Transitional Health Justice and a Care-First Response to Our Times

Nov 18, 2025 Christina S. HoAdd a Comment

Christina S. Ho

Himani Bhakuni and Lucas Miotto have teamed up to place a useful concept in our midst, namely the concept of Transitional Health Justice (THJ).

They draw upon the scholarship concerning Transitional Justice, which can be roughly understood as an extension beyond “ordinary justice” to encompass “the full range of processes and mechanisms associated with a society’s attempts to come to terms with a legacy of large-scale past abuses.” Transitional justice is not demanded when a society undergoes a smaller-scale disruptions, such as isolated episodes of disaster or armed conflict. After such events, society’s goal might plausibly be described as restoration after an aberrant event. But other ruptures go to the foundations of collective life, after which justice cannot be done by merely returning to the status quo ante, if indeed there is anything left to return to.

In the wake of the pandemic and rampant health disinformation, amidst the necropolitical horrors of the U.S. carceral security state run amok, given DOGE and the recent reconciliation bill’s plundering of our medical science and health infrastructure top to bottom, Bhakuni and Miotto’s call to train a transitional justice lens onto the crises in our health domain rings particularly urgent.

Accounts of health justice tend to focus on the justice of the health system we might envision, but the distance between this ideal and our previous normal, not to mention the distance from our current circumstances, can seem daunting. Bhakuni and Miotto help us map the preconditions of justice required to get from here to there. For instance, rather than rampant denialism, we need “acknowledgment and redressal of mass scale human rights violations that are markers of broken health systems.” (HHR 86.) We need to foster trust, reset norms, and nurture a shared understanding that enables people to inhabit new roles, new duties, and new social relations in the new system.

Colleen Murphy has identified four circumstances that characterize a society in need of transitional justice, and Bhakuni and Miotto have adapted that framework as four circumstances of transitional health justice: “(i) pervasive structural inequality, (ii) normalized collective and political wrongdoing, (iii) serious existential uncertainty, and (iv fundamental uncertainty about authority.” (Transitional Health Justice P. 218.) I argue the U.S. meets those now.

First, the presence of pervasive structural inequality seems inarguable. The persistent racial inequality of our health system and all the stratification exacerbated by COVID already signaled moral and practical crisis. The reconciliation bill that Trump recently rammed through Congress features a near-trillion dollar raiding of Medicaid to fund tax cuts for billionaires. Meanwhile border enforcement brutalizes, abuses, and denies needed medical care, targeting racial, ethnic, or religious minorities.

Second, the U.S. health system suffers from normalization of collective or individual wrongdoing. Such conditions, in Bhakuni and Miotto’s words, “erode faith in systems that govern…health and create a sense of helplessness. This can only be repaired with a change in the social relations between citizens and their public health systems, which would essentially require a transformation.” (Transitional Health Justice P. 221.) It is little wonder that patients have lost trust in the health system, given Trump, Robert F. Kennedy Jr., Roy Bhattacharya and others’ role in normalizing COVID and vaccine denialism, when in the post-Dobbs world, one’s ob-gyn may be restricted from providing life-saving reproductive health care, and when doctors are routinely conscripted by for-profit health insurers like United HealthCare to the project of denying needed coverage. All these corruptions and distortions corrode patient trust and inflict moral injury upon the providers facingpervasive pressure for wrongdoing.

A situation that calls for THJ is also one where people experience serious existential uncertainty; indeed, we now face constant heightened anxiety about our health. Apart from the epidemic of gun violence, the Trump Administration is simultaneously seeding future mass casualty events by defunding health care, dismantling FEMA, undermining vaccination, hobbling TSA, and eliminating weather forecasting capabilities. Add to all that ICE’s masked kidnappers and concentration camps, and the label “existential uncertainty” seems no overstatement. It is hard to deny that the infrastructure on which our health and security depend cannot be sustained and verges on collapse.

And finally, the circumstances of THJ exist when we have lost faith in the legitimacy of authority in our systems of health and safety. I don’t think my health law colleagues need much convincing that these circumstances are amply satisfied. RFK Jr. has fired the seventeen members of the Advisory Committee on Immunization Practices, threatened to fire the US Preventive Services Task Force, dismantled FDA, and shows no signs of stopping there.

With each of Bhakuni and Miotto’s THJ circumstances met, what then will provide the kind of Transitional Health Justice that is so clearly called for in our times? While TJ commonly prescribes a number of tools, including truth commissions, apologies, reparations, and accountability, such as “ineligibility for office, or other legal disabilities on the old regime’s adherents,” it is up to us to further specify what THJ requires in response.

Bhakuni and Miotto supply some clues when they declare, “THJ demands that whatever contributes to the circumstances of THJ be transformed—that the circumstances of THJ come to an end.” (HHR 85.) This formulation means that the objects of THJ are beyond the health system itself. I like that this frame points us not to individual or incremental but rather structural changes. And it gives us a reason why those structural changes, even if outside the health system, must be care-first. In other words, they must be designed and conducted with health in mind because it is transitional health justice that on the table. So the kind of Supreme Court, Executive Branch, and Congressional reforms we consider should be envisioned with an eye to whether they provide care and promote flourishing. Just as Gregg Gonsalves and Amy Kapczynski in the depths of the pandemic called for a New Politics of Care, Bhakuni and Miotto now draw from a different literature to sound the same call, and I take the chance here to amplify it.

The Dangers of Regulating Inducing Death as a Medical Practice

Oct 16, 2025 Trudo LemmensAdd a Comment

Trudo Lemmens

Internationally, pressure to legalize or expand euthanasia and assisted suicide is mounting, primarily in industrialized countries. France and the UK are two major jurisdictions that are currently considering legislating some form of what is now often referred to as “assisted dying.” Amid the UK debate on a private member’s assisted suicide bill currently before the House of Lords, Jennifer Hardes Dvorak’s recent article, Is Assisted Dying Really A Matter of Medical Regulation?, raises crucial—yet often overlooked—questions related to the role of medicine: Should assisted suicide and euthanasia be regulated as medical practices? What are the implications of involving medical professionals?

