text:
Medical Malpractice Reform: Historical Approaches, Alternative Models, and Communication and Resolution Programs
Joseph S. Kass, MD, JD and Rachel V. Rose, JD, MBA
AMA J Ethics. 2016;18(3):299-310. doi: 10.1001/journalofethics.2017.18.3.pfor6-1603.
Legal responsibility for medical malpractice is not a new concept, with a history that can be traced back to the Code of Hammurabi in 2030 BCE [1]. Roman law recognized medical malpractice as a legal wrong, and this concept was expanded and introduced to continental Europe around 1200 CE [1]. English common law, from its medieval origins, "provide[s] an unbroken line of medical malpractice decisions, all the way to modern times" [2]. Derived from English common law, United States medical malpractice law—grounded in the legal concept of tort law—has evolved through decades of state and federal court decisions and been modified by legislative intervention [1]. As Black's Law Dictionary defines it, "A tort is a legal wrong committed upon the person or property independent of contract" [3]. It is an umbrella concept encompassing myriad categories such as negligence, gross negligence, professional negligence, recklessness, and acts of intentional harm (referred to as intentional torts). Medical malpractice is a form of professional negligence, since professionals discharging their professional duties are expected to act with a higher standard of care than nonprofessionals.
To prevail in a medical malpractice claim against a physician, the injured party (the patient or patient's family) must demonstrate that it was more likely than not (this requirement is known as the "preponderance of the evidence" standard) that the following four elements were present: (1) the physician had a duty to the patient; (2) the physician was negligent in his or her execution of the duty, (i.e., by breaching the standard of care); (3) the physician's negligent action was the proximate cause of the patient's injuries; and (4) the patient's injury resulted in damages, whether economic or other [4]. A breach of a physician's duty to patients can take many forms. For example, injuries may result from misdiagnosis, errors in the choice or technical execution of procedures, improper administration of medications, failure to follow up appropriately with a patient, and failure to obtain adequate informed consent [5]. The standard of care requirement means that the finder of fact, typically the jury, must hear testimony from both sides of the litigation about what the standard of care is and then evaluate that information to decide if the physician breached it, i.e., whether a reasonably prudent physician confronting similar circumstances would not have acted as the defendant physician did.
Studdert, Mello, and Brennan state that "[t]here are three social goals of malpractice litigation: to deter unsafe practices, to compensate persons injured through negligence, and to exact corrective justice" [6]. Thus, patients might reasonably expect medical malpractice law to serve as a deterrent to the improper practice of medicine and to compensate—through a negotiated settlement or a trial—patients who are victims of physician negligence. However, only a small number of harmed patients receive compensation, and a large number of compensated patients appear not to be victims of actual negligence [7, 8]. As Kessler [9] asserts, "[w]hile it is more difficult to assess the extent to which the malpractice system has provided incentives for appropriate care, a variety of evidence suggests that it has not" [10].
A significant literature suggests that physicians believe that pressure to avoid malpractice litigation leads to "defensive medicine" [9, 11]. Defensive medicine is medical practice performed primarily to limit future risk of a successful lawsuit against the physician and only secondarily to adhere to the medical standard of care. Defensive medicine can lead to a broad set of consequences: providing care that is "unproductive, not cost effective, or even harmful" or "declining to supply care that could be beneficial" [10]. Additionally, defensive medicine can also inflict moral harm on the physician and damage the patient-physician relationship. Defensive medicine is problematic ethically because it moves the focus of medical care away from the best interests of the patient toward the best interests of the physician. The ethical consequences of this change in focus are considerable. As Rentmeester and George write,
when a practitioner orients herself to a patient defensively, for example, the scope of her moral perception narrows and she draws her concern away from her patient toward herself. This kind of physician-centered practice suggests a physician's narrowed moral outlook toward her patients: what constitutes a reason to respond with care to a patient is defined narrowly (instead of broadly), exclusively (instead of inclusively), and meagerly (instead of generously) [12].
Studies measuring the effect of malpractice pressure on malpractice premiums, claims frequency, or claims severity tend to find evidence of defensive, unproductive care [7, 13, 14]. The costs of defensive medicine to the health care system, which a Cleveland Clinic study estimated to be $6 billion—in addition to the economic and noneconomic costs of malpractice litigation itself—have driven advocacy for malpractice reform [15]. Furthermore, it appears that medical malpractice tort reform does have a positive impact on the health care bottom line. For example, the Congressional Budget Office concluded in 2009 that "the weight of the empirical evidence now demonstrates a link between tort reform and the use of healthcare services" [16].
This article examines this country's historical approach to medical malpractice, traditional reform models, proposals based on alternative models, and the role of mediation and ethics consultation in medical malpractice cases.
Background: Malpractice Reform Attempts
In the United States, medical malpractice claims began to appear in the 1800s [17], but it was not until the 1960s that a surge of medical malpractice claims appeared in the courts [18]. This surge was likely driven by a number of factors: new and more complex treatments with higher risks of iatrogenic harm, a changing legal landscape that removed barriers to lawsuits and changed liability rules that had previously shielded charitable institutions from suit, and changes in satisfaction with the health care system, among others [19]. The rising incidence and costs of malpractice litigation led organized medicine to lobby for state and federal interventions to curb the burdens of the current malpractice liability system [9].
Medical malpractice reform is the product of political processes, whereby groups with different interests attempt to push their agendas. Physicians and physician organizations have tended to view most medical malpractice claims as spurious and injurious to the medical system, whereas patient advocates view the malpractice system as both a deterrent against the practice of dangerous medicine and an avenue for much-deserved compensation for injured patients [9].
In 2011, the National Conference of State Legislatures (NCSL) compiled an analysis of medical malpractice reform goals and initiatives [20]. The NCSL sought to address the challenges of cost containment while acknowledging that medical malpractice reform (i.e., tort reform) needs to address three major areas: limiting the costs associated with medical malpractice, deterring medical errors, and ensuring fair compensation for patients who are harmed [20].
