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June 26, 2008

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By MIKE STOBBE, The Associated Press
Tuesday, June 24, 2008; 7:32 AM

ATLANTA — The elderly fear breaking a hip when they fall, but a government study indicates that hitting their head can also have deadly consequences: Brain injuries account for half of all deaths from falls. The study by the Centers for Disease Control and Prevention is the first comprehensive national look at the role brain injuries play in fatal elderly falls. It examined 16,000 deaths in 2005 that listed unintentional falls as an underlying cause of death.CDC researchers found that slightly more than half of the deaths were attributed to brain injuries. The other deaths were due to a variety of causes including heart failure, strokes, infections and existing chronic conditions worsened by a broken hip or other injuries sustained in a fall.

“A lot of people don’t think a fall is serious unless they broke a bone, they don’t think it’s serious unless they break a hip. They don’t worry about their head,” said Pat Flemming, a senior physical therapist and researcher at Vanderbilt University

Each year, one in three Americans age 65 and older fall. About 30 percent of such falls require medical treatment.

Previous CDC research showed that the U.S. death rate from falling has risen dramatically _ about 55 percent _ for the elderly since the 1990s. The new study highlights the role that brain injuries play in such deaths.

As people age, veins and arteries can be more easily torn during a sudden blow or jolt to the head, said Marlena Wald, a CDC epidemiologist who co-authored the study.

That can cause a fatal brain bleed. Other factors can contribute, such as the use of blood-thinners, said Judy Stevens, another CDC researcher and co-author.

The severity of brain injuries isn’t always immediately apparent, and some people may not lose consciousness. Wald noted a scenario seen in hospitals in which an elderly fall victim comes in alert and talking, but dies an hour or two later.

The study also found that deaths and hospitalization rates for fall-related brain injuries increased with age. Brain injuries accounted for about 8 percent of hospital stays for non-fatal falls.

There are several steps older Americans can take to try to prevent falls. Exercise can increase leg strength and balance. Glasses or other vision correction measures can help people avoid obstacles. And being careful with the use of drugs that can affect thinking and coordination _ such as tranquilizers and sleeping pills _ can also make a difference.

“Falls are not an inevitable consequence of aging. These head injuries are not inevitable, either,” Wald said.

The research is being published in the June issue of a scientific publication, the Journal of Safety Research.

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June 17, 2008

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By Arnold Wax, MD

Negligence and malpractice can injure patients, but so can juries, as this specialist discovered.

I’m a medical oncologist who was one of the original forces behind the tort reform movement in Nevada. Overall, I’m happy with the changes in our state, which I believe were necessary to keep good physicians practicing here. Nevertheless, one particular case showed me how the system can backfire.

In 2002, a delightful woman I’ll call Mary was referred to me. Two years earlier, she had developed a skin lesion on her pubic area, which her family physician removed and a pathologist diagnosed as a dysplastic nevus. The margins were cleared, and Mary went on her way.

In 2004, the lesion recurred and her FP again removed it. This time it was malignant. Mary was then referred to a general surgeon for a wide excision and primary closure. Because of the lesion’s proximity to lymphatics, I requested a lymphoscintigram and a sentinel lymph node biopsy. The surgery was completed and, much to my surprise and chagrin, the lymph node biopsy was positive for melanoma.

Mary was an active person who needed to be fully ambulatory to keep her job and help care for her grandchildren. With this in mind, we discussed the possibility of an inguinal lymph node dissection. But because the surgical complications would interfere with her ability to make a living, she declined.

After a negative staging workup, we discussed her other options: observation, clinical trial, or interferon therapy. Mary wanted to treat her disease, so she passed on watchful waiting. Likewise, participating in a clinical trial was out of the question, because she’d have to leave town to be treated. That left interferon therapy, which she agreed to.

Earlier evidence of malignancy

In the interim, a second pathologist reviewed Mary’s original report from 2002 and found the results were consistent with a diagnosis of malignant melanoma, not a dysplastic nevus. Shortly thereafter, the original pathologist admitted that he’d misread the slides.

Then came the interferon therapy, complete with the expected side effects-fever, chills, sweats, fatigue, and depression. Mary’s health declined to the point where she had to take a leave from work. She also developed an unexpected side effect: marked liver function abnormalities, which led to profound weight loss. The interferon was stopped, but the abnormalities persisted. A liver biopsy was performed, and Mary was found to have an autoimmune hepatitis, unmasked but not caused by the interferon. Plans for further therapy were abandoned and, in time, her liver problems resolved.

As I’d expected, Mary sued the pathologist who had misread the original biopsy. Soon after, one of her attorneys asked me to serve as an expert witness in the case. As her treating physician, I felt a moral obligation to support Mary’s claim. Her lawyer said she was asking only for damages to help provide for her grandchildren-which ultimately became more important when her husband died unexpectedly from a post-surgical pulmonary embolus.

It appeared that the case would be resolved quickly, considering that the defendant freely admitted his error. However, this turned out to be far from true.

Juries can be fickle and misinformed

Affidavits were submitted and depositions taken, including mine. With the comments and bare facts now available, the case went to trial. While this easily could have been a $1 million-plus case, tort reform in Nevada meant Mary couldn’t receive more than $350,000 in noneconomic damages (pain and suffering) or any collateral source payments. The value of Mary’s medical costs, which exceeded $100,000 and were covered by insurance, wouldn’t be included in any award.

The trial lasted six days. I was on the witness stand for two hours for direct and cross examination. I described the statistical decrease in Mary’s five-year survival, as well as all treatment variations between the different stages of melanoma. I also stated that I thought the pathologist’s admission of his mistake was “honorable.”

As I’d expected, the jury found the original pathologist negligent. But, to my surprise, Mary wasn’t awarded any damages. One of her attorneys later told me that the jury wanted to pin an award on the pathologist’s professional corporation, but it hadn’t been named in the suit. The jurors reasoned that the pathologist had not acted maliciously, and that if he were found liable for a monetary award, he might leave the state. They were likely influenced by political ads that ran during the state’s tort reform ballot campaign, describing physicians who were leaving Nevada because of its malpractice crisis.

The trial judge was incensed by the verdict, because the jury didn’t follow the legal standard that should have been applied in the case. I was later informed that the defense attorneys planned to go after Mary for court costs, something that the judge vowed he’d never let happen.

Today, Mary is a widowed grandmother, caring for her grandchildren with few resources-injured, admittedly, by a physician’s error. She’s been off of all therapies since the interferon, which proved successful. But if her melanoma recurs, it will likely be fatal.

When I helped spearhead the tort reform movement in Nevada, I didn’t foresee the unintended consequences of innocent, truly injured individuals not receiving their rightful awards due to jurors’ misguided emotions. Had I been aware of that possibility, what would I have done?

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WASHINGTON, June 5 (Reuters) - Hispanic workers in the United States are killed at work at a 25 percent higher rate than other U.S. workers with many deaths coming in construction, federal health officials said on Thursday.

Hispanics disproportionately take dangerous jobs like construction. Some may hesitate to speak up about safety hazards and may accept risky tasks for fear of being fired, the U.S. Centers for Disease Control and Prevention said.

The most common causes of death were falls at construction sites and roadway incidents including crashes or being hit by a car while working on a road crew, the CDC said. Deaths from workplace falls increased about 370 percent from 1992 to 2006.

The report tracked Hispanic workplace fatalities of U.S. citizens, legal immigrants or illegal immigrants.

Immigration has become a potent political issue in the United States where about 12 million illegal immigrants live, many from Mexico, Central America and South America.

In 2006, the death rate for Hispanics was 5 per 100,000 workers, compared with 4 per 100,000 for all workers, 4 per 100,000 for non-Hispanic whites and 3.7 per 100,000 for non-Hispanic blacks, the CDC said.

Hispanics are the nation’s fastest-growing minority. There were 19.6 million Hispanic workers in the United States in 2006, 56 percent of them foreign born.

They have become an increasingly important source of labor in U.S. construction.

An analysis of construction deaths found that Hispanic workers had higher rates than non-Hispanics in the same occupations such as laborers or roofers, the CDC said.

Dr. Sherry Baron of the CDC’s National Institute for Occupational Safety and Health said inadequate training and supervision of workers, often made worse by language barriers or literacy problems, were factors behind this trend.

From 1992 to 2006, 11,303 Hispanic workers — 95 percent of them men — died due to workplace injuries, accounting for about 13 percent of overall such deaths in the United States.

The CDC said 67 percent of Hispanics killed in job injuries were foreign born, almost three quarters from Mexico. It said the work-related injury death rate for foreign-born Hispanic workers is about 70 percent higher than U.S.-born Hispanics.

The highest job fatality rates for Hispanics were in South Carolina (22.8 per 100,000 Hispanic workers), Oklahoma, Georgia and Tennessee, the CDC said. (Editing by Alan Elsner and Maggie Fox)

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June 4, 2008

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This case presents two issues of first impression. We hold that under some circumstances a minor’s invitation to enter the premises may bind the landowner for purposes of premises liability, and that a trampoline may constitute an attractive nuisance. In this case both issues turn on facts not appropriately resolved on summary judgment.

Facts and Procedural History
On January 30, 2002, twelve-year-old Alisha Palmer was at home after school with her brothers, Dylan, nine, and Michael, ten. Her mother, Beth Palmer Kopczynski, was still at work. Next door, six-year-old Bryan Barger was jumping on the Bargers’ trampoline in an unenclosed area behind the Bargers’ house. Bryan was jumping without supervision, which was not unusual.

At some point that afternoon, Bryan asked Dylan to jump with him, and Michael Spears, another neighbor, aged thirteen or fourteen, also joined them. Alisha testified that she also started using the trampoline a short time later, after Bryan “asked me if I wanted to jump with him.” The parties agree that Bryan’s invitations to Alisha and her brother were the first communications between the Palmers and the Bargers.

Alisha had previously watched Bryan jump, but she had never been on a trampoline before. As she was jumping, someone “stole” her jump, i.e., landed and changed the tension and height of the surface just before she landed. As a result, she injured her knee.

