bluuebunny/crossref_metadata_2025 huggingface dataset:
One Advocate's Viewpoint: Conflicts and Tensions in the Baby K Case
Authors: Flannery Ellen J.
Published: June 2007

What was really going on in the Baby K case? Many people have posed that or similar questions to me when I have been introduced as the attorney for Baby K's mother. In a nutshell, the courts in Baby K ruled that a hospital is required to provide emergency medical care to an anencephalic baby at the mother's request. In this paper, I provide some insights into the factors that underlie the litigation and the legal issues decided by the courts. In my view, this case involved a myriad of legal questions, religious principles, power struggles, and health care resources arguments that could arise in other contexts.
Practice Guidelines: How Good are Medicine's New Recipes?
Authors: Capron Alexander Morgan
Published: June 2007

Over the last decade, standards for when and how to undertake a wide range of medical interventions have poured forth from medical specialty groups, commercial and nonprofit organizations, and state and federal panels. Known by a variety of names—from practice parameters to clinical guidelines—and intended for a range of purposes—from diminishing the incidence of maloccurences in hospitals to cutting the costs of health care—these guidelines share one important feature: the intention of decreasing the range of variation in medical practice. Such standardization immediately appeals to anyone interested in improving the quality of health care and, in particular, reducing inappropriate medical interventions, in light of the difficulties for a conscientious physician today in adhering to the best standard of practice when faced with ever increasing medical knowledge and the growing number and complexity of diagnostic, preventive, and therapeutic interventions.
Practice Guidelines and Private Insurers
Authors: Parker Christine W.
Published: June 2007

Practice guidelines are an increasingly relevant feature of health insurance. One hundred and seventy-eight million people in the United States have some form of private health insurance coverage; coverage for 150 million of them is employment-related. Traditionally, this coverage was provided by employers purchasing a group contract under which an insurance carrier provided indemnity coverage for employees—that is, the insurance company paid all usual, customary, and reasonable charges incurred by an employee for medical care, subject in some cases to an annual deductible and to a percentage of covered expenses, co-paid by the employee, for each service. In recent years, however, employers in greater numbers have switched to so-called self-insurance plans in which employees’ health care claims are paid directly by the employer (although an insurance company or other third party may be retained to administer the claim payment process).
Practice Guidelines: Can They Save Money? Should They?
Authors: Pauly Mark V.
Published: June 2007

To achieve lower medical spending with as little reduction as possible in good outcomes, practitioners and policy makers alike have been experimenting with the use of practice guidelines. These guidelines both recommend certain types of therapies and proscribe others in the treatment of patients with particular conditions. This paper explores the question of whether guidelines which do reduce total resource costs of medical care to a population will (1) be feasible and (2) produce “acceptable” results. The definition ofacceptableis part of the policy problem, so it will be left open for a while, but the question of which outcomes match with which levels of resource cost will form the positive basis for the normative judgment of “acceptability.”
Can the Development of Practice Guidelines Safeguard Patient Values?
Authors: Halpern Jodi
Published: June 2007

In response to increasing use of practice guidelines in medicine, physicians have focused their attention on how these guidelines can restrict their medical practices. However, guidelines not only restrict physician discretion, but they also limit the treatment options available to patients. As a result, treatments which patients consider beneficial may not be recommended; for example, some hysterectomies for abnormal uterine bleeding, and cataract surgery in patients with dementia. When guidelines are used to determine which medical treatments a health care organization or insurer will cover, these recommendations become restrictions. Thus far, guidelines have been developed without adequate attention to the impact that their restrictive use has on diverse patient values.

Two significant tensions in current medical ethics relate to the inclusion of patient values in practice guidelines. First, a tension exists between the traditional paternalistic model of care, in which the physician judges unilaterally which treatments will benefit the patient, and the more recent autonomy model, in which the physician elicits the individual patient's health values to determine which treatments will be beneficial.
The Oregonian ICU: Multi-Tiered Monetarized Morality in Health Insurance Law
Authors: Rie Michael A.
Published: June 2007

Resource finitude, cost containment, and a purchaser monopsony market have created public concern-about the moral and legal responsibility for quality assurance in health plans. Resource allocation and standards of care represent a clash of moral values in intensive care treatment. This essay advances a procedural model, based on legislation passed in Oregon, that could govern the incorporation of private sector health insurance plans in Oregon to assure democratic input from consumers, providers, and employers into a limited vision of individual entitlement to consume futile or inappropriate care in intensive care units (ICUs). The model, which I call the Oregonian ICU, presumes that rationing of care is implicit and not publicly disclosed under managed care. It focuses on maximizing the quality of limited benefits available in the basic managed care insurance tier. Limitations to futile and inappropriate care are developed on the basis of morally weighted prognostic scoring systems that inform the creation of negotiated private sector contracts.
Business vs. Medical Ethics: Conflicting Standards for Managed Care
Authors: Mariner Wendy K.
Published: June 2007