Dvorak offers a nuanced analysis—grounded in empirical evidence from existing regimes—of the problems with medical models of ‘assisted dying’. These are models in which physicians (and in some countries also nurses) play an essential role as prescribers, or as those providing a lethal injection, and in which medical criteria determine whether a person obtains access. She also discusses whether what is often treated as a ‘demedicalized’ model, like Switzerland, where assisted suicide is organized by volunteer organizations with only a limited role for physicians, offers a better approach. Her paper presents a balanced review of regulatory approaches and highlights the complexities of interpreting evidence in this polarized debate. The paper makes a compelling argument about the challenges with medical models of assisted dying, while also acknowledging that a demedicalized system of legalized assisted dying is not unproblematic.

Dvorak identifies four key issues complicating the regulation of legalized assisted dying: pragmatic concerns about physician involvement, the effects of medicalization, the intersection of medical and criminal law, and health economic pressures.

Discussing the practical challenges, she notes that integrating assisted dying into medical regulation can impact in very contrasting ways. On the one hand, it may hinder access due to conscientious objection and the emotional burden it places on physicians. On the other hand, it can open the door to overuse, particularly through “doctor-shopping.” She gives the example of a woman whose Alberta physicians diagnosed her with a treatable reaction to mental health medication, which would have made her ineligible for ‘Medical Assistance in Dying’ [MAiD], but who was approved by out-of-province British Columbia physicians after an online consultation. An injunction ultimately blocked the BC provider from ending her life. But there is now even another court case which documents how a provincial health authority explicitly facilitated, and even organized doctor-shopping. In this case, a young woman’s MAiD request had been blocked twice after only one assessor of the two assessors in two subsequent requests considered her eligible, but the Alberta health authorities then appointed the first assessor as the tie-breaker for the second request. The young woman, according to her father, had autism and otherwise no diagnosed illness. Dvorak also notes, as a pragmatic issue, how institutional culture, and bullying, may result in additional pressure on physicians to participate in MAiD, further undermining the notion of professional independence. This has indeed also been documented in the Canadian context.

Dvorak’s deeper engagement with the concept of ‘medicalization’ is particularly compelling. Drawing on sociological literature, she illustrates how assisted dying regimes transform dying into a medical procedure—an issue that is often overlooked by commentators who claim that assisted dying empowers people in the face of overbearing medical practice. While medicalization is sometimes presented as a means of destigmatizing death and delineating the practice through the identification of medical access criteria, Dvorak is skeptical of its overall benefits. She discusses how the vagueness of medical criteria tends to lead to bracket creep and often results in expanding the practice beyond its original intention. Her point that medicalization can individualize social problems—masking structural inequalities—is especially powerful.

Dvorak examines as examples of bracket creep the expansion of euthanasia for mental illness in the Netherlands, and Canada’s broadening of eligibility beyond the end-of-life context. It is not a coincidence that in the two jurisdictions she selected, most cases of assisted dying are euthanasia cases (thus involving deadly injections), and in both jurisdictions there never was an explicit restriction to a terminal illness with limited survival prognosis. The developments in those jurisdictions highlight, according to Dvorak, how medicalized regimes can normalize and expand assisted dying in ways that risk obscuring structural harms. Interestingly, more recent evidence in both jurisdictions, not yet discussed in the paper, provides further support for her argument. Dutch experts have recently raised the alarm about the striking increase in cases of euthanasia for mental illness among very young people, particularly women. With respect to Canada, several Ontario coroner reports, of which she cites one, now confirm how even suffering directly resulting from structural inequalities and lack of support and only vaguely connected to a medical condition, has been transformed into a medical problem for which euthanasia is now considered a therapy. Dvorak further questions whether a healthcare system’s promotion of assisted death as medicine can be reconciled with key public health goals of improving people’s lives and alleviating the health impact of structural inequalities.

But Dvorak is also attentive to the limitations of models that claim to avoid medicalization altogether. The article further nuances convincingly the claim that the Swiss model of assisted suicide is fully ‘demedicalized,’ and argues why this model is also not without problems. Discussing recent case law, she shows how it operates in a grey zone. Prescription practices are still regulated by the state and the medical profession, and the criminal law still applies in the margins. Dvorak expresses caution about embracing this model as a solution to the concerns raised by more medicalized assisted dying regimes, particularly given the challenges related to transparency and oversight, and the difficulties of using the criminal law to delineate the practice.

In her final section, Dvorak emphasizes the importance and real challenge of addressing the broader social context in which assisted dying operates. As she notes, “Decisions to medicalize AS/E are not neutral; instead, they are heavily laden social decisions.” She highlights how economic pressures on patients, families, and healthcare systems influence these choices, and questions whether medical professionals can adequately evaluate such complex decisions: “Expecting all medics to be sociologists and ethicists, on top of already overburdened workloads may be too much to ask.”

Dvorak explicitly leaves open whether a fully ‘demedicalized’ model is to be preferred. In concluding, she retreats to what is perhaps an overly familiar response: calling for more data collection and improved oversight. Her recommendation that regulation must ‘ensure voluntary choice’ is obviously important, but she understandably offers no clear solution how to ensure that, in light of the impact of structural inequality, and considering the failures of current systems.

A recent British Medical Journal commentary puts more bluntly that “[a]ssisted dying is an existential matter rather than a treatment matter.” Its authors argue that integrating any form of assisted dying into medicine risks undermining healthcare practice and medico-legal doctrine. Perhaps legal scholars should more readily acknowledge, in the face of mounting evidence, that existing assisted dying regulations are really causing irreversible harm, without feeling the need to suggest vague and perhaps unrealistic solutions under the guise of pragmatism. Still, Dvorak’s paper enriches the debate with a thoughtful, balanced, and evidence-informed critique of the challenges facing legalized assisted dying regimes, both medicalized and ‘demedicalized’ alike.

Preventive Care Utilization and Health Insurance Literacy

Sep 18, 2025 Amy Monahan2 comments

Amy Monahan

Despite the Affordable Care Act’s fifteen-year-old mandate for full coverage of preventive care, potentially life-saving cancer screenings remain persistently underutilized. In Can Legal Knowledge Save Lives? A Randomized Experiment in Preventive Health Screenings, Professors Christopher Robertson and Wendy Netter Epstein delve into this critical health policy puzzle and present the results of a survey that aims to uncover the extent to which ignorance about the legal requirement for free preventive care contributes to underutilization and whether experience with medical debt might also play a role.

The literature has long established that individuals in the United States receive recommended cancer screenings at suboptimal rates and that cost concerns play a role in that outcome. The ACA’s preventive care mandate was explicitly designed to address this piece of suboptimal utilization by removing cost from the equation. It is doubtful that free coverage would entirely remove barriers to care, as the screenings themselves often come with some discomfort and inconveniences. Yet, it is crucial for lawmakers and health policy stakeholders to understand whether and to what extent law can help move patients toward optimal utilization by examining the extent to which individuals covered by health insurance actually understand the coverage terms that might influence their care decisions.