Alisha and her mother filed a complaint for damages against the Bargers, alleging both premises liability and liability for an attractive nuisance. The Bargers moved for summary judgment, claiming that Alisha was a trespasser and that the attractive nuisance doctrine did not apply. The trial court granted summary judgment in favor of the Bargers.

The Court of Appeals affirmed, finding no premises liability because Alisha was a trespasser and there was no evidence of willful or wanton conduct on the part of the Bargers. Kopczynski v. Barger, 870 N.E.2d 1, 9 (Ind. Ct. App. 2007). The Court of Appeals also found that the attractive nuisance doctrine did not apply because the plaintiffs failed to establish either that the trampoline was particularly dangerous or attractive to children or that the Bargers knew that children would trespass and be injured on the trampoline. Id. at 10. Judge Crone dissented, concluding that material issues of fact remained as to both Alisha’s status on the premises and also whether the trampoline was an attractive nuisance. Id. at 11. We granted transfer. 878 N.E.2d 215 (Ind. 2007) (table).

Standard of Review
In reviewing summary judgment rulings, we apply the same standard as the trial court. Row v. Holt, 864 N.E.2d 1011, 1013 (Ind. 2007). We affirm summary judgment unless there is a genuine issue as to a material fact or the moving party is not entitled to a judgment as a matter of law. Id. All facts and reasonable inferences from them are to be construed in favor of the nonmoving party. Naugle v. Beech Grove City Sch., 864 N.E.2d 1058, 1062 (Ind. 2007).

I. Count I―Premises Liability
The amended complaint describes Count I as a claim for negligence. The plaintiffs’ brief on appeal asserts that discovery had “more clearly defined” that count as a claim for premises liability and a claim for negligent supervision. However, the plaintiffs’ argument focuses entirely on premises liability, and cites the alleged lack of supervision as evidence of breach under premises liability rather than as a separate tort, so we will treat it as such.

A landowner’s liability to persons on the premises depends on the person’s status as a trespasser, licensee, or invitee. Burrell v. Meads, 569 N.E.2d 637, 639 (Ind. 1991). The Bargers argue that Alisha was a trespasser, and therefore their only duty was to refrain from willful or wanton behavior. The plaintiffs contend Alisha was a social guest and therefore an invitee to whom the Bargers owed a duty to exercise reasonable care for her protection while on the premises.

The Court of Appeals held that the determination of Alisha’s status—and therefore the duty owed to Alisha by the Bargers—is a matter of law for the trial court. Kopczynski v. Barger, 870 N.E.2d 1, 5 (Ind. Ct. App. 2007) (citing Taylor v. Duke, 713 N.E.2d 877, 881 (Ind. Ct. App. 1999)). We have observed that the existence of a duty is ordinarily a question of law for the court to decide, but it may turn on factual issues that must be resolved by the trier of fact. Rhodes v. Wright, 805 N.E.2d 382, 386 (Ind. 2004) (citing Douglass v. Irvin, 549 N.E.2d 368, 369 n.1 (Ind. 1990) (“While it is clear that the trial court must determine if an existing relationship gives rise to a duty, it must also be noted that a factual question may be interwoven with the determination of the existence of a relationship, thus making the ultimate existence of a duty a mixed question of law and fact.”)); see Restatement (Second) of Torts § 332 cmt. l (1965) (“Since the status of the visitor as an invitee may depend upon whether the possessor should have known that the visitor would be led to believe that a particular part of the premises is held open to him, the question is often one of fact for the jury, subject to the normal control which the court exercises over the jury’s function in such matters.”). For the reasons explained below, we conclude that factual issues preclude summary judgment in this case.

If Alicia entered the Bargers’ property without authority, she was a trespasser. See Burrell, 569 N.E.2d at 640. If her entry was authorized, she was either a licensee or an invitee. See id. In some contexts the distinction between licensees and invitees is murky, but Burrell makes it clear that a social guest is an invitee. Id. at 643. Because her visit was solely social, Alisha was not a licensee, and was either a trespasser or an invitee. Alisha’s status as trespasser or invitee, therefore, depends on whether she was authorized to be on the Bargers’ property.

Bryan’s invitation to join the group on the trampoline is the only evidence suggesting Alisha had permission to enter the Bargers’ property and use the trampoline. “[A]n invitation is conduct which justifies others in believing that the possessor desires them to enter the land.” Restatement (Second) of Torts § 332 cmt. b. An invitation does not have to come directly from the landowner. Whether a landowner’s consent can be based on the action of another turns on standard agency principles. See Botka v. Estate of Hoerr, 21 P.3d 723, 727-28 (Wash. Ct. App. 2001) (“Permission sufficient to establish invitee or licensee status can be implied from the prior conduct and statements of the property possessors or their agents.”); Kern v. Ray, 724 N.Y.S.2d 457, 458 (N.Y. App. Div. 2001) (holding that children were acting as parents’ agents in inviting people to their house); cf. St. Mary’s Med. Ctr. of Evansville, Inc. v. Loomis, 783 N.E.2d 274, 279 (Ind. Ct. App. 2002) (holding that employee’s knowledge of unsafe condition on premises is imputed to employer). In the absence of actual authority to invite third parties to the house, the issue is whether the landowner’s conduct gave the third party reason to believe that the landowner was willing to allow the third party to enter the land. See 62 Am. Jur. 2d Premises Liability § 112 (2005) (“The word ‘consent’ or ‘permission’ indicates that the possessor of the land is in fact willing that the visitor, or entrant, enter and remain thereon, or that the possessor’s conduct gives the entrant reason to believe that the possessor is willing to allow him or her to enter if he or she desires to do so.” (citing Restatement (Second) of Torts § 330 cmt. c)); cf. Holman v. State, 816 N.E.2d 78, 82 (Ind. Ct. App. 2004) (applying a totality of the circumstances test to determine the validity of a minor’s invitation in a criminal residential entry case).

The plaintiffs concede that the Bargers issued no express invitation because Bryan was not a landowner and did not have actual authority to invite Alisha onto the premises. Thus, the question becomes whether the Bargers gave Alisha reason to believe that they were willing to allow her on their land. The Bargers testified that they had once run off some children who were jumping on the trampoline, one of whom was Michael Spears. But Alisha had never met the Bargers, and was not among the group the Bargers had “run off.” Whether she had reason to know that Bryan did not have actual authority is a factual question. Although Bryan was only six years old, his parents left him alone in the unfenced backyard. Bryan’s age might suggest to an adult that he lacked authority. But Alisha is also a minor. A landowner’s greater duties to children may arise “taking into account the abilities, age, experience, and maturity of the child . . . .” Johnson v. Pettigrew, 595 N.E.2d 747, 750-51 (Ind. Ct. App. 1992) (citing Restatement (Second) of Torts §§ 339, 343). Accordingly, we agree with Judge Crone that “the reasonableness of twelve-year-old Alisha’s belief that she had permission to jump on the Barger’s trampoline by virtue of six-year-old Bryan’s invitation . . . presents a genuine issue of material fact that precludes a determination of her status as a matter of law.” Kopczynski, 870 N.E.2d at 11 (Crone, J., dissenting). Summary judgment as to Count I must be reversed.

II. Count II―Attractive Nuisance

The plaintiffs argue that even if Alisha was a trespasser, they may recover under the attractive nuisance doctrine, which imposes on a landowner a duty of care for a child trespasser if the following elements are met: 1) the structure or condition complained of is maintained or permitted on the property by the owner or renter; 2) the structure or condition is particularly dangerous to children and unlikely to be comprehended by children; 3) the structure or condition is especially attractive to children; 4) the owner or renter has actual or constructive knowledge of both the structure or condition and the likelihood that children will trespass and be injured; and 5) the injury is a natural, probable, and foreseeable result of the wrong. Pier v. Schultz, 243 Ind. 200, 205, 182 N.E.2d 255, 258 (Ind. 1962); Morningstar v. Maynard, 798 N.E.2d 920, 922-23 (Ind. Ct. App. 2003). An unenclosed junkyard is an example of a condition that may constitute an attractive nuisance. See Borinstein v. Hansbrough, 119 Ind. App. 134, 82 N.E.2d 266 (1948). The purpose of the attractive nuisance doctrine “is to protect children from dangers which they do not appreciate.” Restatement (Second) of Torts § 339 cmt. m (1965). However, because the attractive nuisance doctrine imposes a substantial burden on the property owner, it is narrowly construed and does not, for example, generally apply to “common or ordinary objects or conditions” such as walls, fences, or gates. 62 Am. Jur. 2d Premises Liability §§ 290, 366, 368 (2005).

The Bargers argue that Count II of the plaintiffs’ complaint is deficient for several reasons. They contend that a moving landing surface is a danger that can be comprehended by a twelve year old; trampolines pose no particular attraction to children; the Bargers had no reason to suspect that Alisha would trespass; and Alisha’s injury was not the natural, probable, and foreseeable result of Alisha’s use and trespass. The Court of Appeals held that the attractive nuisance doctrine does not apply because in general the dangers of jumping on a trampoline should be as obvious to children as “the dangers of falling from heights.” The Court of Appeals also found that the plaintiffs failed to designate evidence establishing the latent danger of jumping on a trampoline. Kopczynski v. Barger, 870 N.E.2d 1, 10 (Ind. Ct. App. 2007).