Traditionally, reforms have attempted to change the medical malpractice climate in one of three ways: (1) allowing fewer lawsuits by creating barriers to filing, such as a prefiling certification or review of the medical merits of the case [20]; (2) limiting plaintiffs' compensation by imposing damage caps for noneconomic damages such as pain and suffering [21]; or (3) changing how awards are paid out to plaintiffs (payments over time versus large lump-sum settlements) [22]. Caps on noneconomic damages are the most common types of reforms and have been implemented in over half the states in various forms [23].
Hyman and colleagues used claim-level data to estimate the effect of Texas's 2003 cap on noneconomic damages on jury verdicts, post-verdict payouts, and settlements in medical malpractice cases closed during 1988-2004. The investigators found that the cap affected 47 percent of verdicts favoring plaintiffs and reduced mean allowed noneconomic damages by 73 percent and mean total payout by 27 percent. The noneconomic damages cap affected 18 percent of cases settled without trial and reduced predicted mean total payout by 18 percent [24]. In addition to affecting indemnity payments, it appears that damage caps also modestly reduce the rise in malpractice insurance premiums [25].
Although malpractice reform in the form of caps on noneconomic damages may reduce the actual payouts to plaintiffs, the broader impact of these reforms on reducing defensive medicine is less clear. Waxman and colleagues attempted to gauge the impact of these reforms on emergency department care in three states with malpractice reform—Texas, South Carolina, and Georgia—as compared to neighboring states without reforms [26]. Using a 5 percent random sample of Medicare fee-for-service beneficiaries, the investigators identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. They examined pre- and post-reform changes in the use of computed tomography or magnetic resonance imaging, per-visit emergency department charges, and the rate of hospital admissions and they did not find any policy-attributable reduction in care intensity: no significant reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no significant reduction in charges in Texas or South Carolina was found. Georgia, however, did see a modest 3.6 percent reduction in per-visit emergency department charges [26].
Alternative Dispute Resolution Methods
While traditional malpractice reform efforts could reduce the number and success of malpractice lawsuits in some states, they do little to help patients injured by physician negligence obtain what research suggests they truly desire: (1) an account of why the harm occurred; (2) an apology from the health care professionals involved; (3) information about how similar harms can be avoided in the future; and (4) appropriate restitution for an avoidable harm [27].
Society as a whole has an interest in cultivating a medical system in which medical practitioners do not practice defensive medicine but rather engage in process improvement at both the individual level and the system level. Therefore, to be effective, medical malpractice reform must balance the needs of all parties. The health care system must promote a culture of open communication between clinicians and patients that persists even after a patient has experienced a negative outcome (regardless of who or what is to blame), allows for robust process improvement, and offers compensation to injured parties. A possible beneficial effect of such a culture may be that patients trust their physicians when physicians truthfully explain that a poor outcome was due to the natural history of disease rather than the negligent practice of medicine. Such a system would be adversarial only as a last resort, and even under those circumstances it should build on mediation-based models such as communication and resolution programs, discussed in more detail below.
A 2013 study estimated that between 210,000 to 400,000 people die annually in the US due to medical error [28]. Ethically, a reformed medical malpractice system must address the fact that medical errors do injure patients and are at play in a significant number of malpractice cases. For example, Studdert and colleagues analyzed 1,452 closed malpractice claims from five liability insurers and concluded that 63 percent of the claims did, in fact, involve injuries due to medical error [29].
Alternative dispute resolution (ADR) models, which allow physicians and the health systems in which they operate to acknowledge openly when errors have occurred and offer reasonable compensation to the injured parties, balance the needs of clinicians—to act ethically by being truthful and engaging in vigorous quality improvement—and of patients—to receive compensation for negligence-induced iatrogenic harm. Alternative dispute resolution allows litigants to move out of a "battle" mentality and into a facilitated conversation to achieve resolution of the conflict.
Alternative dispute resolution typically includes either mediation or arbitration. These two approaches are quite different, but both can be quite effective in resolving disputes in a less adversarial and less costly manner than traditional litigation [30]. A number of health care institutions have experimented with a unique twist on ADR by developing communication and resolution programs (CRPs), novel approaches to addressing medical error that have paid off in terms of the costs associated with malpractice litigation [31-34]. These programs encourage open communication and transparency with patients and their families and facilitate restitution for injured parties when appropriate. They also support physicians in disclosure conversations with patients.
The Lexington, Kentucky, Veterans Affairs (VA) Medical Center was a pioneer in this area. In 1987, the Lexington VA implemented its CRP, which provided a full disclosure of the occurrence that led to harm as well as an expression of regret on behalf of the institution and its personnel [33]. Under this system, patients and their families are invited to bring attorneys to discuss offers of compensation early in the process. Although ADR in a health care situation likely provides a number of benefits to both the health care provider (by promoting honesty and ethical behavior) and to the patient and patient's family (by providing an honest accounting of what happened, including a statement of regret and possibly an offer of compensation), the empirical literature discussing ADR typically emphasizes quantitative, economic measures in the form of payouts as a measure of success. With the implementation of this program, the Lexington VA became the VA hospital with the lowest payouts. Between 1990 and 1996, the average settlement per claim in Lexington was approximately $15,622 [33], whereas in other VA institutions it was $98,000. Additionally, the average duration of cases decreased from 2-4 years to 2-4 months [35].