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, fee-for-service (FFS) medical practice creates incentives to provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, “managed care, by its nature, places the good of the patient into conflict with … (1) the good of all the other patients served by the plan; (2) the good of the plan and the organization, themselves…; and (3) the self-interest of the physician.
Authority in Ethics Consultation
Authors: Agich George J.
Published: June 2007

Authority is an uneasy, political notion. Heard with modern ears, it calls forth images of oppression and power. In institutional settings, authority is everywhere present, and its use poses problems for the exercise both of individual autonomy and of responsibility. In medical ethics, the exercise of authority (along with power) has been located on the side of the physician or the health care institution, and it has usually been opposed by appeal to patient autonomy and rights. So, it is not surprising, though still ironic, that ethics consultation, which develops from this patient rights-dominated ethic, should itself bring forth questions of authority. Nonetheless, it does.

Insofar as authority has been discussed in ethics consultations, it has been understandably approached from the broad perspective of legitimation and power, which are common themes in social and political treatments of authority. These treatments have dominated twentieth-century discussions of authority, which primarily view authority as legitimate power.
Genetic Information and Health Insurance: State Legislative Approaches
Authors: Rothenberg Karen H.
Published: June 2007

We may create a catch-22 so that only people who are unlikely to need health insurance can afford it.... Genetic risk testing is important because it exposes the logic of a system that provides access to health insurance to those least likely to need it.
Testing Children for Genetic Predispositions: Is it in Their Best Interest?
Authors: Hoffmann Diane E. , Wulfsberg Eric A.
Published: June 2007

Researchers summoned a Baltimore County woman to an office at the Johns Hopkins School of Public Health last spring to tell her the bad news. They had found a genetic threat lurking in her 7-year-old son's DNA—a mutant gene that almost always triggers a rare form of colon cancer. It was the same illness that led surgeons to remove her colon in 1979. While the boy, Michael, now 8, is still perfectly healthy, without surgery he is almost certain to develop cancer by age 40.

This genetic fortune-telling was no parlor trick. It was the product of astonishing advances in recent decades in understanding how genes build and regulate our bodies. And as scientists pinpoint new genes and learn to forecast the onset of more inherited disorders, millions of people are likely to demand their medical prognosis.
Panel Comment: The Attempt to Pass the Genetic Privacy Act in Maryland
Authors: Holtzman Neil A.
Published: June 2007

The Genetic Privacy Act (GPA) is a comprehensive effort to protect individuals from unauthorized analysis of their DNA and from unauthorized disclosure of information resulting from genetic analysis. Irrespective of merit, every bill must survive legislative scrutiny. This is a considerable challenge, particularly for a bill as complex and far-reaching as the GPA. To illustrate my point, I describe the fate of two bills introduced into the Maryland Senate in 1995 by Senator Jennie Forehand. The first, also entitled the Genetic Privacy Act (S. 645), was a slightly modified version of the model legislation prepared by Annas, Glantz, and Roche. After a hearing, the bill received a 9-2 unfavorable vote from the Economic and Environmental Affairs Committee. The second was a much shorter bill, DNA Testing – Informed Consent and Confidentiality (S. 707), which simply stated that “DNA analysis may only be performed with the informed consent of the person being analyzed” and that the results of such analysis “are the exclusive property of the person tested, are confidential, and may not be disclosed without the consent of the person being tested.” This bill had a hearing but was never put to a vote by the Judicial Proceedings Committee. My principal aim is to examine the testimony on these bills. I will conclude with some suggestions about accomplishing the goals of genetic privacy legislation.
Tax-Exempt Status and Integrated Delivery Systems
Authors: Choi Lisa C.
Published: June 2007

Within the health care industry, the move from regulatory cost controls to market competition has generated rapid and dramatic restructuring of providers. To enhance their competitive positions in the evolving market, many health care organizations are pursuing the ownership and integration of all elements and stages of health care delivery and payment, with the goal of increasing access to capital and lowering costs through administrative efficiencies and economies of scale. As of July 1994, 24 percent of hospitals were members of an integrated delivery system (IDS), and 47 percent were involved in IDS development.

