Competing institutions: Law, medicine, and family in neonatal intensive care

To understand the varying impact of law, we must compare the effects of legal institutions with the effects of rival institutions and the impact one law with the impact of another. We must also ask how the setting in which institutions compete and laws are implemented - very often an organization - shapes outcomes. Using the competition between legal, medical, and familial institutions in infant intensive care units as an example, this article elaborates a theory of institutional competition and therefore of the influence of law in organizations. I show that institutions, including legal institutions, gain influence by working through internal organizational processes. Thus, the impact of law on medical decisionmaking varies with whether legal actors have learned how to be present when decisions are to be made, make legal issues into organizational problems, introduce choice points that require action, and alter the possibility space of eligible solutions. Using variations among the major categories of laws that govern the practice of infant intensive care, the article also shows how organizational and institutional theories help explain why some laws have more impact than others.