Prominent Indonesian Muslim intellectual Nurcholish Madjid once declared “Islam Yes; Islamic political party No!” Voters in contemporary Indonesia seem to agree with this basic sentiment. Despite the recent Islamic revival that has dramatically increased public expressions of piety, Islamic political parties have failed to gain any significant electoral traction in Indonesia. In fact, between the 2004 and 2009 national elections, support for Islamic parties actually decreased from 38 percent to approximately 28 percent. Yet during those same five years, the Islamic political parties that failed to win at the ballot box mobilized enough political and popular support to pass one of Indonesia’s most divisive pieces of legislation—the Anti-Pornography Law. These seemingly contradictory elements of Indonesian politics provide starkly different impressions of Islam’s political role. Does a weak showing in the country’s electoral politics indicate the imminent demise of Islam in Indonesian politics? Or does the politically adept maneuvering of Islamists—who seek political power through legislation about bodily discipline—foretell gloomy days ahead?

Explanations for this paradox depend largely on where we look for “the political.” Political scientist Greg Fealy has described Islam in Indonesia as a mosaic. If we spend too much time focusing our gaze on one single area, he observes, we lose sight of other patterns elsewhere in the mosaic. To understand political Islam by ballot box alone is to miss the cultural undercurrents that have direct bearing on Islam and politics in Indonesia.

The anti-pornography bill was not only a political battle waged inside the parliament building; it was also a media drama that played out in the newspapers, televisions, and on the Internet. Human rights and women’s advocacy groups vehemently protested an early version of the bill, which stipulated that women would be prevented from leaving their homes during certain evening hours. From a different vantage point, the mostly Hindu island province of Bali threatened to secede, arguing that the article prohibiting “revealing” clothing in public would wreak havoc on the island’s tourism industry, still sluggish after devastating bomb attacks in 2002 and 2005. Whereas many non-Muslims worried about the “Islamization” of Indonesia, proponents of the bill lamented the “degradation of national morality.”

Popular Muslim television preachers were among the bill’s most vocal supporters. Eager to parlay their celebrity appeal into political clout, TV preachers Ustad Jefri Al-Buchori and Arifin Ilham helped to lead the so-called Million Muslim March to rally public support for the anti-pornography bill. Celebrity preacher and self-help guru Abdullah Gymnastiar led a sophisticated multimedia campaign to promote the bill through television, radio, the Internet, text messages, and public rallies. All of these popular preachers, in step with the political strategy of the Indonesian Council of Ulamas, invoked the religio-political language of moral crisis in an attempt to control the terms of political debate. Unable to win an election, Islamic groups flexed their moral muscle in the public sphere. From the pulpit of his Sunday afternoon television program, Gymnastiar characterized those against the bill as “having no shame” before God or country. Nearly every single political party, anxious not to appear “un-Islamic,” voted to support the anti-pornography legislation.

The political participation of a new generation of media-savvy religious leaders reveals a sentiment quite different from Nurcholish Madjid’s liberal aspirations. As one proponent of the Anti-Pornography Law put it, “Islamic political party No; Political Islam Yes!” Whereas utopian visions of the international caliphate may not resonate with Indonesian voters, it appears that political Islam—as played out on the public stage—is alive and well. What remains to be seen, however, is whether those who engage in the politics of piety also have the moral courage to champion Indonesia’s more pressing issues of poverty and corruption.

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Shorenstein APARC Dispatches are regular bulletins designed exclusively for our friends and supporters. Written by center faculty and scholars, Shorenstein APARC Dispatches deliver timely, succinct analysis on current events and trends in Asia, often discussing their potential implications for business.

Malpractice liability, along with medical technology and payment system distortions, regularly figures among the most-cited reasons for escalating health-care spending in the United States. On the one hand, Harvard economist Amitabh Chandra conservatively estimates that upwards of $60 billion, or 3 percent of total health care costs ($1.8 trillion), is spent annually as a result of direct litigation and indirect defensive medicine costs. On the other hand, tort reform advocates place the figure at $200 billion by extrapolating, to the entire U.S. population, the results of research conducted by Stanford professor Dan Kessler and Mark McClellan. Their 1996 study shows that tort reforms reduced provider liability costs for Medicare heart patients by 5 to 9 percent.