CRPs also exist outside the VA system and come in two varieties: early settlement and limited reimbursement [36]. The University of Michigan Health System (UMHS) was the first non-VA health system to adopt a CRP, implementing an early settlement model in 2001. UMHS self-insures [37]; all its physicians are employed and insured by the university rather than by commercial malpractice carriers, thereby simplifying buy-in to the CRP. This model has four components: (1) acknowledging when patients are injured due to medical error; (2) compensating fairly (commensurate with degree of harm) and quickly when there is a deviation from the standard of care; (3) aggressively defending against meritless cases; and (4) studying all adverse events to determine how health care delivery can be improved. Because the payments are made on behalf of the institution only, they are not reported to the National Practitioner Data Bank (NPDB) [36]. This operational detail is significant because the NPDB, which was created by Congress, "contains information on medical malpractice payments and certain adverse actions related to health care practitioners, entities, providers, and suppliers" [38]. It is publically available information that may affect a physician's reputation and follows a physician throughout his or her career. By not reporting this information to the NPDB, UMHS reduces an important barrier to physician participation in this CRP.
In a retrospective chart review of UMHS claims reported in the eight years before and the five years after full implementation of the CRP in 2003, investigators compared the number of new claims for compensation, the number of claims compensated, the time to claim resolution, and claims-related costs from 1995-2007 [31]. After full implementation of the CRP, the average monthly rate of new claims decreased from 7.03 to 4.52 per 100,000 patient encounters, the average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters, and the median time from claim reporting to resolution decreased from 1.36 to 0.95 years. Moreover, the average monthly cost rates decreased by at least 50 percent for total liability, patient compensation, and noncompensation-related legal cost [31].
The model employed by COPIC Insurance Company, a large medical liability insurer in Colorado, is an example of a limited-reimbursement model, the second type of CRP. In 2000 COPIC developed its 3Rs program—Recognize, Respond, and Resolve—to address situations in which their enrollees' patients were unsatisfied with their health outcomes [32, 39]. When patients suffer adverse outcomes they receive a disclosure of what occurred and compensation for out-of-pocket expenses not covered by insurance (up to $25,000) and for lost time (up to $5,000). Disclosure and compensation occur without a determination of physician fault. Patients retain the right to sue, and payments are not reportable to the NPDB. Physician participation is voluntary, and participating physicians undergo disclosure training. Exclusion criteria include death, clear negligence, attorney involvement, a complaint to the state board, and a written demand for payment. From October 2000 to October 2007, there were 4,800 qualified events, with 1,026 patients receiving payments averaging $5,286. Seven paid cases were litigated, and only two resulted in tort compensation. Sixteen unpaid cases were litigated, and six resulted in tort compensation. Anecdotal evidence and survey data suggest to the COPIC leadership that the system is successful. The majority of physicians and patients find the system effective and only a small fraction of cases that go through the 3R system evolve into litigated and compensated claims. Because of the open disclosure and compensation, the animosity between the injured patient and the physician appears to be reduced, and many patients maintain their therapeutic relationship with their physician [32].
Facilitating CRPs: Apology Laws
CRPs are one innovative approach to medical malpractice reform that address both patient and institutional needs. CRPs require, however, a culture shift in the medical community and a management of expectations on the part of injured patients who may be anticipating larger payouts than they are offered in this type of system. CRPs also require a favorable legal environment; they work best if "apology laws" explicitly protect clinicians and health institutions from penalty for discussing adverse events openly and honestly with patients and their families. Currently, apology and disclosure laws in the majority of states do not go far enough in fostering open communication after a medical error has occurred.
A 2010 study of state apology laws found that the laws of 34 states and the District of Columbia were not written in ways that foster open and honest communication between the physician and the injured party [40]. Of these jurisdictions, 25 states and the District of Columbia had "sympathy only" laws. This type of law prevents an expression of sympathy (e.g., "I'm sorry") from being entered into evidence as proof of malpractice. However, an explanation of the cause of the error and admission by the person at fault could be used at trial as evidence of malpractice. Only six states have laws protecting expressions both of sympathy and of fault; only three protect expressions of sympathy and an explanation of why the error occurred [40]. Furthermore, only nine states even require physicians to disclose an error to the patient, although hospital accrediting bodies such as the Joint Commission do in general terms require disclosure to patients. The Joint Commission Standard RI.2.90 states: "Patients and, when appropriate, their families are informed about the outcomes of care, treatment, and services that have been provided, including unanticipated outcomes" [41].
The interplay between CRPs and a given state's legal landscape surrounding malpractice reform (e.g., damage caps) and evidentiary standards (e.g., apology laws and protection of peer review), is complex and a full discussion of the many ways in which individual state laws affect CRP implementation is beyond the scope of this article. However, in general terms, certain state laws are believed to threaten CRP implementation. Sage and colleagues aver, "Consequently, changes to malpractice law and procedure might play a useful role in convincing providers and insurers to adopt CRPs…. Lack of motivation is a greater risk in states such as Texas and Washington that have less malpractice litigation; risk aversion is a bigger problem in states with more and more costly litigation, such as New York, Alabama, and Illinois" [42]. CRPs provide a system for physicians to discharge their ethical obligation to communicate honestly with patients. Even outside the context of a CRP, physicians should understand that patients are less likely to sue when they believe they have been dealt with honestly. Furthermore, attorneys, as a practical matter, rarely introduce apology-related information as evidence during trial because doing so contradicts the narrative of the physician as uncaring. However, these trends are not absolutes, and limited evidentiary protection of physician disclosure likely stymies open and honest conversation (thereby necessitating the development of CRPs) [42].
While CRPs require buy-in from an entire health system, a grass roots effort to encourage open communication after an adverse event began in 2005, inspired by the Lexington, Ky, VA approach. This advocacy organization, called Sorry Works!, aims
to encourage physicians, hospitals, and insurers to think differently about the medical malpractice crisis… [and] want[s] healthcare, insurance, and legal professionals to realize the solution was in their hands (as opposed to a legislature) by simply developing disclosure and apology programs that pro-actively heal everyone injured by an adverse event [43].
Sorry Works! has developed commercially available toolkits to train health professionals about disclosure. However, buy-in from the medical community is still a challenge outside an organized CRP. For example, in 2015 Medscape polled 4,000 physicians, including oncologists, about their experience with medical malpractice lawsuits, asking them if apologizing "would have helped avoid or mitigate a malpractice claim" [44]. Only 2 percent of male physicians and no female physicians reported feeling that an apology would have helped. However, the survey did not ask about experiences with disclosure and apology training [44].