Robertson and Epstein’s experiment is designed to test two distinct hypotheses. First, that informing insured individuals who have not received at least one recommended cancer screening that such screenings are not only recommended but free of charge will increase their likelihood of undertaking the screening and, second, that individuals with current or past medical debt will be less likely to pursue missed cancer screenings if they are first primed to think about their medical debt before indicating their willingness to seek out screening. Robertson and Epstein ultimately found that a “free care disclosure”—informing individuals that most plans cover breast, cervical, and colorectal cancer screenings in full with no patient cost sharing—increased the likelihood of taking steps toward screening by five percentage points, from 42% to 47%. While the overall numbers may appear modest, a population-wide increase of 5% in recommended cancer screenings could lead to significant gains in cancer survival. Interestingly, medical debt priming did not influence screening behavior, and that result held at all levels of medical debt.

The survey was limited to moderate income individuals with health insurance coverage who, based on age and sex, were eligible for colorectal, breast, or cervical cancer screenings but had not received at least one of those recommended screenings. Participants were randomly assigned to one of two main treatment groups to investigate whether fee disclosure or medical debt salience influenced the likelihood of pursuing recommended cancer screening. In the first treatment group, half of the respondents were informed that the ACA provides that, for most plans, these cancer screenings must be covered in full by the health insurer. The other half of this group received no information on the preventive care mandate. Both groups were asked whether they would like a link to assist them in obtaining the recommended screening, which was the main outcome measure for the study. In the second treatment group, half of the respondents were first asked various questions about their own medical debt history before being asked whether they would like the screening link. The other half of this group was asked about their medical debt only after they had indicated their desire to take a step toward screening by requesting the link, with the idea being that priming an individual to think about medical debt might influence their willingness to interact with the health care system for discretionary care. Respondents in both treatment groups were also asked various survey questions about their reasons for not previously getting a recommended cancer screening and their attitudes toward the health care system.

The primary finding of the experiment, that fee disclosure can meaningfully increase the likelihood of pursuing cancer screening, suggests that such disclosures could be a meaningful policy intervention if broadly implemented. But, as the authors acknowledge, doing so is more difficult than it might appear. Disclosing fee information is complex for a number of reasons, even with something as relatively straight forward as routine cancer screenings. First, not all forms of health insurance are subject to the preventive care mandate, so a blanket statement that such services are covered in full will be inaccurate. And being informed that “most” plans must cover these services in full may not be sufficient to overcome genuine cost concerns. Health plans may also place certain limitations on preventive care services, including not only network requirements but also restrictions on the scope of the screening itself, such as covering only traditional mammography and not 3D/digital breast tomosynthesis imaging. In addition, as Robertson and Epstein’s survey reveals, one of the top reasons that individuals forgo recommended screenings in the first place is not just the cost of the screening itself, but also the cost of any necessary follow-up care. For example, a woman who receives abnormal mammogram findings might be told to follow up with either an ultrasound or biopsy. But those services would be diagnostic in nature rather than preventive, which means they would be subject to the plan’s ordinary cost-sharing rules. One stark finding from the survey is that 80% of participants agreed with the statement that “going to the doctor or hospital can be dangerous financially” – a finding that is perhaps not surprising given the intricacies of both legal requirements and health insurance coverage terms.

The article presents many other interesting findings in addition to those I have just highlighted and is an important contribution to the literature on medical utilization decisions and the impact that health insurance literacy has on those decisions. More broadly, this research serves as yet another important reminder of the very real costs of our health care system’s complexity.

Editors note: Reviewers choose what to review without input from Section Editors. Jotwell Health Law Section Editor Wendy Netter Epstein had no role in the editing of this article.

Emergency Abortion Laws: Vague by Design, Lethal in Practice

Aug 5, 2025 Nadia Sawicki1 comment

Nadia Sawicki

Prof. Maxine Eichner and her co-authors at the University of North Carolina have written a first-of-its kind empirical study and legal analysis that sheds light on the challenges doctors face in interpreting and applying “emergency exceptions” to state abortion bans. In The Inevitable Vagueness of Medical Exceptions to Abortion Bans, they present the findings of in-depth interviews of thirty-five maternal fetal medicine (MFM) physicians in the Southeast United States post-Dobbs, revealing “recurring patterns that create indecision regarding whether statutory exceptions will shield doctors from suit.” They use their empirical findings in support of a robust constitutional argument that state abortion bans with exceptions for medical emergencies are unconstitutionally vague.

Cases like those of Amanda Zurawski in Texas – who experienced preterm premature rupture of membranes (PPROM) at 18 weeks and did not receive an abortion until she developed sepsis three days later and one of her fallopian tubes had closed, compromising her future fertility – and Amber Thurman of Georgia – who died of septic shock because doctors waited 19 hours to remove fetal tissue from a self-managed medication abortion – demonstrate with brutal clarity that abortion ban carveouts for medical emergencies do not effectively protect patients experiencing obstetric emergencies. Troublingly, some legislators and judges in abortion ban states have placed the blame on physicians for these tragedies, arguing that pro-choice doctors are intentionally misinterpreting these laws to make a political point at the expense of patient health and safety. Eichner et al’s robust research demonstrates that this couldn’t be farther from the truth. These statutes, written by legislators with no medical expertise or understanding of the nuances of obstetric emergencies, are so ambiguous that physicians struggle to understand their meaning. And when the penalty for unintentionally violating an abortion ban might be life in prison, it is understandable that these laws have a chilling effect on well-meaning obstetric providers who want to preserve their patients’ health.

The physicians the authors interview highlight several concrete challenges they face in interpreting and applying abortion laws in obstetric emergencies. The overarching challenge is that these statutes are unclear about the degree of medical risk a patient must be facing in order for her condition to qualify as an emergency. According to one physician interviewed, “Nobody knows what the law means until a judge interprets it. So, until you get in front of a judge, it’s just words on paper.”

