bluuebunny/crossref_metadata_2025 huggingface dataset:
Are Adolescents Good Candidates for RU 486 as an Abortion Method?
Authors: Senderowitz Judith
Published: June 2007

There is little experience with, and virtually no documentation of, adolescents’ use of RU 486 as a means of terminating pregnancy. While this void is understandable presently, it must be filled in order to determine how best to apply this new medical method to a special population—teenagers. It is imperative to know how adolescents might react differently from older women physiologically and psychologically, how they would accept this method of abortion and how health service providers should respond to their special needs. Counseling, for example, is particularly important for adolescent use of any family planning or abortion service.

Although it is not possible to review directly adolescent experience with RU 486, it is instructive to examine related attitudinal and behavioral patterns to assess the potential for adolescent use of a medical method of abortion. Documented experience with contraception and surgical abortion underscores the major challenges—present and new—for adoption of a new approach.
Antiprogestin Drugs: Ethical Issues
Authors: Macklin Ruth
Published: June 2007

Does the prospect of introducing RU 486 into the United States pose any unique ethical issues? Or are the ethical questions raised by antiprogestins similar to those that arise when any new medical technology comes along? The short answer is that the ethical issues are not new or different, but the politics of abortion can seduce us into thinking that antiprogestins bear ethical hazards of a novel sort.

One transcending ethical question stands before us: Would it be the right thing to do to introduce RU 486 into the United States today? The deceptive simplicity of that question requires further analysis.
Do Pharmacists Have a Right to Refuse to Fill Prescriptions for Abortifacient Drugs?
Authors: Weinstein Bruce D.
Published: June 2007

Some pharmacists who believe that abortion is immoral are troubled by the thought that they might be required to fill prescriptions for abortifacient drugs like mifepristone. Do pharmacists have the right to refuse to fill such prescriptions?

Questions about the rights of professionals have both moral and legal dimensions. I will assume—although this assumption is by no means axiomatic or uncontested—that the rights and responsibilities of persons in general and professionals in particular ought to be grounded in morality and not the law. For example, a person who breaks the speed limit to bring a critically ill friend to a hospital's emergency room violates the law, but may be morally justified in doing so. There is no legal duty to rescue a person in danger, but many moral communities hold that our moral duty of beneficence requires us to prevent harm to others, at least if in so doing we are not placing ourselves and others at great risk of harm.
RU486, the FDA and Free Enterprise
Authors: Buc Nancy L.
Published: June 2007

One key legal question on everyone's mind is whether RU486 can meet the standards for Food and Drug Administration (FDA) approval for a drug indicated for abortion. It would seem that it can. Under the Food, Drug, and Cosmetic Act, a sponsor must show that a drug is safe and effective for its intended use. Efficacy must be demonstrated by substantial evidence, which means evidence consisting of adequate and well-controlled investigations, including clinical investigations by experts qualified by scientific training and experience to evaluate the effectiveness of the drug. If on the basis of the clinical trials it could fairly and responsibly be concluded by such experts that the drug will have the effect it purports or is represented to have under the conditions of use prescribed in the labeling, and if the drug is safe, the FDA will approve it.
Toward a Theory of Process
Authors: Wolf Susan M.
Published: June 2007

Bioethics has no theory of process. We have labored to develop a widely shared set of substantive values, but have been slow to spell out exactly what processes our values command. Nor have we examined process itself, to gauge the impact of different procedures and debate what we should value in process itself.

The little work that has been done on process focuses almost exclusively on what action should be taken in one-to-one encounters. Thus, much has been said on the obligation of the physician to speak with the patient, share information, and seek consent. Indeed, it would have been difficult to advocate respect for patient autonomy at all, without at least requiring this minimal and individualistic sort of procedure. But the requirement of certain behaviors in individual encounters has not been set in any broader vision of institutional process.
Medical Futility
Authors: Miles Steven H.
Published: June 2007

“Medical futility” may be provisionally defined as a medical conclusion that a therapy is of no value to a patient and should not be prescribed. The current debate about medical futility is one of the most important and contentious in medical ethics. Proponents believe that allowing physicians to determine and withhold futile therapies can he done without disturbing the current paradigm of medical ethics which respects patient autonomy with regard to informed consent and the right to refuse treatment. Others conclude that medical futility is simply an unacceptable form of medical paternalism. Some adopt a middle position that doctors can predict medical futility; they believe that attempting this does not necessarily justify imposing decisions to forgo life-sustaining therapy on patients.