Although most medical malpractice litigation takes place in the context of state law, the federal government's desire to expand alternative approaches to traditional litigation in medical malpractice cases is expressly delineated in the Affordable Care Act (ACA), section 280g-15(a): "The Secretary is authorized to award demonstration grants to States for the development, implementation, and evaluation of alternatives to current tort litigation for resolving disputes over injuries allegedly caused by health care providers or health care organizations" [45]. The Agency for Healthcare Research and Quality (AHRQ) awarded a number of demonstration grants to institutions [46], which implemented novel ways of dealing with physician malpractice [29]. To date, the effects of these novel approaches is unknown, and little has changed in the realm of medical malpractice under the ACA. However, the focus of many AHRQ demonstration grants is the development of CRPs.
Transparency and open communication with patients and families about medical errors allow medical practitioners to fulfill their ethical obligations to their patients even when outcomes are poor. These ethical obligations are grounded in the principles of autonomy, beneficence, and nonmaleficence and the virtues of compassion, courage, and honesty. Alternative dispute resolution models mitigate stress on clinicians, de-emphasize tendencies of health systems to try to hide fault, and help avoid dragging clinicians, patients, and others through time-consuming, costly, and reputation-damaging litigation. They can also mitigate the stress on patients and allow injured parties to receive reasonable compensation in a reasonable timeframe without the emotional and financial toll of the arduous litigation process. Creating a cultural, legal, and economic environment where communication and resolution programs can thrive may be an effective approach to creating a win-win situation for patients, physicians, and therefore society as a whole.
Autonomy/Informed consent,
Informed consent/Criteria,
Law and medicine/Defensive medicine,
Law and medicine/Malpractice,
Ethics/Practice,
Patient safety/Error disclosure,
Patient safety/Apologies
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AMA J Ethics. 2016;18(3):299-310.
10.1001/journalofethics.2017.18.3.pfor6-1603.
Dr. Kass has received payment for work as an expert witness in malpractice litigation cases.
The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
Joseph S. Kass, MD, JD is an associate professor of neurology, psychiatry, and medical ethics at Baylor College of Medicine in Houston, Texas, where he also serves as the assistant dean of students and the vice chair for education in the Department of Neurology. He is the chief of neurology at Ben Taub General Hospital.
Rachel V. Rose, JD, MBA is a principal with Rachel V. Rose—Attorney at Law, PLLC and teaches bioethics in Baylor College of Medicine's Center for Medical Ethics and Health Policy in Houston, Texas. She is co-editor (with Roberta L. Carroll and Peggy Nakamura) of the second edition of Enterprise Risk Management Handbook for Healthcare Entities (American Health Lawyers Association, 2013) and co-author (with Raymund C. King) of The ABCs of ACOs: A Practical Handbook on Accountable Care Organizations (American Bar Association, 2015) and (with Jonathan P. Tomes) What Are…International HIPAA Considerations? (American Bar Association, 2015).
Submit a manuscript for peer review consideration.
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KUNDURA CINEMA CELEBRATES THE 50TH ANNIVERSARY OF HISTORIC MOON LANDING
Kundura Cinema's November film programme presents a special selection of films that celebrates the 50th anniversary of the historic Moon landing. Titled "A Journey to the Moon", the film selection pays homage to American astronaut Neil Armstrong and his journey to the Moon and into history.
"A Journey to the Moon" centers around the films emphasizing the bravery of humans in the face of the unknown by exploring the depths of space. Get ready for an enchanting journey into space within Kundura Cinema's historical atmosphere.
Ticket to the Moon by the director Veronika Janatkova gathers together the participants signed up for the waiting list of Pan Am Airways' first commercial flights to the Moon. It is the Cold War Period, political and economic tensions permeated daily life and Pan Am Airways has the best solution: a trip to the Moon! The film centers around the hopeful story of 100,000 space enthusiasts today and humorously tells their individual moon stories.
Houston, We Have A Problem! Slovenian director Ziga Virc evolves around an intense space race, namely "the space program exchange" allegedly took place between the US and Yugoslavia during the Cold War. Receiving numerous positive and negative criticisms after its premiere in 2016 at Tribeca Film Festival, the documentary includes the real footage of the 35th president of the United States, John F. Kennedy.
Based on the Austrian director Fritz Lang's wife Thea von Harbou's book The Rocket to the Moon, the silent film Woman in the Moon follows a group of people searching for gold in space. Directed by Lang, one of the most assertive director worldwide, the film is also considered as one of the first examples of the sci-fi genre. Woman in the Moon will be screened as a part of the "Live Music to Silent Film" events of Kundura Cinema with a special guest performer.
Best known by building a set inside NASA to create a microgravity effect director Ron Howard's Apollo 13 is based on the true story of the ill-fated 13th Apollo mission bound for the Moon. Leading actors of this tragic story includes Tom Hanks, Kevin Bacon, and Bill Paxton.
Voyage to the End of the Universe Ikarie XB 1 focuses on a journey of a spaceship called Ikarie XB1 and its crew to planet Alfa Centauri to search for extraterrestrial forms of life. This dangerous journey illuminates the unknown corners of the universe while focusing on the everyday worries of its crew. Directed by Jindrich Polák, Voyage to the End of the Universe Ikarie XB 1 portraits a hope for better and morally more advanced humankind.
Hollywood Classics: "Cat On A Hot Tin Roof"
Inspired by the Tennessee Williams' Pulitzer Prize winning play, Cat On A Hot Tin Roof will be screened for the second time on the 29th of November at Kundura Cinema for those who missed it in October. Elizabeth Taylor starring as the lead actress, the film focuses on an alcoholic ex-football player named Brick and his reunion with his father, Big Daddy, who is dying of cancer. Save the date for the beloved Hollywood Classics programme with complimentary drinks and nibbles.
