Chapter 4.C.2--The Helling Case and Defensive Medicine

For additional discussion of the precise empirical issues presented in Helling, see Schwartz & Komesar, Damages and Deterrence: An Economic View of Medical Malpractice, 298 New Eng. J. Med. 1282 (1978); Eddy et al., The Value of Screening for Glaucoma with Tonometry, 23 Survey of Ophthalmology 194 (1983); Comment, Rational Health Policy and the Legal Standard of Care: A call for Judicial Deference to Medical Practice Guidelines, 77 Cal. L. Rev. 1483 (1989); Wiley, The Impact of Judicial Decisions on Professional Conduct: An Empirical Study, 55 S. Cal. L. Rev. 345 (1981); Tucks & Crick, The Cost Effectiveness of Various Modes of Screening for Primary Open Angle Glaucoma, 4 Ophthalmological Epidemiology 3 (1997); Bovin et al., Cost-Effectiveness of Screening for Primary Open Angle Glaucoma, 3 J. Med. Screening 154 (1996).  Givelber et al., Tarasoff, Myth and Reality: An Empirical Study of Private Law in Action, 1984 Wis. L. Rev. 443.

In 2005, the U.S. Preventive Services Task Force recently reviewed all available evidence and concluded that there is  "insufficient evidence to recommend for or against screening adults for glaucoma," meaning that the issues of medical benefits vs. risks is still unresolved.  In particular, the task force "found good evidence that treatment of increased [eye pressure] result in a number of harms, including local eye irritation and an increased risk for cataracts."  The task force concluded that "The uncertainty of the magnitude of benefit from early treatment and given the known harms of screening and early treatment, the USPSTF could not determine the balance between the benefits and harms of screening for glaucoma."  See also http://www.annfammed.org/cgi/content/full/3/2/171.

On the phenomenon of clinical cascades flowing from screening tests, see Richard A. Deyo, Cascade Effects of Medical Technology, 23 Ann. Rev. Pub. Health 23 (2002).

For additional analysis by the two leading empirical researchers of defensive medicine, estimating the savings in medical costs from malpractice liability reform, See Daniel Kessler & Mark McClellan, How Liability Law Affects Medical Productivity, 21 J. Health Econ. 931 (2002).  Furthing documenting the extent of defensive medicine, see David M. Studdert, et al., Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment, 293 JAMA. 2609 (2005) (“Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care”).  Questioning the standard claims about defensive medicine, see Thomas Baker, The Medical Malpractice Myth (2005).

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