Regardless of its policy outcome, this important debate is leading to a reexamination of the nature of a patient's entitlement to health care and of the ends of medicine. It has two aspects. A definitional debate examines rhe concept of medical futility and its derived clinical criteria.
Analysis of Power in Medical Decision-Making: An Argument for Physician Autonomy
Authors: Koch Kathryn A. , Meyers Bruce W. , Sandroni Stephen
Published: June 2007

Two of the patient's rights in a Uniform Act for the Terminally Ill should he a) the right to be treated if there is reasonable doubt of the patient's wishes until it becomes clear that the treatment is not beneficial and that the patient is indeed terminally ill, and b) the right not to he subjected to treatment with no medical benefit. A physician with appropriate supporting independent opinions would he the logical individual to whom the responsibility of protecting those rights should be given. This is particularly true when the patient is incapable of his or her own medical decisions and has left no instructions regarding his or her personal goals in medical care in the event of severe illness. Two cases and an analysis of power in medical decision-making illustrate these points.
Futility: Not Just a Medical Issue
Authors: Alpers Ann , Lo Bernard
Published: June 2007

Is it futile to sustain biologic life when the patient will permanently require intensive medical care? Dr. Koch and Dr. Miles agree that such treatment would be futile; however, their concept of futility rests on no explicit standards and reflects no communal judgment. The authors view the lack of widely accepted medical standards as an impediment to answering this question definitively. Dr. Koch laments that patients and their families have seized too much power and have begun deciding that mere biologic life is worth sustaining. And Dr. Miles sees benefit to perceiving a decision not to sustain such life as “primarily biomedical” and “realistic.”

Here is where we disagree with these authors. We do not see the problem as a lack of standards that are medical. The question of prolonging a patient's life when the patient has no likelihood of regaining consciousness confronts moral, political, and economic issues.
HIV Education and the Law: A Critical Review
Authors: Burris Scott
Published: June 2007

Education to induce people to stop doing things that put them at risk of acquiring HIV infection has been all but universally acknowledged as the primary means of controlling the epidemic. Yet in the United States, official education efforts have been halfhearted. A substantial share of federal prevention money has been invested in individual testing and counseling, while other forms of prevention education have been largely left to private organizations whose effective use of federal education grants has been hampered by blue-nosed content restrictions. Despite the good intentions of many individual officials, the government has never thrown its full weight behind education; on the contrary, its policies of censorship and shame have sounded sympathetically with the AIDS-phobia of leaders in the national media, who for ten years have resisted so slight a step as accepting paid condom advertising. On several occasions, crucial studies of Americans’ sexual behavior have been cancelled under conservative pressure, and only in the past two years has the government begun assessing the success of such education as has been conducted.
Prisoners of Progress or Hostages to Fortune?
Authors: Morgan Derek , Nielsen Linda
Published: June 2007

We shall have to evolve problem-solvers—galore since each problem they solve creates ten problems more

— Piet Hein

The new reproductive technologies, especiallyin vitrofertilization (IVF), have extended the possi- bilities of assisted reproduction to the benefit of the childless couples. At the same time these technologies and their added techniques, however, have fragmented reproduction and exposed the human egg to intervention yet unknown:

The embryo may be divided into several embryos; may be sold; donated; cryopreserved; borne by another woman and returned; or used for research;

Genetic parentage may be present without sexual intercourse, may be different from social parentage and the natural time-span between fertilization and birth may be interrupted.
Japanese Attitudes toward Assisted Procreation
Authors: Shirai Yasuko
Published: June 2007

The first “test-tube baby” in Japan was born in March, 1983 at Tohoku University Hospital. Since then ten years have passed. Table 1 indicares the clinical results of in vitro fertilization in this country. As it shows, more than 145 institutions perform IVF, and more than 3,000 babies have now been born using this procedure.

According to the recommendations issued in October, 1983 by the Japan Society of Obstetrics and Gynecology, IVF is defined as a medical practice for treating infertility, and this procedure is performed only on married couples de jure. Eggs and embryos are not donated for IVF in Japan, nor does any “lending” or “leasing” of wombs take place. However, inFebruary, 1988 the Japan Society of Obstetrics and Gynecology issued new recommendations which allow clinical use of frozen embryos and eggs. The first baby from a frozen embryo was born in 1989, and 60 babies have been born to date.
Transplantation of Organs: A European Perspective
Authors: Abbing H.D.C. Roscam
Published: June 2007

The development of transplantation technology increasingly places before society a multitude of diverse, complex ethical and legal problems. The subject is the more complex because of the various divergent interests involved. There are the interests of the donor of organs, who has a right to protection of his legal position, and those of the patient in need of an often lifesaving organ. There are also the interests of the donor’s relatives, after his death, and those of the transplantation surgeons. The international dimension of transplantation technology makes the picture even more complicated. Though this article is devoted to the European situation, the problems are similar all over the world.
Life after Casey: The View from Rehnquist's Potemkin Village
Authors: Charo R. Alta
Published: June 2007