We agree with the Court of Appeals that the risks associated with trampolines may be obvious, particularly to an adult. See Liccione v. Gearing, 675 N.Y.S.2d 728, 729 (N.Y. App. Div. 1998) (holding that the defendant established as a matter of law that nineteen year old was of sufficient age, education and experience to assume the risks of jumping on a trampoline). But the particular risks associated with jumping on a trampoline are not necessarily open and obvious to children, particularly those who have never jumped before. Cf. Bryant v. Adams, 448 S.E.2d 832, 841-42 (N.C. App. Ct. 1994) (holding that whether or not jumping on a trampoline was an open and obvious danger to a fourteen year old in a products liability case was a disputed fact question for the jury). We agree with the Court of Appeals majority that the harm from falling down is obvious to most. But the dangers of falling onto the ground are very different from the dangers of falling onto a trampoline, particularly one with other jumpers whose presence may unexpectedly change the tension of the trampoline’s surface. See Lykins v. Fun Spot Trampolines, 874 N.E.2d 811, 818-19 (Ohio Ct. App. 2007) (holding that while “jumping on a trampoline involves the obvious risks of losing balance, falling down, falling off the apparatus altogether, and colliding with other individuals if more than one is present on the trampoline,” the court could not find as a matter of law that the particular risks associated with multiple jumpers were open and obvious). And a child may be lulled into thinking a trampoline is safe by watching others jump without incident or injury. See Am. Jur. 2d Premises Liability § 342 (“[A] child may not realize the danger of his or her action where he or she has seen other children engaging in the act without injury.”).

In this case the designated evidence conflicts regarding whether Alisha could have appreciated the dangers of jumping on a trampoline, particularly with multiple jumpers. The plaintiffs designated the affidavit of Alan R. Caskey, Ph.D, who testified: “It is my experience that children under the age of sixteen do not appreciate or understand the dangers of using a trampoline without adult supervision and with multiple jumpers and that the dangers of trampolines are not readily apparent to such children.

Further, the designated evidence reveals that in 1998 about 75 percent of the roughly 95,000 emergency room treatments for trampoline-related injuries involved patients under fifteen. Although Alisha admits she had watched Bryan jump prior to her accident, there is no evidence that Alisha witnessed any injuries or had seen multiple jumpers on the trampoline. Further, Alisha testified that she had never been on a trampoline, was unsupervised, and was not warned of the dangers of jumping in general or multiple jumpers in particular. Accordingly, the Bargers have not established a lack of disputed material facts with regard to the open and obvious nature to Alisha of the dangers of trampolines.

The Bargers next argue that they had no reason to know that Alisha might trespass. Specifically, the Bargers point to designated evidence that the Bargers and Palmers did not know each other, Alisha’s mother told her not to leave the house, and the Bargers allowed children to jump only with their permission. However, the plaintiffs have to show only the likelihood that some child would trespass and be injured, not a particular child. Dr. Caskey testified that “research indicates that trampolines left unattended are particularly attractive to children” and that “injuries are more likely to occur” when the trampoline is left unsupervised. The Bargers have not shown that it is unreasonable to assume that children would be attracted to a large trampoline that sits in the middle of an open yard, particularly when there is an unsupervised child regularly jumping on it. Indeed, the Bargers admit that other children have trespassed and used their trampoline without permission. Moreover, as explained in Part I, it is an issue for the trier of fact whether another child might reasonably regard Bryan as an authorized host. If so, by leaving Bryan alone in the yard, the Bargers increased the risk of unauthorized use of the trampoline by another child.

Finally, the Bargers claim that Alisha’s knee injury was not a natural, probable, or foreseeable consequence of her trespass and jumping. The designated evidence reveals, however, that the trampoline’s warning labels cautioned that multiple jumpers on a trampoline “increase[] the chance of serious injury” and “can result in broken head, neck, back or legs.” Dr. Caskey testified that “research and databases also indicate that the type of knee injury sustained by Alisha Palmer is a type of injury that is seen from multiple jumpers on a trampoline.” Thus, the Bargers have failed to establish a lack of disputed material facts as to the foreseeability of Alisha’s injury.

Conclusion

The trial court’s grant of summary judgment is reversed. This case is remanded to the trial court for further proceedings consistent with this opinion. Shepard, C.J., and Dickson, Sullivan, and Rucker, JJ., concur.

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May 23, 2008

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Helpful Information from NeurologyChannel.comPatients suffering TBI are typically brought to a hospital emergency room for initial diagnosis and treatment. Once vital signs are assessed and stabilized, and other life-threatening injuries are identified and treated, the process of diagnosing the extent of brain injury begins.

A complete neurological evaluation is performed to rule out conditions requiring neurosurgical attention, such as hematomas, depressed skull fractures, and elevated intracrantial pressure (ICP). X-rays, CT scans, and/or MRI scans may be performed to determine if the bones of the skull are fractured and if bone fragments have penetrated the brain tissues.

The patient may be presented with a series of questions (What is your name? Where are you? What day is it?) and given simple commands (Wiggle your toes. Hold up two fingers.) to determine if he or she can open their eyes, move, speak, and understand what is happening around them. If possible, a detailed medical history is performed to identify any previous injuries, existing seizure disorders, learning disabilities, prior psychiatric or psychological treatment, and/or substance abuse.

The patient’s degree of consciousness is assessed to determine the severity of brain injury and predict his or her chances for recovery. To do this, physicians typically use the Glasgow Coma Scale (GCS), which measures the patient’s ability to open their eyes, move, and speak. The more severe the injury, the lower the total score suggesting little chance for complete recovery.

Glasgow Coma Scale

Eye Opening
4 = Responds spontaneously
3 = Responds to voice
2 = Responds to pain
1 = No response

Best Motor Response
6 = Follows commands
5 = Localizes to pain
4 = Withdraws to pain
3 = Decorticate (produces an exaggerated posture of upper extremity flexion and lower extremity extension in response to pain)
2 = Decerebrate (produces an exaggerated posture of extension in response to pain) 1 = No Response

Best Verbal Response
5 = Oriented and converses
4 = Disoriented and converses
3 = Inappropriate words
2 = Incomprehensible sounds
1 = No response

Total scores of 8 or below indicate a true coma and severe brain injury. Scores of 9 to 12 suggest moderate brain injury; scores of 13 and above indicate mild brain injury. However, the severity of the brain injury is not determined by GCS alone, as treatable conditions such as infection and dehydration may lower the GCS score.

When the patient is unconscious, the duration or length of coma (LOC) may be used to assess the severity of TBI and predict outcome. The longer the length of coma, the more severe the injury is. An LOC of less than about 20 minutes reflects a mild brain injury; longer than about 6 hours after admission reflects severe injury; between 20 minutes and 6 hours suggests moderate injury.

The neurological examination may show signs indicating the severity of injury such as increased reflexes and muscle tone (spasticity), abnormal movements (tremors), difficulty swallowing, or slurring of speech, all of which may indicate a moderate to severe head injury.

Imaging
Neuroradiological tests using computer-assisted brain scans help visualize damage to the brain. The most common of these is computerized axial tomography (CAT or CT scan), an x-ray technique that produces a cross-sectional image of the brain. CT scans can detect physical changes in the brain such as hematomas and swelling, which may require immediate treatment. The procedure is painless and takes 15 to 45 minutes, during which the patient must lie completely still.Another useful diagnostic test is magnetic resonance imaging (MRI scan), which uses a large magnet and radio waves to generate computerized images of the brain without exposing the patient to x-ray radiation. MRIs produce high resolution images of brain structures and are painless, but noisy. The patient must lie on a flat table in the machine, typically shaped like a long tube. An MRI can take up to 60 minutes.Depending on individual circumstances, a variety of other diagnostic tools and techniques may be employed. These include the following:

Angiogram–A test to examine blood vessels in the brain. It involves injecting dye into an artery supplying blood to the brain, usually by means of a catheter inserted in the groin. The test takes 1 to 3 hours.

ICP Monitor–A device used to measure intracranial pressure (pressure within the brain). It consists of a small tube, placed into or on top of the brain through a small hole in the skull, connected to a transducer that registers the pressure.

EEG (electroencephalograph)–A test to measure electrical activity in the brain. It uses electrodes, in the form of patches, applied to the head. This painless procedure can be done at bedside or in a hospital’s EEG department. The duration of the test varies. X-rays, MRIs, and CT scans can detect fractures, hemorrhages, swelling, and certain kinds of tissue damage, but they do not always detect traumatic brain injury. This is because TBI, especially in its milder forms, often involves subtle traumas scattered among neurons and supportive tissues, stretched or damaged axon membranes (diffuse axonal injury), chemical injury caused by the biochemical cascade of toxic substances in the brain tissues, and cellular dysfunction. These changes often cannot be found with standard imaging procedures. More sophisticated imaging techniques that measure brain cell metabolism, such as single-photon emission computed tomography (SPECT) or positron emission tomography (PET), can help diagnose such injuries.

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May 22, 2008

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As reported in the Indianapolis Star.

Indiana State Police say a drunken driver crashed into a deputy sheriff’s cruiser in Vermillion County Wednesday.

Vermillion County Sheriff’s Deputy Michael R. Holtkamp, 32, of Perrysville was taken to West Central Community Hospital for neck pain, internal damage and other injuries after his marked vehicle was struck by an alleged

Janet Kay Stevens, 52, of Newport was also treated at West Central for back pain. Stevens was arrested for driving while intoxicated and driving without a valid license, Watts said.

Holtkamp, a eight year veteran deputy, had his lights and siren active and was on his way to assist another law enforcement officer in a car chase when Stevens turned a 1998 Buick Le Sabre she was driving into his path at about 8 p.m., Watts said.

Both drivers were wearing seatbelts, Watts said.

Indiana lawyer, Dan Chamberlain, commented that the sad reality is that on average, there are 10,000 alcohol related crashes in the State of Indiana, per year, and of those, 206 resulted in fatalities.

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May 5, 2008

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By REED ABELSON and MILT FREUDENHEIMPublished: May 4, 2008

The economic slowdown has swelled the ranks of people without health insurance. But now it is also threatening millions of people who have insurance but find that the coverage is too limited or that they cannot afford their own share of medical costs.

Karena Cawthon for The New York Times

When Marianne Falacienski’s husband started a new job, the family could not afford the health plan. Ms. Falacienski, 32, found individual coverage only for him and their daughter, Gabrielle.

The Mounting Burden for Health Care

Many of the 158 million people covered by employer health insurance are struggling to meet medical expenses that are much higher than they used to be — often because of some combination of higher premiums, less extensive coverage, and bigger out-of-pocket deductibles and co-payments.

With medical costs soaring, the coverage many people have may not adequately protect them from the financial shock of an emergency room visit or a major surgery. For some, even routine doctor visits might now take a back seat to basic expenses like food and gasoline.

