Contractual liability in medical malpractice may not benefit patients as proponents claim. Patients may be worse off if required to contract over liability instead of relying on state-imposed malpractice liability. Contractual liability is less beneficial and more costly due to inefficiencies like collective goods, time inconsistency, adverse selection, and network externality problems. This could lead to patients being forced into a less valuable and more expensive form of liability, potentially reducing welfare.