The U.S. Supreme Court’s most recent pronouncement on abortion rights resembles the dieter’s dilemma: one knows exactly how to get where one is going but lacks the willpower to follow through. In an opinion filled with exceptionally progressive, equality-based arguments for reproductive freedom, the Court nonetheless manages to back away from its own ineluctably drawn conclusions. In the end it not only ignores its own best arguments but eviscerates its previous analyses of fundamental rights and judicial protection of personal liberties from the excesses of the polity.
Physicians' Attitudes toward Disclosure of Genetic Information to Third Parties
Authors: Geller Gail , Tambor Ellen S. , Bernhardt Barbara A. , Chase Gary A. , Hofman Karen J. , Faden Ruth R. , Holtzman Neil A.
Published: June 2007

Confidentiality is a cornerstone of the physician-patient relationship. Breaches of confidentiality in the context of genetic testing are of particular concern for a number of reasons. First, genetic testing reveals information not only about a particular patient, but also about his or her family members. Second,genetic testing can label healthy people as “at risk,” subjecting them to possible stigmatization or discrimination by third parties. Third, as genetic testing becomes more widespread and is incorporated into primary care, breaches of confidentiality might inadvertently occur more frequently because primary care providers may not be trained to understand the uniqueness of genetic information. Until now, genetic services have been provided primarily by medical geneticists and genetic counselors. However, with the proliferation of new genetic presymptomatic and carrier tests, primary care physicians are going to become increasingly involved in genetic testing. Currently, little is known about physicians’ attitudes (other than those of medical geneticists) toward disclosure of confidential genetic information to third parties.
Physician Attitudes toward the Regulation of Fetal Tissue Therapies: Empirical Findings and Implications for Public Policy
Authors: Mullen Michelle A. , Lowy Frederick H.
Published: June 2007

The use of aborted fetal tissues in research and therapy (FTT) has raised exciting possibilities and a host of social, legal and ethical issues. Perhaps the most difficult issue is whether the use of materials from elective abortion can be viewed and weighed separately from the abortion itself, or if in using these tissues there is inherent complicity with the abortion act. Those who oppose FTT claim that there is complicity with the abortion act and liken the use of fetal tissue from abortions to the use of data from the Nazi experiments. Within this lobby are those who claim that the option to donate fetal tissues will make abortion a more attractive alternative for pregnant women, and that there are doctors who will offer fetal tissue donation as a positive incentive to abortion-with the net effect that more abortions will take place.
Moral Grounding for the Participation of Children as Organ Donors
Authors: Ross Lainie Friedman
Published: June 2007

More than 24,000 patients await organ transplants and the number is increasing yearly. Living donors are an important source of transplant organs. In this paper, I argue that we can morally justify allowing children to serve as donors. Yet, I also argue that their participation must be restricted in order to prevent their exploitation.

The paper is divided into six sections. In the first section, I show why the traditional principles of personal autonomy and beneficence are not adequate morally to justify the participation of children in the nontherapeutic role of organ donor. Next, I argue that the moral justification of the child’s participation must be based on the intimate family relationship which permits activities that would be unacceptable in the public domain. In the third section, I argue that family autonomy ought to be limited by the principle of respect for persons. In the fourth section, I propose five principles to guide the participation of children as organ donors. In section five, I discuss the role of the child in the decision-making process. In section six, I critically examine the criteria for equity in donor selection.
Tuberculosis in Prison: Balancing Justice and Public Health
Authors: Greifinger Robert B. , Heywood Nancy J. , Glaser Jordan B.
Published: June 2007

During the mid-nineteenth century the annual tuberculosis (TB) mortality in the penitentiaries at Auburn, N.Y., Boston, and Philadelphia exceeded 10 percent of the inmate population. At the beginning of the sanatorium era, 80 percent of the prison deaths were attributed to TB. As the mountain air was “commonly known” to be healthful, the first prison sanatorium was opened in the mountains near Dannemora, N.Y. in 1904. It served to isolate contagious prison inmates until the advent of effective chemotherapy for the disease in the 1950’s. Early antibiotic therapy for TB was such a great success that the public health aspects of TB in prisons remained dormant for the next 40 years.

In 1991, a correctional officer from Auburn Correctional Facility in Auburn, New York died as a result of multidrug-resistant TB. He had been posted to care for hospitalized patients, from whom he acquired his disease. This death, and the transmission of TB infection to health care workers in the same hospital, brought the nature and extent of modern inmate medical care into finer focus.
Wrongful Birth: Medical, Legal, and Philosophical Issues
Authors: Botkin Jeffrey R. , Mehlman Maxwell J.
Published: June 2007