“It just keeps eating into people’s income,” said James Corbin, a former union official who works for the local utility in Tucson.

Mr. Corbin said that under their employer’s health plan, he and his co-workers are now obliged to pay up to $4,000 of their families’ annual medical bills, on top of about $1,600 a year in premiums. Five years ago, they paid no premiums and were responsible for only about $2,000 of their families’ medical bills.

“That’s a big jump,” Mr. Corbin said. “You’ve just lost a month’s pay.

”Already, many doctors say, the soft economy is making some insured people hesitant to get care they need, reluctant to spend a $50 co-payment for an office visit. Parents “are waiting longer to bring in their children,” said Dr. Richard Lander, a pediatrician in Livingston, N.J. “They say, ‘The kid isn’t that sick; her temperature is only 102.’ ”

The problem of affording health care is most acute for people with no insurance, a group expected to soon exceed 48 million, but those with insurance say they too are feeling the pain.

Since the recession of 2001, the employee’s average cost of an annual health care premium for family coverage has nearly doubled — to $3,300, up from $1,800 — while incomes have come nowhere close to keeping up. Factor in other out-of-pocket medical costs, and the portion of the average American household’s income that goes toward health care has risen about 12 percent, according to the consulting and accounting firm Deloitte, and is now approaching one-fifth of the average household’s spending.

In a recent survey by Deloitte’s health research center, only 7 percent of people said they felt financially prepared for their future health care needs.

Shirley Giarde of Walla Walla, Wash., was not prepared when her husband, Raymond, suddenly developed congestive heart failure last year and needed a pacemaker and defibrillator. Because his job did not provide health benefits, she has covered them both through a policy for the self-employed, which she obtained as the proprietor of a bridal and formal-wear store, the Purple Parasol.

But when Raymond had his medical problems, Ms. Giarde discovered that her insurance would cover only $22,000, leaving them with about $100,000 in unpaid hospital bills.

Even though the hospital agreed to reduce that debt to about $50,000, Ms. Giarde is still struggling to pay it — in part because the poor economy has meant slumping sales at the Purple Parasol. Her husband, now disabled and unable to work, will not qualify for Medicare for another year, and she cannot afford the $758 a month it would cost to enroll him in a state-run insurance plan for individuals who cannot find private insurance.

She recently refinanced her car, a 2002 Toyota Highlander, to help pay for her husband’s heart medicines, which cost some $400 a month.

Experts say that too often for the underinsured, coverage can seem like health insurance in name only — adequate only as long as they have no medical problems.

“There’s a real shift in the burden of health care to people who happen to be sick,” said Paul B. Ginsburg, the president of the Center for Studying Health System Change, a research group in Washington.

Companies and policy makers have yet to focus on what the faltering economy means for employees’ medical care, said Helen Darling, president of the National Business Group on Health, a Washington association of about 200 large employers.

“It’s a bad-news situation when an individual or household has to pay out-of-pocket three, four or five times as much for their health plan as they would have at the time of the last recession,” she said. “Americans have been giving their pay raise to the health care system.”

The Mounting Burden for Health Care

Sage Holben, a 62-year-old library technician with diabetes who is active in her local union in St. Paul, says that in 2003 union members agreed to a two-year freeze on wages to protect their health care coverage. But for the union, which will begin talks on the next contract this fall, it may be difficult to continue that trade-off, Ms. Holben said. “It’s at the point where we’re losing, anyway,” she said.

“I live paycheck to paycheck,” said Ms. Holben, who makes close to $40,000 a year at Metropolitan State University.

When she took the job in 1999, she says, the health benefits required no co-payments for doctor visits. Now, her out-of-pocket cost per visit is $25, and she pays $38 a month for her diabetes medicine. She has not been to the eye doctor in two years, even though eye exams are crucial for people with diabetes and she knows she needs new glasses. Nor does she monitor her blood sugar as regularly as she should because of the cost of the supplies.

“It’s not an extravagant expense,” she said. “It just adds up.” And it comes atop the increasing cost of utilities, gasoline and food — and the few hundred dollars of repairs her 1994 Chevrolet Cavalier needs.

Many employers do recognize that their workers are struggling financially even as they are asking them to pick up more of their health-care bills.

“It makes the work we have to do even more challenging,” said Anne Silverman, the vice president in charge of benefits in North America for the publishing company Reed Elsevier. “Employees are being stretched in terms of their disposable income.”

Even so, more companies may see themselves as having little choice but to require employees to pay even more of their health expenses, said Ted Nussbaum, a benefits consultant at the firm Watson Wyatt Worldwide. And when a weak economy undermines job security, he said, workers may simply have to accept reduced benefits.

While Mr. Nussbaum and other consultants say it is unlikely that significant numbers of employers will simply drop coverage for their workers, the weak economy could prompt more of them to push for so-called consumer-driven plans. Such plans tend to offset lower premiums with higher annual deductibles.

And while these plans often allow employees to put pre-tax savings into special health care accounts, they typically end up forcing the worker to assume a bigger share of overall medical costs. About six million people are now enrolled in these medical plans.

Among employers, the hardest pressed may be small businesses. Their insurance premiums tend to be proportionately higher than ones paid by large employers, because small companies have little bargaining clout with insurers.

Health costs are “burying small business,” said Mike Roach, who owns a small clothing store in Portland, Ore. He recently testified on health coverage at a Senate hearing led by Ron Wyden, Democrat of Oregon.

Last year, Mr. Roach paid about $27,000 in health premiums for his eight employees. “It’s a huge chunk of change,” he said, noting that he was forced to raise his employees’ yearly deductible by 50 percent, to $750.

Around the nation, some workers are simply priced out of their employee health plans.

After Brian Falacienski of Milton, Fla., was laid off last year from his job as a surveyor for a construction company, he found another position. But the cost of his new health plan — $800 a month for coverage with a $1,000 annual deductible — was beyond the means of Mr. Falacienski, 38, who is married and has a 2-year-old daughter.

His wife, Marianne, started researching individual insurance policies and was able to find policies for her husband and daughter offering basic, if minimal, coverage, costing $161 a month for father and daughter. But Ms. Falacienski, 32, who has arthritis and the severe digestive disorder Crohn’s disease, is now uninsured. Because of her conditions, she said, four major insurers rejected her.

“I even applied for Medicaid,” she said, “but I wasn’t low-income enough.”

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April 4, 2008

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Medical insurer to halt reimbursements for mistakes it calls preventable Indianapolis-based WellPoint, the nation’s largest commercial health insurer in terms of membership, on Wednesday announced it is changing its policy and halting reimbursement payments to hospitals and doctors for 11 medical errors considered preventable.

WellPoint, which provides benefits to about 35 million Americans, is following the lead of the U.S. Centers for Medicare and Medicaid Services, which last year announced it was planning on ending payments for some medical mistakes.

“We know there are a number of events that happen for hospitalized patients that are absolutely preventable,” said Dr. Sam Nussbaum, WellPoint’s executive vice president for clinical health policy and chief medical officer. “These are errors that really relate to the process of care.”Many hospital-acquired infections, he said, could be prevented by making sure caregivers regularly wash their hands between seeing patients. Nussbaum also urged patients or their family members to be proactive to help prevent errors by asking questions and speaking up if they have concerns about the care being provided.

Other insurers may follow the federal agency’s new policy.

“We continue to evaluate the new Medicare policies and how they may be applied to best meet the needs of our members,” said Debora Spano, spokeswoman for Minnesota-based UnitedHealthcare.

Under the policy change, expected to be rolled out across the nation this year, WellPoint said it will no longer provide payment for three errors: surgery on the wrong body part, a wrong surgery performed on a patient, or surgery on the wrong patient.

The company also said it will not provide payment to cover additional costs incurred by a health provider for eight other mistakes, such as bed sores, a sponge left in the body after surgery and urinary tract infections associated with catheter use.

Officials will use several methods for identifying the errors, including comparing a patient’s diagnosis and condition upon admission to a hospital with the treatment received during the hospital stay.

The 11 errors identified by WellPoint are those that have been defined as preventable by the Centers for Medicare and Medicaid Services and the National Quality Forum.

WellPoint, which operates Anthem Blue Cross and Blue Shield in Indiana, added that it also will make sure its members are not billed for these errors.

The U.S. Centers for Disease Control and Prevention estimates about 2 million infections are acquired each year in hospitals and other health-care facilities, resulting in roughly 90,000 deaths and $4.5 billion in extra costs.

In 2006, Medicare reported 322,946 cases of patients who had a pressure ulcer, or bedsore, as a secondary diagnosis, with the average cost per case exceeding $40,000.

WellPoint’s move is part of an effort across the health-care industry to better link reimbursement rates with quality of care. Other efforts include pay-for-performance programs from which doctors get more compensation if their patients receive recommended care and screenings, such as blood-sugar tests for diabetics.

“What people are doing to create more awareness and transparency in the marketplace is going to be good for the consumer, because those hospitals that have focused on patient-centered care are going to have a business advantage,” said Keith Jewell, chief operating officer of St. Francis Hospital & Health Centers in Indianapolis.

However, Jewell added that he hopes any savings WellPoint gets from halting these payments would result in reduced premiums for patients.

Nussbaum said WellPoint has been promoting safe practices.

WellPoint said it would give consideration in complex cases involving the care of patients who may beprone to developing infections or to other problems included on its list of 11 preventable errors. “Some of these are in a gray zone,” Nussbaum said.

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March 27, 2008

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WASHINGTON — Death rates from motorcycle crashes have risen steadily since states began weakening helmet laws about a decade ago, according to a Gannett News Service analysis of federal accident reports. Deaths have increased, so has the proportion of older riders killed. Dying on a motorcycle could soon become a predominantly middle-aged phenomenon, the GNS analysis shows.

Most states once required all motorcycle riders to wear helmets. But a trend in the other direction began accelerating after 1995, when the federal government decided to stop withholding highway money from states without helmet laws.

As states weakened or repealed the laws, the percentage of riders who wore helmets began dropping. And fatality rates increased.