Uncertainties regarding the level of medical risk required for a condition to rise to the level of an emergency under state law arise from legislatures’ use of language like “necessary to prevent the death” or “save the life” of a pregnant patient. The physicians interviewed pointed out that risk is impossible to predict with certainty in any medical context, can change over time, and varies depending on numerous case-specific factors. The language in abortion statutes, however, not only presumes that it’s possible to predict with certainty the progress of a patient’s condition, but also suggests that the risk needs to approach 100% in order for the abortion to be legally permissible. According to one doctor, “The law was written so poorly, that we couldn’t tell what it meant, like what is dangerous, what counts as lethal. Nothing is 100% lethal, so nothing qualified.” One physician, for example, treated a patient with a cardiac condition that posed a 20-30% risk of heart failure if she continued with the pregnancy. Although medical standards would advise counseling the patient about termination and letting the patient decide, the doctor was unable to do that because (in consultation with hospital counsel) she “ultimately determined that level of risk was insufficient to meet the [state law’s] maternal life exception.” Similar vagueness challenges arise with statutes that permit abortion to prevent “serious health risks,” not just life-threatening emergencies.

Even in cases where doctors feel certain that a patient’s condition rises to the level of risk that would authorize emergency termination under state law, “they were often uncertain about when to perform the abortion in order to comply with statutory requirements.” In cases of infection, for example, a patient can decline into sepsis in a matter of hours, and early intervention is essential to minimizing risk. But physicians, bound by state laws, end up in situations like this: “I watched this woman … she broke her water, she was 17 weeks, she didn’t want to go home … So, we just let her sit on our floor and I just watched, her temperature went up and then her white count went up … And I was like, how long do I have to sit here and watch this before I’m allowed to do something?” The narratives collected by Eichner et al are consistent with quantitative evidence – for example, a 2022 study of patients with pregnancy-related complications at Texas hospitals found that patients waited on average nine days between presenting with complaints and finally receiving medically necessary abortion after the state legislature passed SB8.

Eichner et. al rely on their empirical findings to make a robust argument that because these laws don’t give adequate guidance as to when emergency abortions are lawful, they violate the constitutional prohibition on vagueness. They argue that although Dobbs eliminated the constitutional right to abortion, these laws nevertheless implicate the fundamental right to life and therefore should be subjected to heightened scrutiny.

Some commentators have argued that it is impossible to craft a statute that clearly and effectively outlines the circumstances in which emergency abortions are permissible. Eichner et al agree to some extent, recognizing that abortion “is too complicated to be regulated without risking the lives and health of pregnant persons.” However, they conclude the article by offering a creative proposal for what they refer to as “least-vague abortion exceptions.” Such exceptions would be “clear enough to physicians that they would pass void-for-vagueness standards, significantly reduce chilling, and save some pregnant persons’ lives.” Key elements of their proposed statute include a non-exhaustive list of conditions that satisfy the legal standard, clarification of issues relating to risk and timing, deference to physicians’ good faith medical judgment, and the absence of criminal penalties. The authors’ arguments and proposal are an important starting point for further conversation about the practical implementation of state abortion laws.

Enlisting Employers for Health

Jul 4, 2025 Zack BuckAdd a Comment

Zack Buck

For better or worse, employers have long had a vital but understated role in health care access and policy in the United States. In Employers and the Privatization of Public Health, Professor Sharona Hoffman draws on this context to catalog and illuminate American employers’ roles during a public health emergency. Recognizing the important work of private employers as part of the public health infrastructure and using the COVID-19 pandemic as a focus of the piece, Hoffman persuasively argues for treating employers as the indispensable partners they are when it comes to public health interventions and goals.

In the piece, Professor Hoffman walks the reader through the traditional role of government in public health efforts and the recently diminished reach of traditional governmental power, and provides examples of domains where employers have traditionally been involved in the goals of generally furthering health. These include the interest in workers’ health, the American employer-based health insurance system, wellness programs,, and employee assistance programs—all areas of sustained employer activity.

Notably, Professor Hoffman takes time to work through the legal constraints and incentives for employers as they relate to relevant federal and state laws. It is here that she highlights both the Americans with Disabilities Act (ADA) and Title VII of the Civil Rights Act of 1964, which prohibit employers from discriminating against employees. As for state laws, Professor Hoffman provides examples of laws that prohibit disability discrimination and other laws that address the permissibility of employers’ pandemic response measures in the context of COVID-19.

There are, of course, limitations in empowering employers to pursue public health measures. As Professor Hoffman acknowledges, private employers are not affected by federal constitutional provisions and may be negatively impacted by political beliefs or public pressure campaigns that could limit their effectiveness in this space. In addition to running afoul of rules that would make them state actors, there is a concern that employers may simply not implement measures that are geared toward protecting public health. Instead, with their primary interest being economic, they might fail to appropriately balance public health interventions with their own bottom line.

In the final section of the piece, Professor Hoffman leaves the reader with clear recommendations and a call to embrace employers as public health partners by pointing to employers’ extensive experience and expertise in this space (drawing on examples of employers promoting wellness initiatives or conducting drug testing). Further, Hoffman argues that employers have a real interest in making sure their workers are healthy. This allows them to compete for top-notch talent, avoid the negative impacts of a sick workforce, and address health disparities that exist. In this way, Professor Hoffman encourages the federal government to both offer guidance and provide financial support and incentives for employers to operate in this space.

Professor Hoffman’s piece is a pragmatic reminder about the importance of broadening policy interventions to expand beyond the monolithic action of a sprawling and multifaceted government. Her piece also skillfully avoids the combative rhetoric that has characterized the fight over public health interventions. By placing the focus on the “who,” such a disparate and unique actor as an employer, Hoffman avoids the tired arguments of the “what”—that is, the bitter fights over what kind of public health interventions are allowed, allowable, and defensible. Also, by tying the public health intervention to the bottom line of the employer, Hoffman can recast controversial state-based mandates into employer self-interest, which she can skillfully deploy to achieve a wide swathe of societal agreement.

Perhaps her most interesting suggestion is her push for the federal government to use its taxing and spending powers to encourage and incentivize employers to undertake the hard, in-the-trenches work of safeguarding their employees during a future public health emergency. This, of course, might avoid the societal backlash that often follows state-mandated interventions. These suggestions may not be perfect—Professor Hoffman acknowledges that employer-based actions will lack universality and fail to reach every American—but she convincingly argues that “employers can fill many of the voids left by recent pandemic legislation and jurisprudence.”

Professor Hoffman’s work is always enlightening, and this piece posits a direct thesis and makes a broad, persuasive point. And, coming out of the COVID-19 pandemic, while the hope is that her suggestions will not need to be implemented anytime soon, they are welcome additions to the literature in this space.