“Wrongful birth” is a controversial malpractice action, which has arisen in the past two decades, secondary to an expanding knowledge of human genetics and the constitutionally protected access to abortion. Under the wrongful birth claim, parents of a child with a congenital illness or abnormality may bring suit against a physician who allegedly failed to provide appropriate prenatal counseling or information. Typically, the parents claim that they were inadequately warned of a potential problem in their child, and that this paucity of timely information prevented them from avoiding the pregnancy or from obtaining an abortion. While these cases have arisen in a variety of clinical circumstances, a characteristic example is the obstetrician who fails to offer amniocentesis to a woman of advanced maternal age who subsequently gives birth to a child with Down syndrome. Since the parents were prevented from learning of the abnormality and therefore exercising the option to terminate the pregnancy, they may claim damages for themselves for the wrongful birth of the infant.
Professional Norms and Physician Attitudes Toward Euthanasia
Authors: Preston Thomas A.
Published: June 2007

The chair of the ethics committee of a major medical center agonized over how he, as a physician, and his organization should deal with Initiative 119, which, if passed, would legalize physician involvement in active, voluntary euthanasia in Washington State. In the end, he said, he could not vote for aid-in-dying because, “However much I want to reduce suffering, I myself just couldn’t do it to one of my patients.” He spoke of a personal distaste for the potential act, of a profound desire not to have to do it. It was not an ethical argument, but an honest and compelling expression of feelings.

Why can’t this sincere man do it, even for patients who request such aid? In a 1991 poll, taken in Washington State prior to the vote on Initiative 119, 49 percent of the physicians surveyed supported the initiative, but 75 percent did not want to participate in aid-in-dying.
Toward a New Health Strategy to Control the HIV/AIDS Pandemic
Authors: Mann Jonathan , Tarantola Daniel , O’Malley Jeff
Published: June 2007

Since its recognition in the early 1980s, the global HIV/AIDS pandemic has continued to grow relentlessly. Early efforts in HIV prevention sought to influence behavior by providing information about the dangers of AIDS along with recommendations for safe behavior. This approach helped to alert people about AIDS, but was insufficient to promote or sustain behavioral change.

The second approach attempted to promote individual behavioral change by designing AIDS programs that would deliver a mix of information, materials, and services. This program-based approach emerged within communities, was gradually adopted by some countries, and was subsequently articulated by the World Health Organization as the first Global AIDS Strategy. The emphasis during this period was to ensure that each community and country developed its own comprehensive program by adapting a global model to local and national circumstances.
Managed Competition in Health Care Reform: Just Another American Dream, or the Perfect Solution?
Authors: Reinhardt Uwe E.
Published: June 2007

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.

Because an equitable distribution of health care inevitably requires at least some government regulation, and because government regulations tend to impose rigidity on any system, it is widely believed in the United States (and elsewhere) that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day.
Minority Access and Health Reform: A Civil Right to Health Care
Authors: Watson Sidney Dean
Published: June 2007

Health care reform that includes universal coverage could lower a major barrier to care for people of color and ethnic minorities—the inability to pay for care. But universal coverage alone, even with comparable fee-for-service payment or appropriately risk-adjusted capitated reimbursement, will not eradicate the racial and ethnic inequities in health care delivery. Restrictive admissions practices, geographic inaccessibility, culture, racial stereotypes, and the failure to employ minority health care professionals will still create barriers to minority health care. In addition to universal financing, health care reform should include new civil rights legislation to address and reduce these noneconomic barriers to minority health care.
Commentary: A New Frontier but the Same Old Problem
Authors: King Gary
Published: June 2007

As during other eras of American history, both the current debate and attempts to reform the health care system are fraught with vested interests and conflict among policy makers, consumers, the health and medical complex, insurers, and the business community. The process reflects both the strengths and the limitations of our democratic system, and demonstrates the factional battles that must be waged to attain fundamental social change in American society.

Although racial justice is not the dominant issue, the parallels between the present congressional deliberations and polemics and the passage of civil rights legislation in the 1960s are inescapable. For one, a major goal is to codify the basic human right of health care for all, regardless of medical or socioeconomic condition—that is, universal health insurance. Second, although a general feeling exists among the public that considerable change is needed in our health care system, elected representatives cannot agree on an appropriate course of action.
Commentary: The Public and the Profession: Meeting at the Right Place
Authors: Murphy Donald J.
Published: June 2007

Spielman’s taxonomy of collective decision making about medical futility is timely and insightful. Her conclusion, that laws are the best reflection we have of collective values, may be accurate. However, a closer look at the six alternatives for collective decisions is necessary before we rely too heavily on the legislature.