IDSs pose a singular challenge to the Internal Revenue Service (IRS). The IRS recognizes that its traditional policies for granting tax exempt status are not flexible enough for the competitive and rapidly changing health care market. In recent years, the IRS has taken a more active role in scrutinizing emerging health care institutions seeking taxexempt status.
Research Bioethics in the Ugandan Context: A Program Summary
Authors: Loue Sana , Okello David , Kawuma Medi
Published: June 2007

Researchers, scientists, and physicians in Uganda have become increasingly aware of the need to develop a systematic approach to reviewing bio-medical research conducted in their country. Much of this awareness and their concern stems from Uganda's high seroprevalence of human immunodeficiency virus (HIV) and the consequent large influx of research monies and HIV researchers from developed countries, including the United States and Great Britain.

We report on the proceedings of a five-day symposium on bioethical principles governing clinical trials, which convened in Jinja, Uganda in September 1994. The thirteen male and female workshop participants included representatives from the Uganda Ministry of Health, Makerere University, the Uganda AIDS Commission, Uganda's National Council of Science and Technology, and the National Chemotherapeutic Laboratory. These representatives included ethicists, physicians, researchers, and pharmacists, all of whom have conducted research themselves. Initial workshop sessions focused on the history of human experimentation and the development of protections for human participants in medical research, both in the United States and internationally.
Physician-Assisted Suicide as a Constitutional Right
Authors: Linville John E.
Published: June 2007

The legal treatment of physician-assisted suicide (PAS) is in flux. Reform has been impelled by several forces, including the recent success of novel constitutional arguments in the Ninth and Second Circuit Courts of Appeals. I will review and discussCompassion in Dying v. State of WashingtonandQuill v. Vacco, addressing the constitutional arguments, and then briefly considering the attractions and difficulties of these new constitutional theories.

Before 1990, state criminal laws dealing with assisted suicide had reached a remarkably stable consensus: suicide was not illegal, but assisting suicide was a criminal action with no distinction typically made between physicians and others who assisted. The details of the relevant criminal law varied from state to state. Some states had criminal statutes specifically addressing assisted suicide, while others treated the practice under more general homicide statutes. But in no state was it clearly legal for a physician to prescribe a lethal medication at the request of a dying patient. While remarkable legal developments took place during the 1970s and 1980s regarding other aspects of the rights of dying patients (including the right to refuse resuscitation and other life-sustaining treatments and the right to withdraw from life-sustaining treatment including nutrition and hydration), there was relative quiescence regarding the law of PAS.
Can Physician-Assisted Suicide Be Regulated Effectively?
Authors: Miller Franklin G. , Brody Howard , Quill Timothy E.
Published: June 2007

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declaredunconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide (PAS). Moresigmficant, legally permittingthis controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.

The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths.
Placebo Orthodoxy in Clinical Research I: Empirical and Methodological Myths
Authors: Freedman Benjamin , Weijer Charles , Glass Kathleen Cranley
Published: June 2007

The use of statistics in medical research has been compared to a religion: it has its high priests (statisticians), supplicants (journal editors and researchers), andorthodoxy (for example, p<.05 issignificant). Although the comparison may be more unfair to religion than to research, a useful lesson can nonetheless be drawn: the practice of clinical research may benefit—as does the spirit—from critical self-examination. Arguably, no aspect of the conduct of clinical trials is currently more controversial—and thus in as dire need of critical examination—than the use of placebo controls. The ethical and scientific controversies associated with placebo-controlled trials, never far below the surface, have once again seized public attention. Clearly, concern about these issues within the professional community runs deep and wide, as evidenced by the volume of response generated by Kenneth Rothman and Karin Michels's recent Critique. Criticisms of the use of placebo controls in clinical research are scattered through the literatureo; our objective is to present the case against placebos in a compendious form that takes account of scientific andstatistical as well as normative issues.
Narratives on Pain and Comfort
Authors: Purtilo Ruth B.
Published: June 2007

Pain management has no meaning without the stories of men and women, and boys and girls whose lives are dramatically altered by the presence of pain in their own and their loved ones lives. In this narrative section, four people present their perspectives on the enigma and challenge of pain, its power, and our on-going efforts to limit its hold on our lives.