Listening to Patients

Jun 9, 2025 Emma CaveAdd a Comment

Emma Cave

Dr Rageshri Dhairyawan calls on health professionals to improve their capacity to listen to patients. Published on the front page of the Lancet in February 2025, NHS consultant and researcher Dhairyawan’s essay ‘Reflect, Collaborate and Listen’ draws on some of the key ideas set out in her book: Unheard: the Medical Practice of Silencing (2024).

I grew up in a small village in England, which boasts its own surgery thanks to my father and his practice. There was a strong pastoral element to his and his team’s clinical roles. My childhood recollection of the waiting room was of people chatting and laughing, leaving me wondering if there was anything the matter with them at all. Sometimes, patients would come to the house and seek advice in our front room. Once or twice, they even brought poorly animals. Sometimes he’d receive a phone call and rush out to a remote farm because he’d likely arrive before the ambulance. By listening to his patients and building relationships with them and their families over time, he gained trust and respect, and was, in turn, listened to.

Today the “family doctor,” whose role it is to understand the patient in the context of their family relationship, is less prevalent. As patient demand has increased, families and demographics changed, services expanded, care specialization fragmented, and appointment times shrunken, the very notion of the family doctor has retreated. Whilst there is much to celebrate in the development of primary care in the UK, the reduced capacity, and indeed willingness to listen, has left a gap.

Dhairyawan argues that this gap extends across the National Health Service (NHS). A root cause, she suggests, is a power imbalance between clinician and patient. This is sometimes the result of prejudice flowing from racism, sexism, ageism and other forms of bias. Nowhere is this clearer than in maternity care. MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries) reports have detailed ‘shocking racial and socioeconomic inequalities’ in deaths of women pre-, during, and post-childbirth in the UK and Ireland. Following a raft of recent reports criticising failures to listen and act on women’s concerns, it remains clear that ‘The NHS is still not listening hard enough to families on maternity care’.

Dhairyawan does not duck the difficult question of what needs to be done. Action starts with medical education, where students should be taught the value of listening to patients and equipped with the necessary skills. This would help counteract the biomedical model, which separates the patient from their social context and focuses exclusively on fixing the broken body. Students also need to be better equipped to deal with uncertainty: to acknowledge and share uncertainties rather than gloss over them or omit them because they cannot provide comprehensive answers.

In practice, clinicians should be more reflective about their listening practices and make it a part of their continuing professional development. The patient’s voice, meanwhile, should be elevated and amplified. In health services, we must prioritize the space for private conversations. In primary care, for example, Dhairyawan recommends that patients should be free to choose to sacrifice swifter access to any doctor in preference for continuity with their chosen doctor, if that is their priority.

Dr Dhairyawan’s book and article are timely. Several policy reports have referred to the devastating impacts that can flow from a failure to listen to patients. This was evident in the recent Infected Blood Inquiry final report into the worst treatment disaster the NHS has seen. Tens of thousands of people were infected with HIV and hepatitis C when they received infected blood and blood products in the 1970s, 80s and 90s. In his final report, the Chair, Sir Brian Langstaff set out lessons for the future. One was that “communication means listening: it is more talking with than talking to.” He went on to say that “there can be no proper consent without adequate communication, in particular of the risks and alternatives, but also so that the care of the patient respects the patient’s ownership of their own body and life.”

Listening to patients should not be confused with simply doing what they say. Clinicians should not offer treatment that is not clinically indicated and in the patient’s interests. What it does mean, as Dhairyawan so eloquently expresses, is that the combination of the clinician’s clinical expertise and the patient’s expertise of their illness and body, will lead to better outcomes and patient satisfaction.

This balance between professional expertise and patient autonomy is reflected in case law on informed consent. In Montgomery v Lanarkshire Health Board [2015], the UK Supreme Court required medical professionals to provide information to patients on material risks and reasonable alternatives that empowers patients to make their own informed choices.

Strict Liability for Unreasonable Harm: Aggregating Liability to Restore Compensation and Deterrence to Medical Malpractice Litigation

May 9, 2025 Carl Coleman1 comment

Carl Coleman

The American system of medical malpractice has long been criticized for failing to achieve either of the two primary goals of tort law: compensating victims or deterring misconduct. For victims of medical error, “[t]he malpractice liability system provides little compensation overall, and what infrequent compensation it provides it does so inefficiently with high transaction costs.” As for deterrence, researchers have found “no association between greater risk of malpractice liability and health care quality.” There has been no shortage of proposals to replace the system with potentially more effective alternatives, ranging from the use of specialized health courts to broader systems of enterprise liability to a wholesale replacement of the system with a no-fault compensation regime. In a provocative new article, Aggregating Liability for Medical Malpractice, Omer Pelled of Bar Ilan University School of Law enriches the debate by introducing a novel new approach he calls “strict liability for unreasonable harm” (SLUH), a creative mashup of negligence and strict liability that shifts the focus from discrete medical injuries to the pattern of outcomes resulting from a provider’s acts and omissions over a specified period of time.

Pellad uses the problem of hospital-acquired infections as a paradigmatic case for the application of SLUH. Some level of such infections is expected even in hospitals that engage in reasonable infection-control measures, but a higher level will occur in hospitals that fail to exercise due care. Suppose that a non-negligent hospital of a particular size and with a particular patient profile can be expected to have 100 infections per year, but one such hospital experiences 150 infections over the same time period. Under existing malpractice law, a patient seeking damages would have to show that her infection was more likely than not one of the 50 that would not have occurred had the hospital acted more reasonably. Because this is often an impossible hurdle, few injured patients even seek compensation through the tort system, and the hospital is therefore under-incentivized to invest in reasonable care. Pelled argues that the hospital’s liability should instead be established in the aggregate for all 150 affected patients, without any need to determine precisely how each of those injuries happened to arise. Each patient would be entitled to partial compensation based on the proportion of the total harm caused by the hospital’s failure to exercise reasonable care over the relevant time period, which in this example would be 50/150, or 1/3 of the total amount.

The SLUH approach is “strict” in that it results in the payment of some damages to all injured patients, regardless of whether their individual injuries were more likely than not the result of the hospital’s negligence. However, on an aggregate level, it is consistent with a negligence-based system because it requires the hospital to pay only for that portion of the harm that could have been avoided with the exercise of reasonable care. The system is loosely similar to other proportional approaches in tort law, including the loss-of-chancedoctrine and market share liability, which also dispense with traditional approaches to breach and causation as a means of ensuring that defendants do not escape liability for the increased risks they impose on the world.

