuccessful decisions of the national leadership, which brought about a higher public debt, are the issue of internal public bonds for capitalization of the Privatbank PJSC in 2017 and poor state control over quasi-fiscal operations which may result in default of national Compulsory Social Insurance Funds on their obligations, accumulation of debts on VAT refund, remission of dead tax debts, instalment payment and deferral of money liabilities or tax debts of taxpayers, attraction of sovereign credits by resident economic entities, debt restructuring of such entities with public guarantees, supply of natural gas to heat-and-power engineering companies for generation of thermal energy at preferential prices, accrued receivables of the National Joint-Stock Company 'Naftogaz Ukrainy' for sale of natural gas to the population and heat-and-power engineering companies. (shrink)

Rational Risk Policy is based on Viscusi's Arne Ryde Memorial Lectures, delivered at Lund University in 1996. The organizing principle of these lectures is that the irrationality of individual decisions is often embodied in government regulations. Rather than overcoming the inadequacies in individual risk beliefs and behaviour, governmental regulations often institutionalize them. Viscusi examines how consumers and workers perceive risk and the implications of these risk beliefs and behavioural responses to risk for government policy. Hazard warnings efforts, direct regulation, and (...) liability are among the alternative modes of intervention. The role of risk tradeoffs with respect to the value of life as well as the consequences of wasteful regulatory expenditures are considered in a discussion of riskrisk analysis. Rational Risk Policy also includes a critique of the risk analysis practices used by government agencies as well as a consideration of how liability and social insurance should be integrated into a rational risk management strategy. (shrink)

This article examines the question of whether private obstetric care in South Africa can be saved in view of the escalation in medical and legal costs brought about by a dramatic increase in medical negligence litigation. This question is assessed with reference to applicable medical and legal approaches. The crux of the matter is essentially a question of affordability. From a medical perspective, it seems that the English system as well as American perspectives may be well suited to the SA (...) situation. Legal approaches are assessed in the context of the applicable medicolegal framework in SA, the present nature of damages and compensation with reference to obstetric negligence liability, as well as alternative options to the present system based on fault. It is argued, depending on constitutional considerations, that a system of damages caps for noneconomic damages seems to be the most appropriate and legally less invasive system in conjunction with the establishment of a state excess insurance fund. (shrink)

Until recently, climate scientists were unable to link the occurrence of extreme weather events to anthropogenic climate change. In recent years, however, climate science has made considerable advancements, making it possible to assess the influence of anthropogenic climate change on single weather events. Using a new technique called ‘probabilistic event attribution’, scientists are able to assess whether anthropogenic climate change has changed the likelihood of the occurrence of a recorded extreme weather event. These advancements raise the expectation that this branch (...) of climate science can contribute to climate adaptation efforts. This paper examines the normative underpinnings of these policy discussions. To date, the debates revolve around whether the findings of attribution science can be used to establish moral liability for harms resulting from climate change. On close analysis, this normative framework has serious shortcomings. The paper rejects the moral liability framework and suggests, through a review of the international climate negotiations under the UNFCCC, that the science of event attribution can inform adaptation policy within a risk-pooling and climate risk insurance framework. The proposed framework is defended both on normative grounds and on the basis of its potential application within the Warsaw International Mechanism for Loss and Damage under the Cancun Adaptation Framework. (shrink)