In 1996, 5.6 motorcyclists were killed for every 10,000 registered motorcycles, according to federal transportation officials. By 2006, the most recent data available, the rate was 7.3, the analysis shows.

In raw numbers, the annual death toll rose to 4,810 from 2,160 during that same period. Meanwhile, fatality rates for other passenger vehicles have been falling, transportation officials say.

The numbers appear to contradict claims by some motorcycle groups that helmet laws alone don’t save lives.

“The data are pretty compelling,” said U.S. Transportation Secretary Mary Peters, an avid motorcyclist who survived a crash, thanks to a helmet she displays in somewhat battered condition in her office. “It’s discouraging to see the (fatality) numbers going up. But at least people are talking about it now.”

GNS analyzed data from the federal government’s Fatality Analysis Reporting System on motorcycle deaths from 2002 to 2006. The analysis found that:

Nearly half of the riders killed in 2006 were 40 and older, and nearly a quarter were 50 and older.

Transportation officials say the age trends reflect the growing popularity of motorcycles among older people with higher incomes but declining physical dexterity and slower reaction times.

Half of motorcyclists killed lost control and crashed without colliding with another vehicle. Motorcyclists account for about 2 percent of vehicles on the road but 10 percent of all traffic fatalities, according to federal statistics.

A consistently large majority of those killed — about 90 percent — were men.
Critics of motorcycle helmet laws say riders should be guided by common sense rather than a government mandate when deciding whether to wear a helmet. They argue that wearing a helmet is uncomfortable and obstructs their view.

They promote their view through advocates across the country, including ABATE (American Bikers Aimed Toward Education), which has chapters in almost every state, tracking helmet legislation and lobbying against it.

“It’s my body, and I should have the right to do with it as I choose,” said Terry Howard, state coordinator for ABATE of Colorado, which vigorously fought the state’s recent adoption of a helmet law for riders younger than 18. Not all bikers agree.

Simon Rosa, 22, northern Virginia, doesn’t have a problem with the helmet law there. In 2003, he crashed his Honda sport bike while making a turn. “I still have the helmet, and it has scratches all over it, so I could have suffered a nasty head injury,” he said. “You just never know what’s going to happen, regardless of how good a rider you are.”

Under Indiana law, people younger than 18 or who have a learner’s permit are required to wear a helmet if they operate a motorcycle. But the mandatory helmet law for adults, introduced in 1967, was repealed in 1977. As states try to save lives and cut government medical costs, there are signs that helmet laws may become popular again.

The National Transportation Safety Board unanimously recommended last year that states require all riders to wear helmets. It was the first time in its 40-year history that the independent panel had weighed in on motorcycle safety.

Also last year, 25 states considered laws, including some mandating helmet use, to enhance safety, according to the National Conference of State Legislatures.

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March 20, 2008

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By JEFFREY ROSEN

I.

The headquarters of the U.S. Chamber of Commerce, located across from Lafayette Park in Washington, is a limestone structure that looks almost as majestic as the Supreme Court. The similarity is no coincidence: both buildings were designed by the same architect, Cass Gilbert. Lately, however, the affinities between the court and the chamber, a lavishly financed business-advocacy organization, seem to be more than just architectural. The Supreme Court term that ended last June was, by all measures, exceptionally good for American business. The chamber’s litigation center filed briefs in 15 cases and its side won in 13 of them — the highest percentage of victories in the center’s 30-year history. The current term, which ends this summer, has also been shaping up nicely for business interests.

I visited the chamber recently to talk with Robin Conrad, who heads the litigation effort, about her recent triumphs. Conrad, an appealing, soft-spoken woman, lives with her family on a horse farm in Maryland, where she rides with a fox-chasing club called the Howard County-Iron Bridge Hounds. Her office, playfully adorned by action figures of women like Xena the Warrior Princess and Hillary Rodham Clinton, has one of the most impressive views in Washington. “You can see the White House through the trees,” she said as we peered through a window overlooking the park. “In the old days, you could actually see people bathing in the fountain. Homeless people.”

Conrad was in an understandably cheerful mood. Though the current Supreme Court has a well-earned reputation for divisiveness, it has been surprisingly united in cases affecting business interests. Of the 30 business cases last term, 22 were decided unanimously, or with only one or two dissenting votes. Conrad said she was especially pleased that several of the most important decisions were written by liberal justices, speaking for liberal and conservative colleagues alike. In opinions last term, Ruth Bader Ginsburg, Stephen Breyer and David Souter each went out of his or her way to question the use of lawsuits to challenge corporate wrongdoing — a strategy championed by progressive groups like Public Citizen but routinely denounced by conservatives as “regulation by litigation.” Conrad reeled off some of her favorite moments: “Justice Ginsburg talked about how ‘private-securities fraud actions, if not adequately contained, can be employed abusively.’ Justice Breyer had a wonderful quote about how Congress was trying to ‘weed out unmeritorious securities lawsuits.’ Justice Souter talked about how the threat of litigation ‘will push cost-conscious defendants to settle.’ ”

Examples like these point to an ideological sea change on the Supreme Court. A generation ago, progressive and consumer groups petitioning the court could count on favorable majority opinions written by justices who viewed big business with skepticism — or even outright prejudice. An economic populist like William O. Douglas, the former New Deal crusader who served on the court from 1939 to 1975, once unapologetically announced that he was “ready to bend the law in favor of the environment and against the corporations.”

Today, however, there are no economic populists on the court, even on the liberal wing. And ever since John Roberts was appointed chief justice in 2005, the court has seemed only more receptive to business concerns. Forty percent of the cases the court heard last term involved business interests, up from around 30 percent in recent years. While the Rehnquist Court heard less than one antitrust decision a year, on average, between 1988 and 2003, the Roberts Court has heard seven in its first two terms — and all of them were decided in favor of the corporate defendants.

Business cases at the Supreme Court typically receive less attention than cases concerning issues like affirmative action, abortion or the death penalty. The disputes tend to be harder to follow: the legal arguments are more technical, the underlying stories less emotional. But these cases — which include shareholder suits, antitrust challenges to corporate mergers, patent disputes and efforts to reduce punitive-damage awards and prevent product-liability suits — are no less important. They involve billions of dollars, have huge consequences for the economy and can have a greater effect on people’s daily lives than the often symbolic battles of the culture wars. In the current Supreme Court term, the justices have already blocked a liability suit against Medtronic, the manufacturer of a heart catheter, and rejected a type of shareholder suit that includes a claim against Enron. In the coming months, the court will decide whether to reduce the largest punitive-damage award in American history, which resulted from the Exxon Valdez oil spill in 1989.

What should we make of the Supreme Court’s transformation? Throughout its history, the court has tended to issue opinions, in areas from free speech to gender equality, that reflect or consolidate a social consensus. With their pro-business jurisprudence, the justices may be capturing an emerging spirit of agreement among liberal and conservative elites about the value of free markets. Among the professional classes, many Democrats and Republicans, whatever their other disagreements, have come to share a relatively laissez-faire, technocratic vision of the economy and are suspicious of excessive regulation and reflexive efforts to vilify big business. Judges, lawyers and law professors (such as myself) drilled in cost-benefit analysis over the past three decades, are no exception. It should come as little surprise that John Roberts and Stephen Breyer, both of whom studied the economic analysis of law at Harvard, have similar instincts in business cases.

This elite consensus, however, is not necessarily shared by the country as a whole. If anything, America may be entering something of a populist moment. If you combine the groups of Americans in a recent Pew survey who lean toward some strain of economic populism — from disaffected and conservative Democrats to traditional liberals to social and big-government conservatives — at least two-thirds of all voters arguably feel sympathy for government intervention in the economy. Could it be, then, that the court is reflecting an elite consensus while contravening the sentiments of most Americans? Only history will ultimately make this clear. One thing, however, is certain already: the transformation of the court was no accident. It represents the culmination of a carefully planned, behind-the-scenes campaign over several decades to change not only the courts but also the country’s political culture.

II.

The origins of the business community’s campaign to transform the Supreme Court can be traced back precisely to Aug. 23, 1971. That was the day when Lewis F. Powell Jr., a corporate lawyer in Richmond, Va., wrote a memo to his friend Eugene B. Snydor, then the head of the education committee of the U.S. Chamber of Commerce. In the memo, Powell expressed his concern that the American economic system was “under broad attack.” He identified several aggressors: the New Left, the liberal media, rebellious students on college campuses and, most important, Ralph Nader. Earlier that year, Nader founded Public Citizen to advocate for consumer rights, bring antitrust actions when the Justice Department did not and sue federal agencies when they failed to adopt health and safety regulations.

Powell claimed that this attack on the economic system was “quite new in the history of America.” Ever since 1937, when President Franklin D. Roosevelt threatened to pack a conservative Supreme Court with more progressive justices, the court had largely deferred to federal and state economic regulations. And by the ’60s, the Supreme Court under Chief Justice Earl Warren had embraced a form of economic populism, often favoring the interests of small business over big business, even at the expense of consumers. But what Powell saw in the work of Nader and others was altogether more extreme: a radical campaign that was “broadly based and consistently pursued.”

To counter the growing influence of public-interest litigation groups like Public Citizen, Powell urged the Chamber of Commerce to begin a multifront lobbying campaign on behalf of business interests, including hiring top business lawyers to bring cases before the Supreme Court. “The judiciary,” Powell predicted, “may be the most important instrument for social, economic and political change.” Two months after he wrote the memo, Powell was appointed by Richard Nixon to the Supreme Court. And six years later, in 1977, after steadily expanding its lobbying efforts, the chamber established the National Chamber Litigation Center to file cases and briefs on behalf of business interests in federal and state courts.