Film Programme, November 2019:
November 16th, Saturday 16:00 | Ticket To The Moon - 2019, Veronika Janatková
November 17th, Sunday 19:30 | Apollo 13 - 1995, Ron Howard
November 23rd, Saturday 16:00 | Houston, We Have a Problem! - 2016, Žiga Virc 19:30 | Apollo 13 - 1995, Ron Howard
November 24th, Sunday 16:00 | Woman in the Moon, 1929 - Fritz Lang **
November 29th, Friday "Hollywood Classics" Special Screening 21:00 | Cat On A Hot Tin Roof - 1958, Richard Brooks
November 30th, Saturday 16:00 | Ticket To The Moon - 2019, Veronika Janatková 19:30 | Voyage to the End of the Universe Ikarie XB 1, 1963 - Jindrich Polák
** Woman in the Moon will be accompanied by live music.

redpajama_set_name: RedPajamaCommonCrawl


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Katherine Rebekah Reviews: The Killing Joke
May 9, 2016 May 10, 2016 Alan Moore, Comic-Books, Comicbooks, Comics, DC Characters, DC Comics, Katherine Rebekah Reviews, The Killing Joke, Uncategorized
When Joker escapes once more from Arkham Asylum, he's out to prove a point: that any man can be driven to insanity in just one bad day.
Batman: The Killing Joke is one of the most iconic Batman comics today. Dubbed by many as having the the best version of Joker, it often receives high praise and rave reviews. And it's easy to see why, with stunning artwork and a hooking story line, so horrific you never want to look away. Joker is truly Joker in this comic, and doesn't shy from the most gruesome of acts to prove his terrifying point. But even though I enjoyed The Killing Joke, I felt like there were a few fundamental issues that made it less the comic I thought it would be. Issues that often get lost in the parade of fan fare that follows this iconic piece.
The Joker is out to prove a simple point, that even the sanest man can be reduced to lunacy with just one bad day. He jumps through hoops to prove this, and does things that make your stomach drop with sickness, abusing and dehumanizing some of the most beloved characters in the history of Batman. We truly see how evil The Joker can be. But another layer is added to the plot that shows us the Joker's deeper motive behind his insane crusade when we get a back story for the Clown Prince of Crime.
There are two areas where I think this would be excellent plot fell flat. The first is in the heinous acts committed by the Joker. While you get some people complaining that he was too cruel, I don't feel that way. The Joker gave up to soon. He didn't push far enough. And, in the end, he didn't prove his point. One of the most chilling things about Heath Ledger's Joker (excuse me for comparing a comic to a move) was when he succeeded in proving the cruelty and insanity lying dormant in every man. His success made it all the more powerful when people overcame him. In The Killing Joke, The Joker doesn't get a victory. His point is not proven, and it waters down what could have been a bone chilling story.
The second issue I find in the back story. I'm of the mindset that Joker shouldn't have a back story. I feel it's one of the things that gives him his power. But I was willing to accept one should it be as dark, demented and terrifying as the villain himself. What I got was not what I expected. The backstory is rather generic and I didn't find it satisfying at all. He starts out as a failing comedian who's married and expecting a child. SPOILER His wife dies, he gets caught up with some criminals and ends up falling into a vat of chemicals, which is what turns him insane. SPOILER END I don't like this version because it removes the Joker from his choice of going crazy all on his own. And the Joker's ability to choose insanity is what I feel makes him a powerful villain.
As far as how the Joker acts in this comic, it's golden. He's completely twisted, with no sense of morals and is willing to do anything to prove his point. He is cruel. He is unpredictable. He is insane. He is the Joker. And I loved every second of it.
The same goes for Batman. He acted himself and I enjoyed him when he was on stage. Unfortunately, we didn't see as much of him as I would have liked. I feel like the Joker's experiment should have been directed at Batman, but it wasn't and the paradigm shift felt odd.
The experiment was actually directed at Jim Gordon, who I also felt was very in character and played his part well. If I would complain about anything, I'd say I wish he was a little more emotive. He's dragged through Hell and back in this comic. I wish it would have caused him to crack, just a little.
Barbra is a topic of much controversy in this comic, because of the terrible things that happen to her. She doesn't play a big role other than the victim, which I admit was a bit irksome, because we all know that Batgirl can kick butt. But the way her character acted was understandable, and I enjoyed her during the moments she was center stage. She has one very touching moment with Batman, while in the hospital, that I found absolutely heart wrenching.
The art was stunning and the colors fantastic. It did its job, setting a mood for the story and is possibly my favorite art in a comic yet. It also has some interesting history, as the current version in print is not the same as the version that was first printed. During its first printing the line art was done by Brian Bolland and the coloring by John Higgins. Latter, Bolland had the opportunity to go back and recolor it (he also made a few tweaks to the original line art) to better match the feel he's originally wanted for the story, and boy am I glad he did.
I love the premise of this comic because it's so very Joker. "All it takes is one bad day." It's a wonderful and terrifying promise, but I do think it fell flat because of the delivery. Good triumphed too easily. And perhaps that sounds sadistic of me, but for a comic centered around the Joker I feel a larger struggle was needed.
It should be noted that this comic is graphic. It's violent. It's gut wrenching. It's not for the faint of heart. I strongly urge anyone who isn't comfortable with violence and the dehumanization of characters to stay away. This is serious Joker, guys.
I liked the Killing Joke, but because of a few issues I fell just short of love.However, it's an iconic, thought provoking comic and well worth the read. I recommend it to any and all Batman enthusiasts.
As a side note, I would like the thank the Constant Collectable team for welcoming me into your ranks. I'm so excited to start working with you guys! Looking forward to all the reviews to come.