An advantage of this system is that it does not depend on plaintiffs’ ability to uncover evidence of misconduct in their individual cases. As such, hospitals would no longer have an incentive to hide information about errors or to adopt costly and potentially harmful defensive tactics such as ordering unnecessary tests and procedures in an effort to minimize their litigation risk. (Physicians report that they frequently engage in such practices, although “the true costs of defensive practice, and the extent to which it is driven specifically by litigation risk rather than by broader dynamics, remain somewhat unclear.”) In addition, the approach avoids the problem of underenforcement inherent in the existing medical malpractice system; like class action lawsuits, all it would take is one patient to bring a lawsuit to call into question all the harms experienced in the hospital over the time period in question. Once the share of those harms attributable to the hospital’s lack of due care has been established, anyone who suffered harm during that period would be entitled to seek their proportionate share of compensation, even if they were not involved in the initial litigation establishing the hospital’s fault.

Initially, Pelled argues, legislators could experiment with his proposed approach by giving hospitals the opportunity to opt-into it as an alternative to standard malpractice liability. In addition, its use could be limited to hospital units that already report information about adverse events to surveillance registries, which would facilitate comparisons between the level of injuries in one unit with those of similarly situated units over time. Ideally, he argues, the system would operate alongside an insurance system that provides compensation for any injuries not attributable to the hospital’s negligence, which would combine with the partial compensation granted by the SLUH approach to make patients whole. Pelled argues that this insurance system should not only compensate patients for non-negligent harm but also provide subsidies to hospitals that manage to bring injuries below the level that would be expected if reasonable care were provided. These “negative damages” would ensure that hospitals neither under-nor over-invest in harm-prevention methods (i.e., that they take only those precautions that would be taken by reasonably prudent hospitals), even if courts sometimes make mistakes in determining the proportion of harm attributable to the hospital’s lack of reasonable care.

While Pelled develops the case for the SLUH approach in the context of medical malpractice, he argues that it could also apply to other contexts in which the goals of compensation and deterrence are not well served by the existing negligence regime. He identifies three conditions that would make the use of this approach appropriate: “(i) the total harm across cases is verifiable; (ii) it is possible to determine the reasonable harm for the injurer across time; and (iii) the injurer causes enough harm to justify a statistical inference.” As an example of such a context, he points to “artificial intelligence (AI) devices and products which, despite reducing accident rates, are involved in accidents that reasonable humans would avoid.”

The defects in our existing system of medical malpractice, while widely acknowledged, have long eluded effective solutions. Pelled’s analysis offers fresh insights into this intractable problem and is worth careful attention not only by health law scholars but by anyone with an interest in tort liability and alternative compensation regimes.

The Trouble With Health

Apr 10, 2025 Christina S. HoAdd a Comment

Christina S. Ho

As shown by the renewed backlash against health insurers, this time unleashed by the United Healthcare CEO’s killing in Manhattan, there seems to be something about health. Those of us who work in health law likely chose this field because we’ve always known that, indeed, there is just something about health. But what exactly is it? What makes it so special, so intractable, so compelling, such a lightning rod? Elizabeth Barnes‘ new book, Health Problems, takes this question squarely on, and concludes that we might never solve the mystery, even if we must continue to probe.

The signature puzzles she picks out are 1) the relationship between health and well-being, 2) the relationship between health’s objective nature and its subjective aspect, and 3) the relationship between health and disability. These puzzles are central to our work. They loom over so much of our scholarship that I am constantly bracketing these questions or relying on rough and provisional stand-ins. My perverse skirting of these central matters so as not to get unproductively mired allows me to make at least some progress on other questions that demand urgent answers. I’ve always felt that perhaps in making progress on adjacent questions, we have a chance of shedding light on these enduring puzzles too. Elizabeth Barnes helps locate this approach: first by mapping the bracketed space through her clean no-nonsense chapters (a division of labor that frees us to tackle other tasks) but also by providing perhaps a rationalization for approaching these questions a bit sideways.

The explanation lies in her final chapters, where she suggests a posture of “ameliorative skepticism.” It strikes me as a useful strategy for how to approach certain topics that feature a heavy dose of social construction (gender, others have suggested, is another) and that may be so close to us that it’s hard to get any distance from the mirror to see what we have made of ourselves. Because healthcare and public health are key social practices through which we work out how it is to be alive with one another and what that entails, these practices can’t help being sites of irreducible contestation responding to our many requirements. Part of the mystery and contest is over the extent to which our being alive resides in the body and the extent to which it transcends the body. Small wonder then, that the concept we’ve wrought through these practices is neither unified nor coherent. Barnes cautions against expecting otherwise.

My takeaways from her discussion of the first puzzle include a resolve to temper my habit of letting health stand in for flourishing. Barnes reminds us of what is at stake when I conflate the two. For one, overvaluing health impoverishes our understanding of human flourishing, as the narrow tech-culture trend of biohackingillustrates. Moreover, such elision can undervalue the richness and fullness of the lives of those with serious disabilities (although the two categories of disability and health loss come apart as well). Finally, Barnes analogizes loss of health to the experience of grief in a way I found helpful. Part of being alive is coping with the horizon of one’s frailty and mortality, with the awareness that at any point one could no longer be alive or could find oneself “navigat[ing] the world in a body that falls outside…how we expect bodies to function” (169). So, any picture of human flourishing or wellbeing must save room for loss of health as well.

On the quasi-objective, quasi-physiological nature of health, Barnes acknowledges that “sometimes things like health are normatively significant for reasons independent of how you feel about them” (P. 97). At the same time, health is inescapably subjective because it is “partly constituted by our reactions” (P. 97). She reminds us of this subjective phenomenology, including the primal feeling of being “‘at home’ in your mind and body” and the flip-side experience of illness as constant “aware[ness] of how you feel,” your vulnerability, your instability, and your “constantly interrogating whether you can accomplish normal and everyday tasks” (P. 52). This subjective distress cannot be ignored, since the urgency of how badly a person feels is in no small part what we are trying to address when we tackle people’s health problems, rather than just the biomarkers, functional limitations, or the like. Very little in health justice can be addressed without understanding how we’ve distributed suffering, how we’ve constructed suffering, and how people have internalized their expectations of suffering, a point to which I will return.