The first two alternatives, decisions by professional organizations and by health care facilities, smack of paternalism. Spielman suggests that statements from professional organizations or health care facilities express professional values and lack adequate input from the public. Could it be that some of these statements in fact may be the best reflections of public attitudes?
Federal Regulation of Clinical Practice in Narcotic Addiction Treatment: Purpose, Status, and Alternatives
Authors: Molinari Stephen P. , Cooper James R. , Czechowicz Dorynne J.
Published: June 2007

The regulation of narcotic medications used in narcotic addiction treatment is unique in medical therapeutics. Physicians who want to use narcotics for this indication must obtain a separate annual registration from the Drug Enforcement Administration(DEA).Annual registration is contingent on compliance with both the DEA's security regulations (inventory, record-keeping, andphysical security) as well as treatment regulations jointly promulgated by the Food and Drug Administration(FDA)and the National Institute on Drug Abuse(NIDA).

During the last decade, a number of events have occurred that persuadedNIDAthat it is time to reevaluate the current method by which the Department of Health and Human Services(HHS)regulates methadone treatment. As a result of research during the past twenty years, we have learned about the effective components of methadone treatment. In comparison to other available treatment modalities for opioid addiction, methadone treatment is uniquely effective when administered by well-trained medical staffs.
The Evolution of Workplace Drug Screening: A Medical Review Officer's Perspective
Authors: Broadwell D. Kim
Published: June 2007

In the United States, screening the urine of employees or job applicants for the presence of drugs has become commonplace. A survey of 794 large- and mediumsized companies, conducted by the American Management Association in January 1994, found that 87 percent of them now test job applicants for drug use. In 1987, a similar survey found that 22 percent screened job applicants. Federally mandated drug testing programs with random testing requirements affect millions of workers in the transportation industry, the nuclear power industry, and the United States civil and military services.

As some of these programs pass their fifth anniversary since being instituted, it is important to assess the forces that led to their creation. Whether or not these programs are considered successful depends on what one expects to achieve by such widespread testing.
Prescription Drugs and Nursing Education: Knowledge Gaps and Implications for Role Performance
Authors: Naegle Madeline A.
Published: June 2007

Nurses in all practice roles and settings need to understand the therapeutic use and potential for abuse of prescription drugs. Nursing roles, which include the administration and prescription of medication, health teaching and the implications of application, and the detection ofdrug-related problems, require that such education be timely and comprehensive. This paper discusses the state of knowledge dissemination about prescription drugs within the general context of nursing education. It highlights educational needs and explores the attitudinal factors and knowledge deficits that influence the nursing practices of prescribing, pain management, nursing assessment, and care of persons with drug problems.

Standard educational requirements in all nursing curricula undergird teaching about licit and illicit drugs and medication, as well as their therapeutic use, misuse, and abuse. It has been recognized widely since the early1980s,however, that clinical experiences and didactic content on licit and illicit drugs presented in nursing programs is inadequate.
Truce on the Battlefield: A Proposal for a Different Approach to Medical Informed Consent
Authors: Piper August
Published: June 2007

What is informed consent in medicine? For more than a generation, this deceptively simple question has vexed the law, discomfited medicine, and generated much inspired, provocative, and even contentious commentary.

The question has also spawned several lawsuits. On one side stand patients who claim that, at the time of consent, they were ignorant of a particular risk; who state that, with more or different information, they would have chosen a different treatment; and who argue that, because of an adverse outcome, they now deserve remuneration. On the other side, doctors uneasily watch the lengthening list of suits. Some, troubled by the law's expectations, have reacted by variously describing informed consent as a myth, a fiction, an unattainable goal, or a snare to entrap physicians. They point to the legal commentary condemning informed consent law as ill-defined, diffuse, and fraught with inconsistency, hazy at its best and virtually indecipherable to physicians at its worst: and lacking a fair standard to determine when a patient has sufficient knowledge to give effective consent.
Parents’ Perceptions of Decision Making for Children
Authors: Anderson Betsy , Hall Barbara
Published: June 2007

Futile treatment. Do not resuscitate (DNR). These terms and the thoughts they evoke may be unfamiliar to families with ill children. Similarly, laws, such as the Americans with Disabilities Act or the Emergency Medical Treatment and Active Labor Act, are probably unfamiliar. Yet these terms and laws, and, more important, their implications, are part of a new world of health care into which more families are thrust—the world of wrenching and complicated decisions.

Although the number of these situations is increasing and even predictable, the infrastructure of support services for families dealing with these medical decisions for seriously ill children has not been adequately addressed or developed. Parents know that some children are born with or develop serious illnesses and die. Amid absorbing large amounts of new information and interpreting the parameters and implications of what they are learning about their child's condition, families are forced by circumstances to assess—and to act on—their most critical, and perhaps previously unexamined, values.
The Role of an Ethics Committee in Resolving Conflict in the Neonatal Intensive Care Unit
Authors: Nelson Robert M. , Shapiro Robyn S.
Published: June 2007

What should be the role of an institutional ethics committee (IEC) in resolving conflict concerning patient care decisions in the neonatal intensive care unit (NICU)? This question takes on added importance in light of recent court decisions which suggest that IEC deliberations may serve as persuasive evidence in court, of proposed state regulations that would establish an IEC as an alternative to judicial review, and of recent Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines that require an institutional policy on limitation or withdrawal of treatment to include a specified mechanism for resolving conflict. Unfortunately, despite these developments, prospective case consultation remains one of the most controversial and poorly understood aspects of IEC functions. Questions and concerns persist about the relation the IEC has and should have to actual decisions in specific cases.