Katherine Rebekah Reviews
Previous Press Release:@Cryptozoic Ghostbusters Trading Cards
Next TV Time: @IDWPublishing Bring Locke & Key to TV
Hannah Heath says:
Awesome review, Katherine! I loved all of your different categories. It really helped lay things out clearly. Joker's backstory does seem a little bit off from what I'd expect. I'm pretty sure I'm not going read this one (I can do violence, but not torture) so I liked reading your review. It filled me in on some questions I'd had about this comic book. Thank you so much for sharing! Epic, epic job! Welcome to the team. :D
Katherine Rebekah says:
Thanks, Hannah! I'm so happy to be here. :)
I get what you mean about torture. The torture in here is more psychological, though? I could explain better if I weren't afraid of spoilers. I'll shoot you a DM if you like. There might still be a chance that you'll like it.
NO NO NO NO, YOU need to read it!
I agree! Perhaps I was a bit dramatic and made it sound too dark? I think you would like it. I mean, it's a Batman classic. How can you pass?
Fiiiiiine. If you and Simon say so. Off to place a hold at the library. I guess there's really no way I can skip a Batman essential.
Ahah, you can not escape it. (Seriously, though. If you've got misgivings I can tell you about it.)
transhaan says:
Awesome review! Interesting downsides you've got there. I absolutely adored this graphic novel and highly praise it myself! :P I can't wait for the animated adaptation that's coming out soon. Iconic and amazing talents are coming back to voice Batman and Joker and I even hear they might add extra content to the adaptation. Can't. Wait. :D
– Lashaan
Thank you! I'm really excited about the animated feature too. When I watched the preview I saw Batgirl suited up, so I'm thinking we might just get that extra content. It's going to be so awesome! :D


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Safety Standdown Strives To Normalize Excellence
by Kerry Lynch
- October 30, 2018, 10:46 AM
Bombardier Safety Standdown opened today with chief safety leaders from the FAA, NTSB, and the business aviation community highlighting this year's theme of "Normalization of Excellence" to upwards of 700 attendees.
Entering its third decade, attendance has grown to the point where Bombardier did not have enough space for the 100 more who hoped to attend. Over the years, the event has attracted more than 10,000 people (combined) and scores more listening in to the event that is now webcast online.
Andy Nureddin, vice president of customer support and training for Bombardier, pointed to the shared passion for safety that has stemmed from Bombardier Safety Standdown and reiterated that "our community can't afford to take safety for granted."
Also opening safety standdown was John DeLisi, director of the National Transportation Safety Board's Office of the Aviation Safety, who highlighted the safety record of the U.S. Part 121 operators—which went nine years without a fatal accident until just this past spring—and said now is the time to focus on Part 91 and 135.
A perennial favorite at Safety Standdown, Convergent Performance's Tony Kern outlined the importance of being a "grinder." He pointed out top golfers who were grinders—they do not dwell in their mistakes but push through and look to the opportunity to take new shots. Kern encouraged the audience not to fall into the handcuffs of mediocrity that can come with experience over time. Instead, he challenged them to be a grinder, strive for a high level of professionalism that he said is "normalized excellence."
Noting the importance of maintaining not only safety but the perception of safety for the industry, NBAA v-p of regulatory and international affairs Doug Carr pointed to his association's recent reaffirmation of its commitment to safety with the signing of its safety policy letter earlier this month. Carr lauded the many participants willing to collect and share data to help build on the safety record, and encouraged audience members who have not yet begun such practices to reach out to those who do to learn how to overcome obstacles to data sharing.
Michael Zenkovich, deputy executive director for the FAA's Flight Standards Service, emphasized that "we're all on the same team," adding that while rules and regulations are important, they must come in concert with a strong safety culture.
https://www.ainonline.com/aviation-news/business-aviation/2018-10-30/safety-standdown-strives-normalize-excellence


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Hard to swallow: What's in SLO County's water?
By Chris McGuinness
Correction: PFOA and PFOS was not found in samples of SLO City water, as the data indicated a statistical non-detection, according to SLO City and the EPA.
The water comes out of the tap clear and cool. In the glass it looks just fine. Light dances across its surface, rippling off the liquid's movement.
But appearances can be deceiving. Just ask the 10—possibly more—well owners near the San Luis Obispo airport who recently found out that something potentially dangerous is lurking in their water.
It's called trichloroethene or trichloroethylene, but most refer to it as TCE. The chemical, which is listed as a probable carcinogen, was discovered in amounts above what the Federal Environmental Protection Agency considers safe.
It started with a single well owner who noticed their water had a chemical smell. When the water was tested, TCE was discovered. A test of other nearby wells revealed TCE amounts above the EPA's levels in four additional wells.
PHOTO COURTESY OF THE U.S. DEPARTMENT OF DEFENSE
FOAM: Aqueous Film Forming Foam, of AFFF, is used to fight fires caused by highly flammable liquids, such as oil, gasoline, and jet fuel. The U.S. Military is one of the largest purchasers of AFFF.
A week later, SLO County and state water board authorities were still investigating just how the chemical, commonly used as an industrial solvent, got into the water. There's some speculation that it may have come from the SLO Regional Airport, which sits uphill from the area where the contamination was found. But even as officials investigate further, they are still unsure just how many wells could actually be affected. Rick Moran, a spokesman for the State Water Resources Control Board, told New Times that an additional 37 wells had been tested, and six of those contained levels of TCE beyond the EPA's standards.
The issue continues to grow in scope, and now lawyers are involved. Several of the well owners retained the representation of two law firms that specialize in environmental cases, and they started doing their own testing. One of those attorneys, San Diego-based John Fiske, said his firm tested 20 wells, and at least some of those are expected to test positive for high amounts of TCE.
And while SLO residents continue to keep an eye out for more news of TCE contaminations, the solvent isn't the only questionable chemical found in local water supplies. At least two of those other chemicals could be connected to military installations on the Central Coast.
Emerging contaminants
So far, the presence of high levels of TCE in local wells is relegated to a small area near the airport—Buckley Road, bounded by Davenport Creek Road, Evans Road, and Thread Lane.