Third, Barnes emphasizes that disability and health come apart but that the avoidance of medicalization and the related social view of disability as “mere difference” is not adequate. Barnes insists we must be able to properly acknowledge health needs and health loss and to adequately recognize healthcare as one of the most important priorities for what we owe one another in case of disability, even as we celebrate the full, flourishing, and indeed healthy lives of people with disabilities.

Barnes then dwells quite a bit on a third side of the triangle, the relationship not between health and disability but between wellbeing and disability. It turns out that wellbeing is not necessarily lower for people with what she calls “paradigm” disabilities (like spinal cord injury, achondroplasia, or blindness) (P. 142). But for another set of conditions, disability and reduction in wellbeing are more closely correlated. The conditions she identifies as associated with poor wellbeing are “non-specific chronic pain conditions (such as chronic back pain, headache disorders, or fibromyalgia) and mental health conditions (such as generalized anxiety or depression)” (P. 142). These are, in fact, “the most common reasons that people in Western countries do things like seek disability benefits or ask for workplace accommodations.” And these “tend to be substantially correlated with reduced self-reported quality of life” (P. 142).

Barnes includes this discussion as a qualifier and an additional dimension of complexity in her picture, frustrating conceptual closure. Indeed, this gap in wellbeing effects for different types of disabilities presents challenges for many accounts of health, even, Barnes acknowledges, her own (P. 176). It also opens out into a new kind of inquiry beyond Barnes’ book. It puts me in mind of Mary Crossley’s recent book, Embodied Justice: Race, Disability and Health. Crossley’s is part of a literature that frontally examines how the distribution of disability serves among the cumulatively layered and mutually reinforcing forms of adversity (poverty, trauma, simultaneous unemployment and overwork, carcerality, disruption of family support structures, housing instability, the built environment, etc.) that map onto race and perform a familiarly patterned sorting of life chances. To the extent that disability functions as part of the reinforcing systems of disadvantage and immiseration, it is also a site of struggle and resistance over this apparatus that is the underside of our systems of competitive, disciplinary, “meritocratic” allocation. The category of “disability” for the conditions most implicated in this allocation might be showing up precisely because of its relationship with suffering and the gatekeeping of opportunities to flourish. Coherence and unity are elusive because this too is at stake when we fight over the scope and meaning of health. This is the kind of “messy” thread that Barnes does not address, but which her ameliorative skepticism allows us to pull harder, rather than lop off.

The Overlooked Harms of Inaccurate and Biased Medical Records

Mar 10, 2025 Myrisha Lewis1 comment

Myrisha Lewis

Professor Alice Abrokwa’s article, Too Stubborn to Care for: The Impacts of Discrimination on Patient Noncompliance, focuses on a rarely acknowledged source of bias in the healthcare system: medical records. Although this bias may not be easily visible to the public, medical records can significantly impact the medical care that individuals receive, as well as eligibility for government benefits and the size of medical malpractice awards. 

Professor Abrokwa begins her article by concisely telling the history of Elijah McClain’s interactions with law enforcement and emergency medical personnel, where he was labeled a “non-compliant person” during the interactions that eventually led to his death. As part of this story, she provides a quote from the City of Aurora’s investigative reportand recommendations in the aftermath of Elijah McLain’s death: “[I]mplicit biases can lead medical professionals to perceive Black patients as noncompliant and more resistant to pain, which can impact decisions regarding care to the detriment of Black Patients.” From there, she briefly outlines other instances where the labeling of patients in healthcare settings as “noncompliant” had significant detrimental impacts on their healthcare.

Part I of the article, “Situating the Analysis of (Non) Compliance,” provides practical and scholarly background on the meaning of the word “compliance,” particularly as it relates to Black people and other people of color in the United States. Professor Abrokwa explains that she extends the analysis of other scholars to “argue that norms about race, gender, and (dis) ability operate together to mark the difference between a ‘compliant’ and ‘noncompliant’ patient.” (citation omitted). In doing so, she shows that many individuals, regardless of race, do not “comply” with medical treatment. For example, many patients do not book “follow-up appointment[s] as soon as suggested or perfectly adher[e] to a recommended diet.” Yet, for patients of color, non-compliance can have more significant detrimental health outcomes as outlined in Part IV of the article.

Part II of the article, “Understanding the Stereotypes Underlying Noncompliance Biases and Providers’ Perceptions,” draws from Professor Kimberlé Crenshaw’s intersectionality framework in particular. In Part II.A, Professor Abrokwa “identifies the three stereotypes about Black people in the United States” that she argues are “most at work in driving perceptions of Black patients as noncompliant.” Professor Abrokwa then provides context evincing these stereotypes using media stories, scholarly literature, and historical accounts. In Part II.B, Professor Abrokwa cites to numerous studies demonstrating how racial stereotypes translate into the use of certain terms in patient notes. Moreover, Professor Abrokwa shows how just the use of a biased term in a patient’s medical records will then be transmitted to subsequent health care providers who, even though they may not be biased in the same way as the preceding medical provider, can still perpetuate that bias.

Part III, “Understanding Patients’ Reasons for Noncompliance,” explains why noncompliance is often justifiable and potentially evidence of healthcare providers’ failures, or systemic failures, not patients’ failures. Part III.A notes that patients may wish to undertake another course of action for family reasons or personal politics. Part III.B reminds the reader that in the U.S. health care system, patients may be noncompliant because following their provider’s recommendations is cost prohibitive. Part III.C. explains how provider communication failures can lead to noncompliance, whether the communication failure is about what prescribed medications a patient should undertake or patient education more broadly. Part III.D shows how “[a] patient’s perception that their provider is biased against them can…impact adherence to that provider’s recommendations” including through “reduced use of medical services.” Part III.E, “Medical Mistrust” discusses the many reasons why individuals might be suspicious of the healthcare setting, referencing notable instances of racial discrimination in the health care setting such as the federal government’s mistreatment of Black men in Tuskegee, Alabama. Moreover, Professor Abrokwa cites to Professor Nancy Krieger’s 2022 stunning reminder “…that everyone who is age 57 and older in this country was born when Jim Crow was legal.”