We briefly examine the clinical, organizational, and regulatory complexity of the NICU environment and suggest five potential sources of uncertainty, disagreement, and conflict among parent(s) and NICU staff.
Forgoing Medically Provided Nutrition and Hydration in Pediatric Patients
Authors: Nelson Lawrence J. , Rushton Cindy Hylton , Cranford Ronald E. , Nelson Robert M. , Glover Jacqueline J. , Truog Robert D.
Published: June 2007

Discussion of the ethics of forgoing medically provided nutrition and hydration tends to focus on adults rather than infants and children. Many appellate court decisions address the legal propriety of forgoing medically provided nutritional support of adults, but only a few have ruled on pediatric cases that pose the same issue.

The cessation of nutritional support is implemented most commonly for patients in apermanent vegetative state(often referred to aspersistent vegetative state(hereinafter “PVS”)). An estimated 4,000 to 10,000 American children are in the permanent vegetative state, compared to 10,000 to 25,000 adults. Yet the dearth of literature, case reports, and court decisions suggests that physicians and families of pediatric patients stop medically provided nutrition or seek court orders much less frequently.
Legal Protections for the Scientific Misconduct Whistleblower
Authors: Poon Peter
Published: June 2007

Even with thirty years of academic experience under his belt, nothing could have prepared the medical school department chairman for the unexpected and protracted course of events that would follow his allegations of scientific misconduct against an associate professor in his department. In this actual case of scientific misconduct whistleblowing, the university allowed the accused professor to resign, but the chairman persisted in seeking a full investigation of the matter. Under the direction of the Office of Scientific Integrity (OSI) of the Department of Health and Human Services (DHHS), the institution eventually reopened the investigation, and concluded that the accused professor had fabricated and falsified data, and had plagiarized the unpublished method of other investigators. Thereafter, the professor agreed to a voluntary exclusion from receiving federal funds for a period of three years.

Despite the fact that the chairman's allegations proved true, his involvement as a “whistleblower” entailed consequences that censured rather than encouraged his behavior.
The Charleston Policy on Cocaine Use During Pregnancy: A Cautionary Tale
Authors: Jos Philip H. , Marshall Mary Faith , Perlmutter Martin
Published: June 2007

The conflict between pregnant women freely using cocaine and the well-being of fetuses presents a difficult social problem. Since 1985, at least 200 women, in thirty states, have been criminally prosecuted for using illicit drugs or alcohol during pregnancy. Such policies enjoy considerable public and political support. Nonetheless, treatment programs that include referral to law enforcement officials raise serious ethical and legal issues for hospitals and health care providers. In this paper, we assess the development of one medical university's controversial treatment program for pregnant women addicted to cocaine.

In October 1989, the Medical University of South Carolina (MUSC) instituted a new program, called the Interagency Policy on Management of Substance Abuse During Pregnancy (Interagency Policy), designed “to ensure appropriate management of patients abusing illegal drugs during pregnancy.” This program required some pregnant women to seek drug counseling and prenatal care under the threat of criminal sanctions.
Dethroning Choice: Analogy, Personhood, and the New Reproductive Technologies
Authors: Nelson Hilde Lindemann
Published: June 2007

There is something about the debate over reproductive technologies of all kinds—from coerced use of Norplant to trait-selection technologies, to issues surrounding in vitro fertilization (IVF), to fetal tissue transplantation—that seems to invite dubious analogies. A Tennessee trial court termed Mary Sue and Junior Davis's frozen embryos “in vitro children” and applied a best-interests standard in awarding “custody” to Mary Sue Davis; the Warnock Committee drew an implicit analogy between human gametes and transplantable organs in its recommendation of a voluntary, nonprofit system for collecting and distributing gametes in the United Kingdom; Owen Jones compares the right to trait-selection to the right to abortion; Robert Veatch once claimed that if a woman had signed an organ donation card and then died while pregnant, she had in effect given consent to the attempt to sustain the pregnancy after her death; John Robertson has argued that contract pregnancy poses no problems we have not already encountered with adoption; and Andrea Bonnicksen has compared the wonders of preembryonic genetic screening to the riches housed in the gold museum in Bogota, Colombia.
Bargaining about Futility
Authors: Spielman Bethany
Published: June 2007

What I propose in this article is application of existing dispute resolution practices that take place outside the courtroom to the negotiating that takes place between health providers and families when they try to reach agreement about the limits of medical care that arguably is futile. Specifically, I focus on a bargaining paradigm that is associated with divorce proceedings, and suggest how this paradigm is at work in the conflict about futile treatment. At issue are not the well-publicized aspects of high profile cases, but the rather unpublicized bargaining that goes no further than the clinical setting.