Today, the Chamber of Commerce is an imposing lobbying force. To fulfill its mission of serving “the unified interests of American business,” it collects membership dues from more than three million businesses and related organizations; last year, according to the Center for Responsive Politics, the chamber spent more than $21 million lobbying the White House, Congress and regulatory agencies on legal matters. But its battle against the forces of Naderism got off to a slow start. In 1983, when Robin Conrad arrived at the chamber, the Supreme Court was handing Nader and his allies significant victories. That year, for example, the court held that President Reagan’s secretary of transportation, Andrew L. Lewis Jr., acted capriciously when he repealed a regulation, inspired by Nader’s advocacy, that required automakers to install passive restraints like air bags. In 1986, the chamber supported a challenge to the Environmental Protection Agency’s aerial surveillance of a Dow Chemical plant. The chamber’s side lost, 5-4.

But eventually, things began to change. The chamber started winning cases in part by refining its strategy. With Conrad’s help, the chamber’s Supreme Court litigation program began to offer practice moot-court arguments for lawyers scheduled to argue important cases. The chamber also began hiring the most-respected Democratic and Republican Supreme Court advocates to persuade the court to hear more business cases. Although many of the businesses that belong to the Chamber of Commerce have their own in-house lawyers, they would have the chamber file “friend of the court” briefs on their behalf. The chamber would decide which of the many cases brought to its attention were in the long-term strategic interest of American business and then hire the leading business lawyers to write supporting briefs or argue the case.

Until the mid-’80s, there wasn’t an organized group of law firms that specialized in arguing business cases before the Supreme Court. But in 1985, Rex Lee, the solicitor general under Reagan, left the government to start a Supreme Court appellate practice at the firm Sidley Austin. Lee’s goal was to offer business clients the same level of expert representation before the Supreme Court that the solicitor general’s office provides to federal agencies. Lee’s success prompted other law firms to hire former Supreme Court clerks and former members of the solicitor general’s office to start business practices. The Chamber of Commerce, for its part, began to coordinate the strategy of these lawyers in the most important business cases.

At times, the strategic calculations can be quite personal. Because Supreme Court clerks have tremendous influence in making recommendations about what cases the court should hear, Conrad told me, having well-known former clerks involved in submitting a brief can be especially important. “When Justice O’Connor was on the bench and we knew her vote was very important, we had a case where the opposition had her favorite clerk on the brief, so we retained her next-favorite clerk,” she said with a laugh. “We won.”

In our conversation, Conrad was especially enthusiastic about Maureen Mahoney, a former clerk for Chief Justice Rehnquist and one of the top Supreme Court litigators who coordinate strategy with the chamber. When Mahoney agreed in 2005 to represent an appeal by the disgraced accounting firm Arthur Andersen, which was convicted in 2002 of obstructing justice by shredding documents related to the audit of Enron, few people thought the Supreme Court would take the case. “The climate was very anti-Enron,” Mahoney told me, “and it was viewed as a doomed petition.”

Mahoney rehearsed her Supreme Court argument in a moot court sponsored by the chamber. (”She was absolutely dazzling,” Conrad recalls.) On April 27, 2005, Mahoney stood calmly before the justices and delivered one of the best oral arguments I’ve ever seen at the Supreme Court. She argued that because Arthur Andersen’s accountants had followed a standard document-destruction procedure before receiving the government’s subpoena, they couldn’t be guilty of a crime; they weren’t aware what they were doing was criminal. The Supreme Court unanimously agreed and reversed the conviction, 9-0.

The Arthur Andersen case is a good example of how significantly the Supreme Court has changed its attitude about cases involving securities fraud — and business cases more generally — from the Warren to the Roberts era. In a case in 1964, the court ruled that aggrieved investors and consumers could file private lawsuits to enforce the securities laws, even in cases in which Congress hadn’t explicitly created a right to sue. In the mid-1990s, however, Congress substantially cut back on these citizen suits, and the court today has shown little patience for them. Mahoney says she sees her victory in the Arthur Andersen case as significant because it applied the same principle in criminal cases involving corporate wrongdoing that the court had already been recognizing in civil cases: namely, “refusing to create greater damage remedies or criminal penalties than Congress has explicitly specified.” She describes the case as “a very important win for business.”

This term, the Supreme Court has continued to cut back on consumer suits. In a ruling in January, the court refused to allow a shareholder suit against the suppliers to Charter Communications, one of the country’s largest cable companies. The suppliers were alleged to have “aided and abetted” Charter’s efforts to inflate its earnings, but the court held that Charter’s investors had to show that they had relied on the deceptive acts committed by the suppliers before the suit could proceed. A week later, the court invoked the same principle when it refused to hear an appeal in a case related to Enron, in which investors are trying to recover $40 billion from Wall Street banks that they claim aided and abetted Enron’s fraud. As a result, the shareholder suit against the banks may be dead.

III.

In addition to litigating cases before the court, the Chamber of Commerce also lobbies Congress and the White House in an effort to change the composition of the court itself. (Unlike many other government officials, the justices themselves are not, of course, subject to direct corporate lobbying.) The chamber’s efforts in this area were inspired by Robert Bork’s thwarted nomination to the court in 1987. Business groups were enthusiastic about Bork — not because of his conservative social views but because of his skepticism of vigorous antitrust enforcement. “In reaction to the Bork nomination, it struck us that we didn’t even have a process in place to be a player,” Conrad said.

So the chamber set up a formal process for endorsing candidates after their nominations. The process was designed to be bipartisan; and the chamber has encouraged Democratic as well as Republican presidents to appoint justices. Nominees are evaluated solely through the prism of their views about business. “We’re very surgical in our analysis,” Conrad said.

After the election of Bill Clinton, for example, the chamber endorsed Ruth Bader Ginsburg, who in addition to her pioneering achievements as the head of the women’s rights project at the A.C.L.U. had specialized, as a law professor, in the procedural rules in complex civil cases and was comfortable with the finer points of business litigation. The chamber was especially enthusiastic about Clinton’s second nominee, Stephen Breyer, who made his name building a bipartisan consensus for airline deregulation as a special counsel on the judiciary committee; and who, as a Harvard Law professor, advocated an influential and moderate view on antitrust enforcement.

During Breyer’s confirmation hearings his sharpest critic was Ralph Nader, who testified that his pro-business rulings were “extraordinarily one-sided.” Another critic, Senator Howard Metzenbaum of Ohio, said that the fact that the chamber was the first organization to endorse Breyer indicated that “large corporations are very pleased with this nomination” and “the fact that Ralph Nader is opposed to it indicated that the average American has a reason to have some concern.” The chamber’s imprimatur helped reassure Republicans about Breyer, and he was confirmed with a vote of 87 to 9. “Frankly, we didn’t feel like we had anyone on the court since Justice Powell who truly understood business issues,” Conrad told me. “Justice Breyer came close to that.”

The Breyer and Ginsburg nominations also came at a time when liberal as well as conservative judges and academics were gravitating in increasing numbers to an economic approach to the law, originally developed at the University of Chicago. The law-and-economics movement sought to evaluate the efficiency of legal rules based on their costs and benefits for society as a whole. Although originally conservative in its orientation, the movement also attracted prominent moderate and liberal scholars and judges like Breyer, who before his nomination wrote two books on regulation, arguing that government health-and-safety spending is distorted by sensational media reports of disasters that affect relatively few citizens.

Since joining the Supreme Court, Breyer has also been an intellectual leader in antitrust and patent disputes, which often pit business against business, rather than business against consumers. In those cases, many liberal scholars sympathetic to economic analysis have applauded the court for favoring competition rather than existing competitors, innovation rather than particular innovators. “The court deserves credit for trying to rationalize a totally irrational patent system, benefiting smaller new competitors rather than existing big ones,” says Lawrence Lessig, an intellectual-property scholar at Stanford.

Clinton’s nominations of Ginsburg and Breyer may have been welcomed by the chamber, but with the election of George W. Bush, the chamber faced a dilemma. Ever since the Reagan administration, there had been a divide on the right wing of the court between pragmatic free-market conservatives, who tended to favor business interests, and ideological states-rights conservatives. In some business cases, these two strands of conservatism diverged, leading the most staunch states-rights conservatives on the court, Antonin Scalia and Clarence Thomas, to rule against business interests. Scalia and Thomas were reluctant to second-guess large punitive-damage verdicts by state juries, for example, or to hold that federally regulated cigarette manufacturers could not be sued in state court. As a result, under Conrad’s leadership, the chamber began a vigorous campaign to urge the Bush administration to appoint pro-business conservatives.

When it came time to replace Chief Justice William Rehnquist and Justice Sandra Day O’Connor, the candidate most enthusiastically supported by states-rights conservatives, Judge Michael Luttig, had a record on the Court of Appeals for the Fourth Circuit that some corporate interests feared might make him unpredictable in business cases. (”One of my constant refrains is that being conservative doesn’t necessarily mean being pro-business,” Conrad told me.) The chamber and other business groups enthusiastically supported John Roberts, who had been hired by the chamber to write briefs in two Supreme Court cases in 2001 and 2002. At the time of Roberts’s nomination, Thomas Goldstein, a prominent Supreme Court litigator, described him as “the go-to lawyer for the business community,” adding “of all the candidates, he is the one they knew best.” When Roberts was nominated, business groups lobbied senators as part of the campaign for his confirmation.

The business community was also enthusiastic about Samuel Alito, whose 15-year record as an appellate judge showed a consistent skepticism of claims against large corporations. Ted Frank of the American Enterprise Institute predicted at the time of the nomination that if Alito replaced O’Connor, he and Roberts would bring about a rise in business cases before the Supreme Court. Frank’s prediction was soon vindicated.

“There wasn’t a great deal of interest in classic business cases in the last few years of the Rehnquist Court,” Carter Phillips, a partner at Sidley Austin and a leading Supreme Court business advocate, told me. In 2004, Judge Richard Posner, a founder of the law-and-economics movement, argued that the Rehnquist Court’s emphasis on headline-grabbing constitutional cases had politicized it, and called on the court to hear more business cases. The Roberts court has unambiguously answered the call. As Phillips told me, Roberts “is more interested in those issues and understands them better than his predecessor did.”

IV.