At the heart of these debates is the following question. Does medical malpractice liability achieve its dual goal of compensating victims of medical injuries and deterring medical errors, or does it merely encourage wasteful defensive medicine without improving patient health? Despite considerable empirical research, there is little evidence that malpractice litigation deters medical negligence. The evidence is much stronger—though still hotly debated—that malpractice fears actually encourage physicians to engage in defensive medicine. My work at Shorenstein APARC explores whether malpractice pressures affect physician behavior, patient health, and health care costs in Asia. Studying physicians’ response to legal changes in Taiwan, I find that greater malpractice liability may, under certain circumstances, prompt physicians to perform more services without necessarily improving patient health.

In particular, I focus on how increased medical malpractice liability affects physicians in Taiwan who provide treatment to pregnant women. I have studied how a series of court rulings as well as an amendment to Taiwanese law between 1997 and 2004 impacted physicians’ test-ordering behavior and decisions to perform Caesarian sections. Traditionally, Taiwanese doctors are held accountable for medical malpractice under two bodies of law: tort law in the Civil Code, and criminal law for harm resulting from negligent acts in the course of professional operations. The latter, prosecutorial approach is rare among industrialized nations.

In January 1998, a Taipei District Court decision in favor of plaintiffs in a civil suit for damages sent shockwaves through the medical community. The district court judge disregarded the traditional tort requirement of proving the defendant’s negligence (or fault), and applied the “strict liability” doctrine of the Consumer Protection Law to impose liability on a medical provider without any showing of wrongdoing. The court decision—subsequently affirmed by the Taipei High Court on September 1, 1999 and by the Supreme Court on May 10, 2001—sparked resentment among medical professionals. Passions flared in heated debates between medical and legal scholars about whether medical services should be considered a covered “service” under the Consumer Protection Law. Economists and legal academics questioned whether the traditional justifications for imposing strict liability apply in the highly unpredictable practice of medicine, especially in obstetrics. The saga concluded in April 2004, when the legislature amended the Medical Law to require negligence or fault in medical malpractice cases.

My research considers the effect of these court rulings and legal amendments on physicians’ test-ordering behavior and their propensity to perform Caesarean sections. I identify two sources of variation in perceived risks of malpractice liability: (1) the differences between the level of exposure to malpractice risks due to the ownership structure and size of the physicians’ place of practice; and (2) the differences in perceived risks based on the physicians’ geographical location.

My results are consistent with the existence of defensive medicine. First, with respect to their propensity to increase laboratory tests and reduce Caesarean sections, physicians who own their clinics (“physician-owners”) in Taiwan reacted more strongly to the legal changes than did physicians who are salaried employees at larger hospitals (“nonowners”). Physician-owners’ behavior did not change, however, in discretionary expenditures that were not associated with defensive medicine. Second, physician-owners working in areas under the jurisdiction of the Taipei District Court reacted more strongly to legal change than did those practicing in Kaohsiung, Taiwan’s second largest city, at the opposite end of the island.

The negative connection between the likelihood of Caesarean deliveries and increased malpractice liability deserves special mention, since most published studies find a positive association between malpractice liability risks and Caesarean rates. However, economists Janet Currie and Bentley MacLeod at Columbia University suggest that reforms in which liability is closely aligned with defendant’s actual levels of care may produce the opposite effect. In the Taiwan context, increased medical malpractice liability accrues directly to the physician-owners. Since Caesarean sections are generally riskier than natural deliveries, it seems logical that higher tort liability in Taiwan may actually decrease the likelihood of deliveries by Caesarean sections. In this sense, my study confirms Currie and MacLeod’s predictions and empirical results.

My work contributes to our understanding of health law and policy in several concrete ways. First, I add support to the existence of defensive medicine, even in a non-Common Law jurisdiction. Since I focus on Taiwan—an environment that lacks malpractice insurance, in which physicians are either owners or employees at providers of varying sizes—my research isolates the pure effect of malpractice liability to a greater extent than do many current studies. Second, I show that interaction between the payment and legal systems may either enhance or mitigate the hypothetical pure effects of legal policies. In a fee-for-service system, physicians subject to higher malpractice risks appear much more willing to increase laboratory tests than to reduce profitable Caesarean sections. Third, my research indicates that, by altering physicians’ exposure to risks, different organizational forms and ownership structures of health care provision may affect defensive medicine at differing rates.

In sum, the practice of “defensive medicine” appears not to be a uniquely American phenomenon. Indeed, it may also play a role in health care cost escalations in Asia, especially under heightened physician liability regimes.

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Shorenstein APARC Dispatches are regular bulletins designed exclusively for our friends and supporters. Written by center faculty and scholars, Shorenstein APARC Dispatches deliver timely, succinct analysis on current events and trends in Asia, often discussing their potential implications for business.