A young man, terminally ill and in extreme suffering, asks to be removed from life support, requesting morphine first so he'll be asleep when the machine stops. His physician agrees, but the hospital's chief administrator intervenes, arguing that the morphine might itself cause death, leaving the physician open to criminal indictment for murder. To placate the administrator, the doctor and patient reach a grim compromise: life support will be disconnected first, and only after manifest signs of suffering appear will the (...) physician administer the morphine, to alleviate pain. The patient's request is ultimately respected, but many staff members feel he has been made to suffer needlessly. This is just one of many cases Ruth Macklin discusses in Enemies of Patients, an eye-opening look at the growing number of forces that are hostile to the interests of patients, including hospital administrators, lawyers who represent hospitals, insurance companies, government regulations, and even some well intentioned physicians. Macklin, a highly regarded medical ethicist, the author of Mortal Choices and the subject of a New York Times Magazine cover story, provides a behind-the-scenes look at how the patient's ethical rights are often violated. She describes, for instance, how a new breed of hospital administrator, the risk manager, acts consistently as an enemy of the patient, often urging physicians to continue aggressive, expensive treatments for critically ill patients--even when the patient and doctor agree the treatment should cease--for fear of lawsuits, bad publicity, or criminal indictment. (Macklin points out, for instance, that even though no physician has ever been convicted of a crime for withdrawing treatment from a patient in a permanent vegetative state, hospital lawyers and risk managers regularly assert that there is a danger of criminal liability in such cases.) The government also can become an enemy of patients. The most egregious case, according to Macklin, is the Federal government's "gag rule" which has prohibited health care facilities that receive Title X funds from discussing abortion with pregnant women, violating the patient's right to full information. And physicians themselves can become enemies of patients. Some, seeing themselves as fiscal gatekeepers, ration expensive health care procedures on financial rather than medical grounds. Some physicians refuse to treat patients who don't follow their advice (a cardiologist, for instance, who will not take care of patients who smoke) and others won't treat patients who pose a threat of lawsuit (such as a California woman in need of life-sustaining dialysis, who had previously sued another physician). Packed with numerous case histories drawn from the author's experience in a major urban medical center, Enemies of Patients will give readers a better understanding of their rights as patients and show them how to forge an alliance with their doctors against common enemies. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Grieving the Loss of What Medicine Was Supposed to BeKaterina V. LiongI attended a conference this year. The timing was less than ideal because it was held the weekend before the Internal Medicine clerkship exam. But as with all things, especially during medical school, there is never a "right time" to be doing anything. It was fortunate that I attended the conference anyway because I met an incredible doctor (...) there. She had given a talk called "The Myth of Physician Wellness," and somewhere in our lengthy discussion, she asked me this:"Have you ever considered that since entering medical school, you've never been able to stop and really grieve the loss of what you thought medicine would be?"I am writing this in the downtime during my surgery rotation, regretting that I didn't wait until I got home to fully feel the feelings of writing this because I cannot cry here in front of others. At the same time, I feel guilty spending time writing at all; I should instead be doing UWorld practice questions for my upcoming exam. I can feel it in my body, the feeling of being plugged up—I have allowed tears to leak out too many times this year.The first time was in Internal Medicine, after seeing an elderly patient with a terminal rectal cancer that was so far along you could see it grossly. The bulging mass was so obvious during the patient's digital rectal exam that the senior resident was able to take off his still-clean gloves mere seconds after putting them on. The patient had come in for abdominal pain and difficulty defacating; the [End Page E20] only management he'd been able to receive for his known cancer was multiple hospitalizations in the last few months for emergency blood transfusions when his Hemoglobin level, indicating blood loss from the cancer, got too low. As I was taught to do, I gave a summary statement: "So you're here because you had a primary care appointment for a regular checkup, but they wouldn't see you because they didn't take your insurance? And they sent you to the county hospital, but even though they take uninsured patients, you are technically insured, just under a terrible plan … so they transferred you here. Is that right?" Unfortunately, the man's sí of affirmation was enough to make me lose composure, and I had to step out to let the resident finish the interview.After that, all it takes recently for the tears to well up is for an attending to pull me aside for feedback and ask, "How is third year going for you?" or even "What do you feel you've done well?"I almost wonder if holding in tears is like constipation. In medical school, we learn that sometimes what we think is diarrhea in patients is actually constipation—the stool is so impacted that the only thing that can leak past the plug is liquid. We see the leakage and first interpret that as diarrhea. I have to wonder if people interpret the same about me—emotional lability? Or is my inability to prevent the tears from leaking out simply a product of all the plugging up I have been doing all along? My inability to properly grieve the loss of what medicine was going to be? Maybe the first step in processing that loss is identifying it:I thought medicine meant caring for patients. Why am I going through 7+ years of training if insurance companies are allowed to undermine us so easily?I thought medicine meant connecting with patients. Why am I spending 30 minutes seeing my patients and 2 hours writing notes?I thought medicine meant leadership. Why are others bypassing two-thirds of my time in training and ending up with almost the same job … but the only "leadership" left is that their liability falls on physicians?I thought one must be well to take care of others. Why are students working all day and studying all night, residents too overworked to take a lunch break, and attendings made to work while visibly sick and diaphoretic?I thought... (shrink)