Essay # 5 in our Book Symposium on Beth Burch’s The Pain Brokers, by Renee Knake Jefferson (Houston).
If you’ve been following the essays in this symposium on Elizabeth Chamblee Burch’s compelling new book, The Pain Brokers: How Con Men, Call Centers, and Rogue Doctors Fuel America’s Lawsuit Factory, by now you should be convinced it is a must-read.
Burch, a University of Georgia law professor and nationally recognized expert on mass tort litigation, spent two years conducting more than 150 interviews in motels, law offices, and roadside diners across the country (p. xi). The result is a work of narrative nonfiction that reads more like a crime thriller than a legal treatise.
It is worth taking a moment to appreciate how this book came to be. It is a product of Burch’s decision, as a tenured law professor, to enroll in the MFA Program in nonfiction at the University of Georgia’s Grady School of Journalism. Her commitment, in her words, “to turn the injustices of mass tort litigation into a story for general readers” (p. 291) is impressive. We might benefit from more academics investing time and energy into making their work accessible to readers beyond the so-called ivory tower. Burch is a gifted writer. Her book will keep you up late and haunt you long after you read the last page. I can already see it being made into a miniseries (think Jonathan Harr’s A Civil Action meets Apple TV’s Palm Royale set in 2015 instead of 1969—much of the action happens in Florida).
Burch exposes how the legal system facilitated a profitable market fueled by the pain of women injured with defective transvaginal mesh. What makes Burch’s analysis especially disturbing is the vivid portrayal of women who face life-threatening medical conditions with increasingly less ability to make informed, safe choices for their reproductive health. It is yet another example of how the legal system in many jurisdictions denies women full bodily autonomy.
Along the way we meet Sharon Gore, Jerri Plummer, and Barbara Shepard, three women who were each victimized twice: first by the unnecessary removal of their pelvic mesh and again by the legal system which should have compensated them, but instead rewarded those who took advantage of their suffering. These women, many poor and in chronic pain, were recruited through predatory telemarketing, transported to a fly-by-night pseudo-surgical center set up in a Florida office park, subjected to unnecessary or botched procedures, unwittingly saddled with high-interest loans when their insurance would have covered treatment, and then funneled into mass tort cases where the primary beneficiaries were not the victims but the lawyers and middlemen who had assembled the “inventory” of women in the first place (p. 49).
The scheme involved a network of con men, rogue doctors, and call-center operators who exploited tens of thousands of women. At the heart of the enterprise was what Burch labels a “LINO”—a law firm in name only (p. 8). According to Burch, Alpha Law, LLC “took no depositions, tried no trials, and sued nobody” (p. 8). Instead, the Florida-based entity was a “marketing firm that funneled clients to real lawyers in a manner that was illegal in Florida and everywhere else except Washington, DC” (p. 8). The “DC loophole,” as Burch calls it, is actually a rule of professional conduct. Most jurisdictions follow ABA Model Rule 5.4, which prohibits individuals without law licenses from owning or investing in law firms. DC has an exception in its version of 5.4 exploited by Alpha Law. (Notably, Arizona completely eliminated its Rule 5.4 in 2021, with recent mixed reviews both documenting positive innovations in the delivery of legal services and harms to consumers. No other state has followed Arizona’s lead.)
I want to situate The Pain Brokers in the context of other market failures in the legal system. In my own book Law Democratized: A Blueprint for Solving the Justice Crisis, I argue that the American legal profession faces a profound access-to-justice crisis. Every year, millions of individuals confront serious legal problems—eviction, debt collection, family disputes, consumer fraud, medical issues, and more—without meaningful access to legal representation. Civil courts across the country routinely see litigants navigating complicated legal procedures on their own. Many never even recognize their problems as something that could be resolved through the legal system.
The void in legal help is not merely the product of information asymmetries and limited financial resources; it is also the result of institutional design. Burch’s book paints a dramatic portrait of what can rush in to fill this void and the picture is not pretty. Where Law Democratized diagnoses a civil justice system plagued by scarcity, The Pain Brokers shows how predators exploit that desperation.
The parallels to Law Democratized are instructive and troubling. My book documents how 87 percent of American households facing civil legal problems never even seek legal help, a statistic that reflects not indifference but a market that does not reach ordinary people (p. xii). The women Burch profiles did not suffer from a lack of legal contact. They were inundated with it. Call centers found them, lawyers signed them up via electronic sleight-of-hand, and surgeons cashed in before the legal machinery had even begun to grind. What Burch reveals is that when the formal legal services market fails ordinary people, an informal and predatory one may fill the gap.
As I learned more about the market for pain facilitated by the “LINO” Alpha Law, it caused me to rethink my own recommendations in Law Democratized for reform of Model Rule 5.4 to allow individuals without law licenses to participate in law firm ownership (p. 145-46). While I still favor reforms to expand who may be authorized to provide legal help and how they may do so, The Pain Brokers is a cautionary tale that must guide any such reform efforts.
Burch is particularly incisive on the structural features of multidistrict litigation, or MDL, that enable this predation. In MDL proceedings, thousands of individual cases are consolidated before a single federal judge (p. 1). A small group of insider plaintiffs’ attorneys—chosen through a “good-ol’-boy network,” as Burch describes it—controls the litigation, sets the settlement terms, and collects the fees (p. 4). Traditional legal markets tend to serve those with full information who can afford to pay; in The Pain Brokers, Burch shows how MDL structures similarly concentrate profit and information at the top of the plaintiffs’ bar, even in litigation nominally waged on behalf of the powerless.
For scholars of legal ethics, the market harms Burch describes raise questions that extend well beyond MDL litigation. The legal profession has long framed professional responsibility primarily in terms of rules governing individual lawyers and their duties to clients. Yet the pelvic mesh litigation marketplace illustrates how profoundly lawyers shape institutions as well as individual cases. Through litigation strategies, case aggregation, and relationships with intermediaries, lawyers helped construct the very systems through which legal claims are identified and resolved.
Lawyers sit at the center of this system. They are the actors who transform personal injury into legal claims, who aggregate those claims into large-scale litigation campaigns, and who ultimately negotiate the settlements that distribute billions of dollars in compensation. Yet Burch’s account reveals how modern mass-tort practice resembles a supply chain. Potential plaintiffs may be identified through digital advertising, routed through lead-generation companies, and matched with law firms assembling vast portfolios of cases for multidistrict litigation. In such a system, the lawyer-client relationship—long understood as the ethical core of legal practice—can become attenuated as claims move through layers of intermediaries before reaching the courtroom. The “inventory” of clients may never meet their lawyer at all. Seen from that perspective, Burch’s narrative is not simply a study of mass-tort practice. It is an invitation to reconsider how professional responsibility should be understood in an era when legal markets operate on a national and increasingly digital scale.
The Pain Brokers is a rigorous indictment of a legal system that allowed financial incentives to crowd out human dignity. At times the book’s narrative momentum runs ahead of its policy analysis. Burch is a formidable legal scholar but the book’s general-audience framing keeps structural reform largely in the background or relegated to footnotes (for example p. 290). Readers learn in vivid detail what went wrong; the “Band-Aids” chapter (pp. 243-248) gestures toward solutions, but Burch leaves her audience desperate for justice. I hope The Pain Brokers inspires more to read about her scholarly proposals for reform. And I’d love to read the sequel.