In Part IV, Professor Abrokwa explains how noncompliant patients can lose disability benefits, suffer reputational damage in benefits cases, and suffer potential reductions of damage awards in tort cases. In the next part, she provides solutions to minimize these harms. Part V.A. provides practical solutions that can reduce labels of “noncompliance” and render medical care more accessible in the United States, such as structural changes, hiring more providers of color, and hiring more providers with proficiency in multiple languages. She also acknowledges the limitations of these solutions, even referencing a study that found primary care providers would need “26.7 hours per day to see an average number of patients” in compliance with national guidelines. Part V.B focuses on the role of legal advocacy, including a description of one study, which found that “[m]ore than 1 in 5 patients perceived mistakes in their notes, judging more than 40% of them as serious.” In light of the role of medical records in litigation and benefits determinations, it is important that healthcare providers provide accurate notes. Lawyers can aid patients in requesting amendments to their health care records as that “process… can be time-consuming, resource-intensive, and emotionally taxing for patients to do on their own.” Moreover, Professor Abrokwa encourages attorneys to file complaints or pursue private litigation as appropriate and additionally advocates for attorneys, administrative law judges, and other judges to “carefully consider” why a patient might be noncompliant, in light of the reasons provided in Part III. She also encourages the Social Security Administration to issue guidelines that are less punitive of noncompliance.

The article brings attention to a significant but overlooked issue. Many individuals do not pay attention to their medical records after a provider visit, especially the section of their health record containing the summary of their visit with their providers’ notes. For those who do examine their own health records they may not realize that these provider notes exist not only for patient history but also as tools for physicians who have been counseled to write those notes in a way that minimizes the likelihood of lawsuits against them or more successful litigation outcomes as physicians. Yet, for patients, their providers’ notes, which are difficult to change, can be biased and harmful. Moreover, beyond legal outcomes, as Professor Abrokwa noted at the outset of her article, “[n]ot everyone survives being seen as non-compliant.”

Euthanasia Review Report: What is Happening in The Netherlands?

Feb 13, 2025 André den Exter1 comment

André den Exter

The Regional Euthanasia Review Committees (RERCs) in the Netherlands are required by statute to report annually on euthanasia and physician-assisted suicide (PAS) procedures carried out in the Netherlands. The general conclusion of the latest periodic evaluation was that euthanasia and PAS procedures are generally carried out with great care. It also concluded that the degree of willingness among physicians to report euthanasia remains high. Apart from these general observations, the report provides valuable information about euthanasia and PAS practice in the Netherlands, as well as how RTEs fulfill their statutory task of reviewing notified cases.

Understanding the Dutch practice requires some further explanation of the legal setting, i.e. Termination of Life on Request and Assisted Suicide Act (‘the Act’). Though euthanasia and PAS remain criminal offenses, physicians are released from liability if the statutory due care criteria are met and the act is reported to an RERC. Requests for euthanasia or PAS typically come from patients experiencing unbearable suffering with no prospect of improvement, who see these options as the only escape. All requests for euthanasia or PAS must be made earnestly and with full conviction. However, patients do not have an absolute right to euthanasia, and doctors have no duty to accept the patient’s request to perform it.

Doctors must report all unnatural deaths to the municipal pathologist. In cases of euthanasia or PAS, the pathologist notifies an RERC, which is comprised, at a minimum, of medical doctors, ethicists, and legal experts. The committee assesses whether the physician has fulfilled the statutory due care criteria. These criteria require the physician to: (i) be satisfied that the patient’s request is voluntary and well-considered; (ii) determine that the patient’s suffering is unbearable, with no prospect of improvement; (iii) inform the patient about situation and prognosis; (iv) confirm that there is no reasonable alternative for the patient’s situation; (v) ensure that an independent physician has examined the patient, and (vi) exercise due medical care and attention in the process of terminating life. Physicians who fail to meet any of these criteria are subject to prosecution. The review committee procedure ensures transparency and consistency in reporting and evaluating cases.

The 2023 report shows an increase in notifications of cases of euthanasia and PAS (9,068 compared to 8,200 in 2022; 7,666 in 2021). Cases involved patients with cancer (5,105); neurological disorders such as Parkinson’s disease, multiple sclerosis and motor neuron disease (605); cardiovascular disease (393); pulmonary disorders (340); or a combination of conditions, usually somatic (1,599) (P. 13). Though cancer was the most common cause, there were also instances of euthanasia or PAS based on mental suffering and dementia causing unbearable suffering with no prospect of improvement. There were 328 cases involving patients in early stages of dementia who still had insight into their condition and its symptoms, such as spatial and temporal disorientation and personality changes. An additional eight notifications involved patients in an advanced stage of dementia who no longer had decision-making capacity and were no longer able to communicate meaningfully regarding their request. In these cases, the patient’s consent was based on an advance directive (P. 13). In addition, 138 euthanasia notifications concerned patients whose suffering was (largely) caused by one or more psychiatric disorders. The report stressed that physicians must exercise particular in these situations (P. 15).

Multiple geriatric syndromes – such as sight impairment, hearing impairment, osteoporosis and its effects, osteoarthritis, balance problems, or cognitive decline – may cause unbearable suffering without prospect of improvement. These syndromes generally develop in older age and can lead to an accumulation of symptoms. In conjunction with the patient’s medical history, life history, personality, values, and stamina, they may give rise to suffering that the patient may experience as unbearable and without prospect of improvement (P. 15).

If both members of a couple make simultaneous requests for euthanasia and both requests are granted, the RERCs register this as ‘double euthanasia’. This occurred 33 times in 2023 (66 notifications). In each case, the due care criteria set out in the Act must be satisfied separately. Each partner must be examined by a different independent physician to safeguard the independence of assessing their requests (P. 20).

In five of the notified cases in 2023, the RERCs found that the physician who performed the act did not comply with all the due care criteria. In one of these cases, the committee found that the independent physician was not truly independent because he was registered as a patient in the practice of the general practitioner who performed the euthanasia. In three cases, the committee found that the physician had not exercised the necessary particular caution concerning a patient whose suffering was caused by a psychiatric disorder or a combination of a somatic condition and a psychiatric disorder. In another case, the committee found that the physician had not exercised due care because he left the medication with the patient before performing euthanasia (P. 20).

What makes the report interesting to read is the practice of euthanasia and physician-assisted suicide in the Netherlands, the number of reported cases, and examples of which physicians are struggling with. That counts particularly for instances of euthanasia or PAS based on mental suffering and dementia causing unbearable suffering. Although the Act was initially aimed at somatic suffering, gradually, its scope has extended towards other instances, causing unbearable suffering with no prospect of improvement.

© Nature of Conditions, Annual report 2023 Regional Euthanasia Review Committees