But two other chemicals, ones currently unregulated but considered to be "emerging contaminants" by the EPA and state officials, have also been found in water samples taken throughout the county.
They are called perfluorooctane sulfonate and perfluorooctanoic acid, or as they are more commonly referred to PFOS and PFOA. Both belong to a larger group of chemicals known as perfluorinated chemicals, or PFCs. The chemicals are man-made and have been utilized for numerous commercial and industrial purposes. According to the EPA, they've been found ubiquitously in the environment.
"As a result, they are widely distributed across the higher trophic levels and are found in soil, air, and groundwater at sites across the United States," a 2014 EPA report on the two compounds stated. "The toxicity, mobility, and bioaccumulation potential of PFOS and PFOA pose potential adverse effects for the environment and human health."
The EPA is still studying the health risks of exposure to high amounts of PFOA and PFOS. In 2006, the agency's science advisory board determined that PFOA met the requirement to be designated as "likely carcinogenic" to humans. Other studies found possible links between the chemicals and everything from kidney and bladder cancer to thyroid disease, though most noted that further research was necessary.
"Studies indicate that PFOA and PFOS can cause developmental, reproductive, and other adverse effects in laboratory animals," an EPA response to questions from New Times stated. "The most consistent findings from epidemiology studies are elevated serum total cholesterol levels among exposed populations with more limited findings related to low infant birth weights."
The evidence was not enough for the EPA to classify PFOA or PFOS as a hazardous substance or waste. Instead, the agency issued a provisional health advisory in 2009 identifying them as "emerging contaminants." EPA officials told New Times that the agency plans to issue a lifetime advisory on both chemicals later this year. However, advisories are simply guidelines and not standards that the agency can enforce under federal law.
"Health advisories are not enforceable federal standards," the EPA's statement to New Times said.
It isn't just the EPA that's concerned. The Reproductive Toxicant Committee of the California Office of Environmental Health Hazard Assessment is considering whether to put both chemicals on a list of substances that cause reproductive harm under the state's Proposition 65 law.
"After considering presentations by the staff, [the committee] decided to assign both chemicals a high priority for future listing consideration," said Sam Delson, deputy director for External and Legislative Affairs for the California OEHHA.
In our water
Both PFOA and PFOS fall under the EPA's Third Unregulated Contaminant Monitoring Rule, or UCMR 3. Created as part of the 1996 Safe Drinking Water Act, UCMR 3 requires the EPA to issue a list of no more than 30 unregulated contaminants to be monitored by public water systems every five years. Both PFOA and PFOS are on the most recent list. Private wells aren't required to be tested under the rule.
"It's a way for the EPA to gather more information about those chemicals," said Jeff Densmore, District 6 supervisor for the State Water Resources Control Board Division of Drinking Water Programs. "Typically it's the local water utilities who take those samples."
CONTAMINATION: Thousands of gallons of chemical foam has been used by the military to train soldiers to fight fires at military installations, including those located in SLO and Santa Barbara counties. Now, the EPA worries that the practice caused possibly harmful chemicals to leach into the soil and groundwater.
According to the EPA's data, both chemicals appeared in multiple water samples taken across SLO County between 2013 and 2015. Under the monitoring rule, about 510 samples were taken and tested for the contaminants on the list. PFOA or PFOS showed up in water samples taken from all over the county, including the city of San Luis Obispo, Santa Margarita, Morro Bay, Atascadero, Paso Robles, Arroyo Grande, Grover Beach, and Nipomo. Even samples from the California Men's Colony contained the two chemicals.
Just how much is in that water, and is it safe? In 2009, the EPA's provisional health advisory established the presence of PFOS above 0.2 micrograms per liter and PFOA above 0.4 micrograms per liter as amounts at which "action should be taken to reduce exposure."
The EPA's data showed that 99 percent of all the samples in SLO County that tested positive for PFOS or PFOA were below those levels. A single sample taken in Atascadero in 2013 had PFOA equal to, but not above, the EPA's recommendation.
It's unknown whether those chemicals are present in SLO County's non-public water sources, such as private wells, and in what amounts. While county environmental health officials recommend residents test their private wells once a year, there's no law or requirement that they do so.
Even small amounts of contaminants in water could become a problem in the future, due to the effects of the state's drought. As part of the county's investigation into the TCE contamination, information from the SLO County Environmental Health Department's website noted that the increased amounts could be the result of lowering water levels allowing contaminants to become more concentrated.
"According to the water board staff, it is possible that the drought may be contributing to the increase in TCE concentrations due to a decreased dilution effect," the website stated. "Meaning TCE may represent a higher proportion of the water content in use since groundwater levels are historically low."
Densmore, whose region includes SLO County, agreed that the drought was having an impact.
"We have seen a change in water quality in our district," he said. "Nitrates and man-made chemicals, they've been effected by the drought. The concentrations can become higher."
The military connection
If there are PFCs in SLO County's water, how did they get there? The question is made all the more perplexing because PFOA is being voluntarily phased out of use, and PFOS is—according to the EPA—no longer manufactured in the United States as of 2002. However, the EPA's rules still allow limited use of those PFCs for specific, technical uses where no alternative option is available and for existing stocks of PFC-based chemicals manufactured or imported before 2002.
A massive amount of that pre-2002 stock is held by a single entity: the United States Military.
The EPA's reports and information on PFCs note numerous times that the chemicals, particularly PFOS, are present in Aqueous Film Forming Foam, or AFFF. The foam was developed as a way to fight fires caused by highly flammable liquids, including jet fuel. Burning at temperatures between 800 and 1,500 degrees Fahrenheit, fires from aircraft crashes and other accidents can't be put out easily with water.
The military began widespread use of the PFOS-based foam as far back as the 1960s according to the Department of Defense's Chemical and Material Risk Management Directorate.