In the first story, Dr. Robert McQuillan, an anesthesiologist with Creighton University School of Medicine, conveys the fear some patients suffering chronic pain face when seeking pain medication over the long term. Dr. Christine Cassel, chair of the Department of Geriatrics and Adult Development at Mount Sinai Medical Center and immediate past president of the American College of Physicians, recounts the plight of a fellow physician whose pain treatment of a patient led to suspension of his professional license and to personal bitterness after many years of exemplary medical practice.
Narratives on Pain and Comfort: Dr. M's Story
Authors: Cassel Christine K.
Published: June 2007

Dr. M is a fifty-nine-year-old internist with a successful practice in a major Eastern United States city. He has lived in this city his whole life and is a highly esteemed citizen. Because of his broader social concerns and energetic support of activities to improve access to health care and quality of care for the underserved, Dr. M became involved in a number of local and regional medical organizations and quickly rose to prominence as as a director of a board of a major national organization. In this position, he was an effective, articulate spokesperson, highly respected for his integrity and thoughtfulness.

Before one of the meetings of thithis s board, Dr. M personally contacted the organization's other directors, including me, to warn us that we might be hearing some scandalous news about him. He wanted us first to hear it from him personally. This was the scandalous news.

Dr. M had assumed the care of a patient of a recently retired colleague. The patient was an older woman with multiple musculoskeletal complaints related to lumbar stenosis and advanced degenerative arthritis of the spine, which left her in immense pain.
Pain Management and Disciplinary Action: How Medical Boards Can Remove Barriers to Effective Treatment
Authors: Hyman Chris Stern
Published: June 2007

The current debate about physician-assisted suicide and the question of whether patients would ask for such help if their pain were adequately controlled place in sharp focus the issue of undertreated pain. Studies have repeatedly documented the scope of the problem. A 1993 study of 897 physicians caring for cancer patients found that 86 percent of the physicians reported that most patients with cancer are undermedicated for their pain. A 1994 study found that noncancer patients receive even less adequate pain treatment than patients with cancer-related pain, and that minority patients, the elderly, and women were more likely than others to receive inadequate pain treatment. Although the problem of undertreatment of pain is multifaceted, I only address how state medical boards contribute to the problem and suggest possible remedies.

The literature on palliative care describes the numerous barriers that impede effective pain management and that result in the inadequate prescribing of pain-relieving drugs for terminally and chronically ill patients.
Pain: Ethics, Culture, and Informed Consent to Relief
Authors: Post Linda Farber , Blustein Jeffrey , Gordon Elysa , Dubler Nancy Neveloff
Published: June 2007

As medical technology becomes more sophisticate the ability to manipulate nature and manage disease forces the dilemma of whencanbecomesought. Indeed, most bioethical discourse is framed in terms of balancing the values and interestsandthe benefits and burdens that inform principled decisions about how, when, and whether interventions should occur. Yet, despite advances in science and technology, onecaregiver mandateremains as constant and compelling as it was for the earliest shaman—the relief of pain. Even when cure is impossible, the physician's duty of care includes palliation. Moreover, the centrality of this obligation is both unquestioned and universal, transcending time and cultural boundaries.

Although universally acknowledged, pain is a complex phenomenon for both the patient and the caregiver, influenced as much by personal values and cultural traditions as by physiological injury and disease.
Legal and Ethical Commentary: The Dangers of Reading Duty Too Broadly
Authors: Clayton Ellen Wright
Published: June 2007

The term duty is used in philosophy and law to de scribe the obligation one person owes to another. Yet what these two disciplines mean by duty often differs. Perhaps even more important, a determination by the law that a duty exists has different social consequences than does a similar assessment by philosophy Moral or ethical obligations between individuals make living in society possible, but breach of these obligations usually results only in social opprobrium, personal guilt, or shame. A legal duty, by contrast, enables a person to use the power of the state to enforce claims against another, either by injunction to make the duty-ower fulfill his/her responsibilities or more commonly by award of damages in the event the duty-ower fails to meet these obligations. In some cases, society itself chooses to impose criminal penalties on those who fail to meet certain important obligations.

The use of the term duty in both disciplines creates the temptation to extend a definition formulated in one setting to the other discourse. Ronald Green does not bite this apple, but his efforts to draw on the law to support his moral arguments, while not clearly identifying the distinctions between legal and moral obligations, may make it easier for others to see moral and legal duties as the same. Yielding to the enticement to equate moral and legal duties can lead to a host of difficulties. My purpose here is to demonstrate why the duties and privileges proposed by Professor Green are not and should not be adopted and enforced by the law.
Bioethics, Public Health, and Firearm-Related Violence: Missing Links Between Bioethics and Public Health
Authors: Turner Leigh
Published: June 2007