Exactly how successful has the Chamber of Commerce been at the Supreme Court? Although the court is currently accepting less than 2 percent of the 10,000 petitions it receives each year, the Chamber of Commerce’s petitions between 2004 and 2007 were granted at a rate of 26 percent, according to Scotusblog. And persuading the Supreme Court to hear a case is more than half the battle: Richard Lazarus, a law professor at Georgetown who also represents environmental clients before the court, recently ran the numbers and found that the court reverses the lower court in 65 percent of the cases it agrees to hear; and when the petitioner is represented by the elite Supreme Court advocates routinely hired by the chamber, the success rate rises to 75 percent.

Faced with these daunting numbers, the progressive antagonists of big business are understandably feeling beleaguered and outgunned. “The fight before the court is generally not an even one,” said David Vladeck, who once worked for the Public Citizen Litigation Group and now teaches law at Georgetown. “There’s us on one side, with a brief or two, and industry on the other side, with a well-coordinated campaign of 10 or 12 briefs, with each one written by a member of the elite Supreme Court bar that address an issue in enormous depth.” He added, ruefully, “You admire their handiwork, but it’s frustrating as hell to deal with.”

To gauge the degree of the frustration, I recently paid a visit to Ralph Nader, a few weeks before he announced his most recent campaign for president of the United States. It was a surprise to find that his office, the Center for Study of Responsive Law, shares an address in a grand building with the Carnegie Institution for Science. But the office itself, reassuringly, is buried on the ground floor, where Nader received me at a conference table surrounded by file cabinets stuffed with faded back issues of Mother Jones and The Nation.

Nader was uncontrite about his 2000 run against Al Gore — which is often credited with helping George W. Bush win the presidency — and he insisted that because Clinton appointed justices like Breyer, Gore would have done the same. “Breyer hasn’t been worse than I feared, because I had real concern when he was nominated,” Nader told me. He conceded that, like Breyer, Democratic justices appointed by President John Kerry would presumably have been better on civil rights and liberties than John Roberts and Samuel Alito. Nevertheless, he disparaged Breyer as a “deregulation quasi-ideologue” who was able to weave a “tapestry of illusion” in his arguments by dealing in abstractions.

The main casualty of the 2000 run, Nader said, is that he is no longer collaborating with America’s trial lawyers. They would ordinarily be his natural allies in representing consumer interests, but they donated heavily to Gore’s campaign. After 2000, the trial lawyers “have been vitriolic,” Nader explained. He blames them for not using their money to help counteract the influence of the Chamber of Commerce and other business groups before the federal courts. In part as a result of their stinginess, he said, his colleagues at Public Citizen are underfinanced and worn down. “There were some lawyers who left Public Citizen because they got tired of losing,” he said. “Everyone is desperately trying to hold on to whatever issues are left, and then they become demoralized and discouraged.”

Thirty years after the Chamber of Commerce founded its litigation center to counteract his influence, Nader all but conceded defeat in the battle for the Supreme Court. With the decline of economic populism in Congress, the weakening of trade unions and the rise of globalization, the political climate, he lamented, was passing him by. “I recall a comment by Eugene Debs,” Nader said, looking at me intensely. “He said: The American people live in a country where they can have almost anything they want. And my regret is that it seems that they don’t want much of anything at all.”

Nader chuckled quietly and shook his head. “I say ditto.”

V.

If there is an anti-Nader — a crusading lawyer passionately devoted to the pro-business cause — it is Theodore Olson. One of the most influential Supreme Court advocates and a former solicitor general under President George W. Bush, Olson is best known for his winning argument before the Supreme Court in Bush v. Gore in 2000. But Olson has devoted most of his energies in private practice to changing the legal and political climate for American business. According to his peers in the elite Supreme Court bar, he more than anyone else is responsible for transforming the approach to one of the most important legal concerns of the American business community: punitive damages awarded to the victims of corporate negligence.

Punitive damages — money awarded by civil juries on top of any awarded for actual harm that victims have suffered — are designed to penalize especially egregious acts of corporate misconduct resulting from malice or greed, and to deter similar wrongdoing in the future. In the 19th century, courts generally demanded a clear assignment of fault in cases where victims sued for injuries caused by malfunctioning products. It was hard for plaintiffs to recover in personal-injury cases unless the corporation was obviously at fault. But in the 20th century, in liability cases involving a rapidly expanding class of potentially dangerous products like cars, drugs and medical devices, courts increasingly applied a standard of “strict liability,” which held that manufacturers should pay whether or not they were directly at fault.

The animating idea was that manufacturers were in the best position to prevent accidents by improving their products with better design and testing. They and their insurance companies (rather than society as a whole) would shoulder the costs of accidents, thus giving them an incentive to make their products safer. Encouraged by Ralph Nader’s book, “Unsafe at Any Speed,” published in 1965, courts began to see car accidents as predictable events that better car design could have prevented. In 1968, for example, a federal court held that car manufacturers could be sued for failing to make cars safe enough for drivers to survive crashes, even if the driver was at fault for the crash.

A series of well-publicized awards in the 1980s and ’90s culminated in the largest punitive damage award in American history the $5 billion levied against Exxon after the Exxon Valdez oil spill in 1989. This was hardly typical: the median punitive award actually fell to $50,000 in 2001 from $63,000 in 1992. Nevertheless, critics like Olson claimed that multimillion-dollar punitive-damage verdicts were threatening the health of the economy. They resolved to fight back on several fronts. In his first Supreme Court argument, in 1986, Olson set out the broad contours of his argument: for most of English and American history, private litigants were entitled to be compensated for whatever damages they suffered, including pain and suffering, but any public wrongs like the failure of American business to make cars safer by adopting air bags should be addressed by legislation or regulation, not by the courts.

Olson decided that his clients deserved not just a lawyer who could argue a case but a lawyer who could change the political culture. “You had to attack it in a broad-scale way in the legislatures, in the arena of public opinion and in the courts,” he told me recently. “I felt the business community had to approach this in a holistic way.” He set out, in lectures and op-ed pieces, to publicize especially egregious examples. The poster child for punitive-damage abuse, widely derided in TV and radio ads paid for by the business community, was a New Mexico grandmother who, in 1994, was awarded $2.7 million in punitive damages when she scalded herself with hot McDonald’s coffee. Consumer advocates countered that she had originally asked for $20,000 for medical expenses, which McDonald’s refused to pay, and the award appeared to have the effect of persuading McDonald’s to serve its coffee at a safer temperature. Nonetheless, the campaign to vilify plaintiffs’ lawyers has been effective enough that the American Association of Trial Lawyers recently changed its name to the fuzzier American Association for Justice.

The business community made other inroads against punitive damages. Corporations financed campaigns against pro-punitive-damage state judges who had been elected with the assistance of large contributions from plaintiffs’ lawyers. The business community also helped persuade more than 30 states to either impose caps on punitive-damage awards or direct substantial portions of the awards to be paid into special state funds. In 1996, it helped persuade the Republican Congress, led by Newt Gingrich, to pass legislation that would cap punitive-damage awards in product-liability cases in every state court in the country. But in 1996, President Clinton, with what must have been perverse pleasure, vetoed the bill on the grounds that it violated principles of federalism and states rights to which conservatives claimed to be devoted.

Thwarted by Clinton, and unable to persuade Congress to override the veto, opponents of punitive damages turned their attention back to the Supreme Court, looking for a victory they were unable to win in the political arena. Here, they were remarkably successful. As late as 1991, the court had refused to impose limits on a large punitive-damage award. But in a case in 1996, the court held for the first time that punitive-damage awards had to be proportional to the actual damage incurred by the plaintiff. The case involved a man who said he was deceived by BMW when it sold him a supposedly “new” car that was, in fact, used and had received a $300 touch-up job. The court, in a 5-4 opinion, overturned a $2 million punitive-damage award as “grossly excessive.” In 2003, the court clarified what it meant: a single-digit ratio between punitive damages and compensatory damages was likely to be acceptable.

Last year, the business community watched with anticipation as Roberts and Alito revealed their views about punitive damages. The case involved the estate of a heavy smoker who sued Philip Morris for deceitfully distributing a “poisonous and addictive substance.” A jury had awarded the estate $821,000 in compensatory damages and $79.5 million in punitive damages — a ratio of about 100 to 1. In a 5-4 opinion written by Breyer, the court held that it was unconstitutional for a jury to use punitive damages to punish a company for its conduct toward similarly affected individuals who are not party to the lawsuit.

This spring, the court will decide the Exxon Valdez punitive-damage case, which many consider the culmination of the business community’s decades-long campaign against punitive damages. In 1989, the Exxon Valdez tanker, whose captain had a history of alcoholism, ran into a reef and punctured the hull; 11 million gallons of oil leaked onto the coastline of Prince William Sound. A jury handed down a $5 billion punitive-damage award.

After the verdict, Exxon began providing money for academic research to support its claim that the award for damages was excessive. It financed some of the country’s most prominent scholars on both sides of the political spectrum, including the Nobel laureate Daniel Kahneman and Cass Sunstein, a law professor at the University of Chicago. (Sunstein says he accepted only travel grants, not research support, from Exxon; and Kahneman stresses that the financing had no influence on the substance of his work.) In a 2002 book, “Punitive Damages: How Juries Decide,” Sunstein studied hundreds of mock-jury deliberations and concluded that jurors are unpredictable and often irrational in punitive-damage cases. Jury deliberations, he found, increase the unpredictability, as well as the dollar amount of the final awards. Sunstein concluded that a system of civil fines determined by experts, rather than punitive damages determined by juries, might be more sensible. When Exxon appealed the $5 billion verdict in 2006, it was reduced by an appellate court to $2.5 billion. The reduced verdict is once again being challenged as excessive.

Walter Dellinger, the lawyer now arguing Exxon’s case before the Supreme Court, is no Republican activist. Like Sunstein, he is one of the most respected Democratic constitutional scholars, as well as a former acting solicitor general for President Clinton. Last month, in his argument before the court, Dellinger argued that because Exxon has already paid $3.4 billion in fines, cleanup costs and compensation connected with the Exxon Valdez spill, and because it didn’t act out of malice or greed in failing to monitor the alcoholic captain, additional punitive damages would serve no “public purpose.”