Physicians and families who disagree about the futility of medical treatments frequently engage in give-and-take exchanges about whether to start disputed treatments, about what period of time might comprise a reasonable trial period if a treatment is to be administered, and about when and how to transfer a patient to another facility if the dispute cannot be resolved.
Does the ADA Provide Protection Against Discrimination on the Basis of Genotype?
Authors: Alper Joseph S.
Published: June 2007

As a consequence of the problems caused by genetic discrimination, federal and state law makers are being pressured to pass a legislative remedy. A primary question is whether the Americans with Disabilities Act of 1990 (ADA) applies to (1) individuals with a potentially disabling genetic disorder who are pre-symptomatic or asymptomatic and may never become ill and to (2) healthy individuals who are carriers of genetic conditions. At present, this question has relevance principally for individuals with the genotype for single gene disorders, like Huntington disease and hemochromatosis, and to asymptomatic carriers of single gene disorders such as cystic fibrosis. Although many such single gene conditions exist, the total incidence of these conditions in the U.S. population is less than 0.4 percent. However, the question concerning the applicability of the ADA will become increasingly important because genetic tests will almost certainly be developed in the near future for common multifactorial diseases like diabetes, heart disease, and certain forms of cancer.
Stemming the Tide: Assisted Suicide and the Constitution
Authors: Coleman Carl H. , Miller Tracy E.
Published: June 2007

On November 8, 1994, Oregon became the first state in the nation to legalize assisted suicide. Passage of Proposition 16 was a milestone in the campaign to make assisted suicide a legal option. The culmination of years of effort, the Oregon vote followed on the heels of failed referenda in California and Washington, and other unsuccessful attempts to enact state laws guaranteeing the right to suicide assistance. Indeed, in 1993, four states passed laws strengthening or clarifying their ban against assisted suicide. No doubt, Proposition 16 is likely to renew the effort to legalize assisted suicide at the state level.

The battle over assisted suicide is also unfolding in the courts. Litigation challenging Proposition 16 on the grounds that it violates the equal protection clause is ongoing in Oregon. More significantly, three cases, two in federal courts and one in Michigan state court, have been brought to establish assisted suicide as a constitutionally protected right.
Legal and Ethical Complexities of Consent with Cognitively Impaired Research Subjects: Proposed Guidelines
Authors: Berg Jessica Wilen
Published: June 2007

When science takes man as its subject, tensions arise between two values basic to Western society: freedom of scientific inquiry and protection of individual inviolability.... At the heart of this conflict lies an age-old question: When may a society, actively or by acquiescence, expose some of its members to harm in order to seek benefits for them, for others, or for society as a whole?
Refusing Life-Sustaining Treatment after Catastrophic Injury: Ethical Implications
Authors: Powell Tia , Lowenstein Bruce
Published: June 2007

In theory, a competent patient may refuse any and all treatments, even those that sustain life. The problem with this theory, confidently and frequently asserted, is that the circumstances of real patients may so confound us with their complexity as to shake our confident assumptions to their core.

For instance, it is not the case that one may always and easily know which patients are competent. Indeed, evaluation of decision-making capacity is notoriously difficult. Not only may reasonable and experienced evaluators, say a judge and a psychiatrist, disagree, but also a person's capacity may change from hour to hour and may extend to some decisions yet not to others. And yet it is on this subtle art of capacity evaluation that life and death decisions often turn, especially when patients decline life-sustaining treatment.

An evaluation of capacity may consider the impact of serious medical or psychiatric illness, as well as the patient's life circumstances.
Auto-Assignment and Enrollment in Medicaid Managed Care Programs
Authors: Ferber Joel D.
Published: June 2007

In the face of escalating Medicaid costs and anticipated reductions in federal Medicaid spending, states are increasingly converting from fee-for-service (FFS) to managed health care systems. The interrelated issues of enrollment and auto-assignment are fundamental to the overall success or failure of Medicaid managed care programs. The purpose of this article is to suggest how policy makers, consumer advocates, and providers should address these issues. My major premise is that implementation of managed care will proceed more smoothly if states adopt enrollment strategies that promote voluntary selection of health plans by Medicaid consumers, minimize the likelihood of auto-assignment, and mitigate the negative consequences of mandatory assignment of consumers to managed care organizations (MCOs).