"Due to their long shelf lives, legacy AFFF, including PFOS-based AFFF concentrate, may still be present in your inventory," an alert issued by the directorate stated.
This "legacy" foam not only contains PFOS, but can also break down into PFOA, according to the alert. The foam is still OK'd for use by the military, and there's a lot of it. According to an investigative report on the issue by the online publication The Intercept, the U.S. military had a 1 million gallon stockpile of the PFOS-based foam as of 2011.
PHOTO BY DYLAN HONEA-BAUMANN
WHATS IN SLO'S WATER : The recent discovery of the chemical TCE in other SLO wells has area residents wondering just what is in the water in their holding tanks.
The foam isn't just used for plane crashes and explosions, which are relatively rare occurrences. It's also used in training exercises to show military soldiers how put out fires. Those trainings resulted in thousands of gallons of the foam being dispersed. For years, those exercises consisted of shooting the foam into what was essentially a hole dug in the earth.
"Although not allowed for use today, the DOD has used unlined, earthen area/basins to support live firefighting training activities," the directorate's alert stated. "These activities may have resulted in soil and groundwater contamination."
The document also noted that, in addition to actual jet crashes and trainings, the foam could also be introduced into the environment from storage tanks, transport lines, and facilities equipped with AFFF fire suppression systems, such as aircraft hangars.
In its statement to New Times, the EPA acknowledged the connection.
"There is a connection between PFC contamination and facilities or locations where fuel fires or fire training activities have occurred. Airplane crash sites, flight lines, and military fire training areas can be point sources due to the use of AFFF to extinguish the fires. This connection is apparent worldwide, not just in the U.S.," the EPA said.
In its investigative report, The Intercept obtained a list from the DOD of active and former military installations that were fire or crash training sites. That list includes two names that SLO County residents will likely be familiar with: Camp Roberts and Vandenberg Air Force Base.
A tale of two bases
Located roughly 15 miles north of Paso Robles, Camp Roberts is a military installation with a rich history dating back to WWII. At its height as a training facility in the 1940s, an estimated 46,000 American soldiers passed through the base. The camp also saw heavy activity during the Korean and Vietnam wars before the Army closed Camp Roberts in 1970 and turned the installation over to the California National Guard, which operates the site to this day.
According to the DOD's information, Camp Roberts is or was home to a "fire training area" as of 2014, making it a likely site where AFFF was used, and a possible site of contamination. Officials from the California National Guard said that Camp Roberts had received no requests to test soil or groundwater for the chemicals, but that the base no longer used "environmentally dangerous" firefighting foam.
Vandenberg Air Force Base, a coastal installation located 20 miles south of Santa Maria in Santa Barbara County, has a similarly rich military history. It started as an Army training center, called Camp Cooke, in 1941. The site was eventually turned over to the Air Force in 1957. Today the base is home to the 30th Space Wing's ICBM and space missions, is the only military installation that launches unmanned government and commercial satellites into polar orbit, and is the only site from which Minuteman III intercontinental ballistic missiles (ICBMs) are launched toward the Kwajalein Atoll to verify weapon systems performance, according to the base's website.
WATER TROUBLES: While municipalities and water utilities are required to test for contamination, it's up to owners of private wells to test their own water.
The DOD also listed Vandenberg as a "fire training area" as of 2014, again making it likely that the PFOS-based foam was and may still be used for firefighting and fire training exercises. Vandenberg Air Force Base officials did not respond to a request from New Times for an interview.
The Air Force, like other military branches, is aware of the issue and has been taking steps to study and mitigate possible contamination from AFFF. A memo of talking points from the Air Force Civil Engineer Center stated that the Air Force planned to begin a three-phase process to indentify potential PFOS and PFOA releases, assess potential human exposure, and if necessary, take action to mitigate any harmful impacts. That three step approach will focus on crash sites, areas with fire suppression systems, and fire training areas, the memo stated.
The DOD's Chemical and Material Risk Management Directorate's alert advised following current standards created to contain and minimize AFFF release into the environment such as double lining the fire training pits, improving wastewater collection systems, and using non PFOs-based "training" foams that are currently available.
Pease AFB is a troubling example
The keen interest taken by the DOD and the other branches of the military over the PFC contamination issues isn't surprising, especially in light of a high-profile incident in Portsmouth, N.H.
In May 2015, Portsmouth officials were forced to completely shut down a city well after PFCs were discovered in levels 10 times above those the EPA deemed safe. The site, a trade port that houses three wells, was formerly Pease Air Force Base—which, like many other bases, conducted fire training exercises using the PFOS-based foam for years. According to a 2015 report from New Hampshire television news station WMUR, nearly 10,000 people work at the trade port, and the area of contamination was also home to two day cares. The state of New Hampshire's Department of Health and Human Services began offering blood tests to residents and expect the results of those tests to come back in April.
The problem could be far more widespread. According to The Intercept's reporting, PFCs have been found in the groundwater at several bases, including the Air National Guard base in Delaware, the Grissom Air Reserve Base in Indiana, and even the Beale and McClellan Air Force bases located in California. Testing at hundreds of sites still appears to be ongoing, and the ultimate impact on nearby groundwater and communities that rely on that water, like those in SLO County, remains unknown.
So while federal, state, and military officials grapple with the questions of just how much of the chemicals are in the water and what risk they may or may not pose to humans, there is little that residents can do to mitigate the problem. Private wells and water sources can be tested and monitored. The EPA suggests that carbon filters, nanofiltration, and reverse osmosis units have been shown to remove PFCs from water, but the agency followed that assessment with a note that will likely give many pause.
"Research for a cost-effective treatment approach for PFOS and PFOA is ongoing," the EPA said.
Staff Writer Chris McGuinness can be reached at cmcguinness@newtimesslo.com, or on Twitter at @CWMcGuinness.
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« Viewer Discretion - Jan. 21, 2016 | You gonna eat that? »
SLO County set to extend Paso Robles groundwater restrictions
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