During the argument, Breyer noted that the $2.5 billion punitive damage award represents a less than 10-to-1 ratio between punitive damages and compensatory damages, which is in the single-digit range that the Supreme Court has considered acceptable in the past. But Breyer also seemed concerned at other points that punitive-damage awards have not been routine in maritime cases like this one, and that the award might create “a new world for the shipping industry.” Alito, who owns Exxon Mobil stock, did not participate, and because a tie would affirm the $2.5 billion punitive-damage award, the plaintiffs who are opposing Exxon need only four votes to prevail. But whether Dellinger gets five votes, a significant triumph is already behind him: he persuaded the court to take the case in the first place.

VI.

Ted Olson and the Chamber of Commerce aren’t only trying to persuade the Supreme Court to cut back on large punitive-damage awards; they’re also arguing that consumers injured by dangerous or defective medical devices and drugs in some cases shouldn’t be able to file product-liability suits at all. Because there is no national product-liability law that allows federal suits for personal injuries, consumers who are injured by, say, defective heart valves or artificial hips have to sue in state courts under state tort law. By asking the Supreme Court to prevent injured consumers from suing in state court, the business community, supported by the Bush administration, is trying to ensure that these consumers often have no legal remedy for their injuries. And the Supreme Court has been increasingly sympathetic to the business community’s arguments.

In a Supreme Court case Olson argued in December, he stood before the justices and argued that the manufacturers of defective medical devices — like heart valves, breast implants and defibrillators — should be immune from personal-liability suits because the federal Food and Drug Administration had approved the devices before they were marketed and the manufacturers had complied with all federal requirements. The case involved Charles Riegel, who had an angioplasty in 1996 during which the catheter used to dilate his coronary artery burst. Riegel, who needed advanced life support and emergency bypass surgery, eventually sued the manufacturer of the catheter, Medtronic. The company is colloquially referred to in the business community as “the pre-emption company” because of its practice of arguing that the Food and Drug Administration’s “premarket approval” of its products pre-empts product-liability suits in state courts.

The lawyer representing Riegel’s estate before the Supreme Court, Allison Zieve of Public Citizen, countered that Congress never intended to ban state product-liability suits when Senator Edward Kennedy sponsored a bill regulating medical devices in 1976. (Kennedy himself filed a brief in the case noting that he indeed intended no such thing.) “Lawyers think this is a close issue, but any time I talk to a nonlawyer about it, they’re shocked,” Zieve told me after the argument. “People think: of course, if somebody makes a defective product you can sue.”

It’s one thing to argue that the federal government’s “premarket approval” of food, drugs and medical devices should pre-empt clearly inconsistent state laws and regulations. After all, if states imposed safety requirements that conflicted with the federal standard, the resulting regulatory confusion would make a national (and global) market impossible. But Olson’s claim that federal regulation of medical devices and drugs should also pre-empt product-liability suits under state tort law is one of the more creative and far-reaching legal arguments of the business groups that litigate before the Supreme Court.

This type of argument arose out of the tobacco litigation of the 1980s and ’90s, which culminated in a $206 billion settlement paid by the top tobacco companies to a consortium of 46 state attorneys general in exchange for dropping tort suits against the companies. The tobacco litigation began modestly: in 1983, Rose Cipollone, a New Jersey woman dying of lung cancer, sued several of the country’s largest tobacco companies for their failure to give adequate warnings about the dangers of smoking. After spending tens of millions of dollars fighting the verdict, the companies decided to take their defense to the next level. They argued that because the federal government required cigarette companies to have warning labels, tobacco companies couldn’t be subject to tort suits in state courts. Jury verdicts, they argued, are no less a form of regulation than laws explicitly adopted by state legislatures.

In a decision in 1992, the Supreme Court endorsed part of the companies’ argument. The decision unleashed a torrent of similar “pre-emption” claims by the manufacturers of dangerous drugs, defective medical devices and cars without air bags. And after the election of President Bush in 2000, the business community’s crusade was aggressively supported by the White House. At the same time that the White House was scaling back on federal health-and-safety enforcement, it insisted that consumers should not be able to sue federally regulated industries in state court. Bush appointed as the general counsel of the Food and Drug Administration a former drug- and tobacco-company lawyer named Daniel Troy. With Troy’s support, the F.D.A. reversed its position, held for 25 years, and argued for the first time that its premarket approval of medical devices should prevent injured consumers from bringing product-liability suits in state court.

After her Supreme Court argument in the Medtronic case, Zieve told me she wasn’t sure what to expect. Until the arrival of Chief Justice Roberts, groups like Public Citizen had found that they had a better chance of winning pre-emption cases before the Supreme Court than in the lower courts. But during the first two years of the Roberts Court, the justices had decided two pre-emption cases in favor of the corporate defendants.

The trend has continued. On Feb. 21, the Supreme Court handed Zieve a crushing defeat: an 8-1 opinion immunizing the makers of defective medical devices from product-liability suits. The lone dissent was written by Ruth Bader Ginsburg, who objected that Congress could not have intended such a “radical curtailment” of state personal-injury suits when it regulated medical devices in 1976. Ginsburg, who is devoted to liberal judicial restraint, has consistently opposed efforts to second-guess punitive-damage awards or expand federal pre-emption. I called Zieve soon after the Supreme Court issued its opinion, and she sounded shocked. “It’s really unfathomable to me,” she said. “I wasn’t sure that this was a business-friendly court, but now I’m finding it harder not to view it that way.” Zieve said that, as a result of the decision, “I think the industry will keep unsafe devices on the market longer and be slower to improve products.”

In the eyes of advocates like Zieve and Public Citizen, the public is now caught in a Catch-22: at the very moment that agencies like the F.D.A. are being strongly reproved by critics — including the agency’s own internal science board — for being unwilling or unable to protect public health, the court is making it harder for people to receive compensation for the injuries that result. On rare occasions, the Roberts Court has held that the Bush administration’s deregulatory efforts circumvent the will of Congress — like the 5-4 decision last year holding that the Environmental Protection Agency acted capriciously when it adopted a rule that said it had no legal authority to regulate greenhouse gases. But by and large, the Supreme Court defers to agencies that refuse to regulate public health and safety. “The industry has a lot of money, and they can routinely hire the biggest names in the biggest firms, while we’re doing it on our own,” Zieve told me. “We don’t charge anything — we’re free. It didn’t cost $250,000 to get us to write the brief.”

VII.

The Supreme Court is unlikely to reconsider its pro-business outlook anytime soon. Nevertheless, there are several currents in American political life that run counter to the court, even if they may not be strong enough, or suitably directed, to reverse it. There are, for example, economic populists in both political parties — John Edwards Democrats and Mike Huckabee Republicans, to cite just two types — who express concern about growing economic inequality and corporate corruption, and blame unchecked corporate power for America’s escalating economic problems. These populists tend to be from the working and middle classes rather than the professional classes, and their numbers may be growing. In recent Pew surveys, 65 percent of Americans agreed that corporations make excessive profits — the highest number in 20 years. Moreover, about half the country now asserts that America is divided on economic lines into two groups — the “haves” and “have nots” — up from only 26 percent two decades ago. And the number of Americans who view themselves as “have nots” has doubled to 34 percent today from 17 percent in 1988. Responding to pressures from this demographic, a Democratic Congress — bolstered by states-rights conservatives — might well try to pass legislation to counteract the court’s recent decisions barring product-liability suits for defective medical devices.

What about the executive branch? It seems unlikely that John McCain, if he were elected president, would push back against the court: he has already pledged to appoint “judges of the character and quality of Justices Roberts and Alito,” rather than justices more devoted to states rights, like Scalia and Thomas. As for Barack Obama and Hillary Clinton, both have sounded increasingly populist notes in an effort to attract union and blue-collar supporters, ratcheting up their attacks on corporate wealth and power, singling out the drug, oil and health-insurance industries and promising to renegotiate the North American Free Trade Agreement. But despite their rhetoric, it is not clear that either candidate would actually appoint justices any more populist than Bill Clinton’s nominees. “I would be stunned to find an anti-business appointee from either of them,” Cass Sunstein, who is a constitutional adviser to Obama, told me. “There’s not a strong interest on the part of Obama or Clinton in demonizing business, and you wouldn’t expect to see that in their Supreme Court nominees.”

Still, the possibility does exist. If the economy continues to decline and blue-collar voters end up being crucial in the election, a Democratic president might appoint an economic populist to the Supreme Court as a kind of payback. Earlier this month, on the campaign trail in Ohio, Obama mentioned Earl Warren, who served as governor of California before becoming chief justice, as a model of the kind of justice he hoped to appoint. “I want people on the bench who have enough empathy, enough feeling, for what ordinary people are going through,” Obama said. He praised Warren for understanding that segregation was wrong because of the stigma it attached to blacks, rather than because of the precise nature of its sociological impact. Appointing a former politician to the court would almost certainly introduce a more populist element: the Supreme Court that in 1954 decided Brown v. Board of Education included, in addition to a former governor, three former senators, a former Securities and Exchange Commission member and two former attorneys general. (By contrast, the Roberts court is composed of nine former judges.)

Whatever happens in November, Robin Conrad says the Chamber of Commerce is prepared to lobby as hard as ever for the appointment of pro-business justices. “If we do have a Democrat president, and that president has opportunities to nominate to the court,” she said in our meeting as I glanced at her Hillary Clinton action figure, “we want to be able to express ourselves and work with that president.” Regardless of how many justices retire in the next presidential term, Conrad is confident that, having helped to transform the Supreme Court in less than 30 years, she and her colleagues can assure American business of a sympathetic hearing for decades to come.

When I told Conrad that Ralph Nader told me that lawyers were leaving Public Citizen because they were tired of losing, she achieved a look of earnest concern. “I hope if they feel they’ve lost,” she said, “they lost for a good reason — not because they’ve been overpowered or muscled by the big, bad business community, but they’ve lost because reason won.”

Conrad looked at me squarely, and then added, “I guess if Ralph Nader wants to say we did him in” — she paused to weigh her words — “so be it.”

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