States seeking to implement Medicaid managed care must apply for a waiver from the secretary of the Department of Health and Human Services (DHHS). Two different types of waivers are available to implement Medicaid managed care.
Ethnicity and Advance Care Directives
Authors: Murphy Sheila T. , Palmer Joycelynne M. , Azen Stanley , Frank Gelya , Michel Vicki , Blackhall Leslie J.
Published: June 2007

Advance care directives for health care have been promoted as a way to improve end-of-life decision making. These documents allow a patient to state, in advance of incapacity, the types of medical treatments they would like to receive (a living will), to name a surrogate to make those decisions (a durable power of attorney for health care), or to do both. Although studies have shown that both physicians and patients generally have positive attitudes about the use of these documents, relatively few individuals have actually completed one.

What underlies this discrepancy between attitudes and behavior with regard to advance care directives? One obvious explanation is lack of access. Emanuel et al. estimated that approximately 90 percent of the population desire an advance care directive, and they pointed to access as the major barrier. Yet interventions that increase accessibility have typically failed to yield more than a 20 percent completion rate. Thus, it appears that access is not the sole determinant of advance care directive completion.
Physician-Assisted Suicide in Context: Constitutional, Regulatory, and Professional Challenges
Authors: Lo Bernard , Rothenberg Karen H. , Vasko Michael
Published: June 2007

Last month, afifty-eight-year old man developed bleeding into his cheek and oozing from sites where previously he had had blood samples drawn. This bleeding was caused by disseminated intravascular coagulation, a complication of colon cancer that had spread to his liver and lungs. This complication occurred even though he was on chemotherapy for the cancer. In the hospital, he received transfusions and was administered medicine to stop the bleeding. However, his condition did not improve. He developed more bruises. When he tried to go to the bathroom without assistance, he fell, struck his head, requiring stitches, and developed a black, swollen eye. The patient, a successful businessman, had already overcome another type of cancer—lymphoma—through chemotherapy, twenty-five years ago. In a few days, this dynamic individual who expected to start experimental chemotherapy now saw his quality of life deteriorate steadily.

We talked about more chemotherapy, about hospice, and about withholding attempts at resuscitation if his heart should stop.
When Physicians Choose to Participate in the Death of Their Patients: Ethics and Physician-Assisted Suicide
Authors: Thomasma David C.
Published: June 2007

Physicians have long aided their patients in dying in an effort to ease human suffering. It is only in thenineteenth and twentieth centuries thatthe prolongation of life has taken on new meaning due to the powers now available to physicians, through new drugs and high technology interventions. Whereas earlier physicians and patients could readily acknowledge that nothing further could be done, today that judgment is problematic.

Most often, aiding the dying took the form of not doing anything further to prolong life. Morally, this act of restraint was not difficult, because few options could have been considered. However, some physicians, rarely, would help patients die either by hastening death directly or by increasing pain control with the risk of hastening death, the so-called double effect. When directly hastening death, physicians either directly caused the death of the patient through euthansia, or supplied the means to the patient to bring about death with or without encouragement to use these means. The latter is physician-assisted suicide (PAS).
Opioid Therapy for Chronic Nonmalignant Pain: Clinicians' Perspective
Authors: Portenoy Russell K.
Published: June 2007

During the past decade, debate has intensified about the role of long-term opioid therapy in the management of chronic nonmalignant pain. Specialists in pain management have discussed the issues extensively and now generally agree that a selected population of patients with chronic pain can attain sustained analgesia without significant adverse consequences. This perspective, however, is not uniformly accepted by pain specialists and has not been widely disseminated to other disciplines or the public. Rather, the more traditional perspective, which ascribes both transitory benefit and substantial cumulative risk to long-term opioid therapy, continues to predominate. According to this perspective, the inevitability of tolerance limits the possibility of sustained efficacy, and other pharmacological properties increase the likelihood of adverse outcomes, including persistent side-effects, impairment in physical and psychosocial functioning, and addiction. If accurate, these outcomes would indeed justify the withholding of opioid therapy for all but the most extreme cases of chronic nonmalignant pain.
Health Care Providers' Liability Exposure for Inappropriate Pain Management
Authors: Shapiro Robyn S.
Published: June 2007

Recent studies have exposed the startling inadequacy of health care providers knowledge about and practice of effective pain management. For example, in one study, it was reported that 79 percent of a random sample of 454 medical-surgical inpatients experienced pain during hospitalization, and that 58 percent of patients with pain considered the pain horrible or excruciating. In another study, 67 percent of 2,415 randomly selected hospitalized patients had pain during the twenty-four hours prior to being interviewed, and 50 percent reported pain at the time of the interview. In a study of seriously ill hospitalized patients reported in 1996, half of the patients complained of pain, and one-sixth reported that they experienced extremely severe pain at least half the time. According to one literature review, 75 percent of cancer patients have reported suffering pain, and one study estimates that 25 percent of cancer patients die with severe unrelieved pain. Chronic nonmalignant pain has been described as an extremely prevalent problem, and over two-thirds of nursing home residents experience serious pain.