Open any standard bioethics textbook, and therein can be found a host of subjects ranging from the abortion rights controversy to the morality of xenographic tissue transplantation. Just as there is a wide scope to the subject matter of bioethics, its practitioners come from a multitude of disciplines, including law, medicine, nursing, theology, philosophy, sociology, and anthropology. And yet, despite a rich variety of investigators and methods, bioethicists overlook numerous subjects that deserve to be addressed. In particular, they neglect issues of public health, preventive medicine, and social medicine. Although topics such as physician-assisted suicide, prenatal genetic testing, and the ethics of new reproductive technologies constitute the contemporary canon of bioethics and deserve sustained analysis, these subjects are not so significant that they should eclipse other issues. For example, gun control policies, the regulation of food additives. immunization programs, prenatal care, leave programs enabling employees to care for dying relatives, the provision of nutrition and medical care to the homeless, and the use of emergency rooms by the most impoverished citizens are all topics neglected by bioethicists.
Commentary: Risks and Benefits, Testing and Screening, Cancer, Genes and Dollars
Authors: Kodish Eric
Published: June 2007

The ability to determine genetic predisposition to cancer represents an opportunity to expand cancer control efforts in a manner that was previously unimaginable. This possibility also forces individual patients, families, health care professionals, and society to confront difficult questions about genetic knowledge. Although genetic testing or screening for cancer risk may hold promise of cancer control benefits, this prospect also raises significant ethical and legal concerns that must inform and shape policy decisions. In “Cancer Genetic Susceptibility Testing,” Benjamin Wilfond and the Cancer Genetic Screening Consortium (CGSC) present a status report and an ambitious agenda for future examination of ethical and policy issues in this embryonic field. The paper provides a provocative and timely discussion of some extremely vexing issues, but it also misses on several critical points.
The Genetic Privacy Act: An Analysis of Privacy and Research Concerns
Authors: Troy Edwin S. Flores
Published: June 2007

In the last few years, a great deal of attention has been paid to the effects that the achievements of the Human Genome Project will have on the confidentiality of medical information. The Genetic Privacy Act (GPA) is an attempt to address the privacy, confidentiality, and property rights relating to obtaining, requesting, using, storing, and disposing of genetic material. The GPA grew out of concerns over the vast amount of genetic information that is a product of the Human Genome Project. The central goals of the GPA are twofold: (1) to define an individual's right to control access to their genetic material and the privilege to control the information derived therefrom; and (2) to prevent potential and actual abuse of genetic information by third parties, such as insurance companies, employers, and government. The GPA is one of a group of proposals that seek to control the flow of medical information from the individual to health care professionals and to other persons.
Professional Self-Regulation and Shared-Risk Programs for In Vitro Fertilization
Authors: Robertson John A. , Schneyer Theodore J.
Published: June 2007

In vitro fertilization (IVF) is now a well-established practice in the field of assisted reproduction. In 1995, over 41,000 IVF cycles were done in the United States, at a cost of more than $300 million. The overall success rate has risen to 22.8 deliveries per 100 egg-retrieval procedures (19.6 deliveries per initiated cycle). As the field has matured, the attention of policy-makers has shifted from questions about the ethical and legal status of human embryos to concerns about providing access and protecting consumers.

Three such concerns have emerged. One is the danger that IVF programs will disseminate misleading information about their success rates in order to attract patients. This problem, however, may be alleviated by the publication in late 1997 of the first of annual national and clinic specific reports, based on randomly audited data, by the Centers for Disease Control and Prevention, the American Society of Reproductive Medicine (ASRM), the Society for Assisted Reproductive Technology (SART), and RESOLVE, pursuant to the federal 1992 Fertility Clinic Success Rate and Laboratory Certification Act.
Bioethics and International Human Rights
Authors: Thomasma David C.
Published: June 2007

Increasingly, the world seems to shrink due to our ever-expanding technological and communication capacities. Correspondingly, our awareness of other cultures increases. This is especially true in the field of bioethics because the technological progress of medicine throughout the world is causing dramatic and challenging intersections with traditionally held values. Think of the use of pregnancy monitoring technologies like ultrasound to abort fetuses of the “wrong” sex in India (where a female's dowry can be a tremendous burden to the family), the sale of human organs in and between countries, or the disjunction between the haves and the have-nots in South America when it comes to bone marrow transplants, while thousands of other children die for want of fundamental goods and services like clean water, basic inoculations, and food itself.
Tort Liability for Managed Care: The Weakening of ERISA's Protective Shield
Authors: Jordan Karen A.
Published: June 2007

The risk of tort liability for health maintenance organizations (HMOs) and other managed care plans has dramatically increased in recent years. This is due in part to the growing percentage of health care rendered through managed care plans. The cost-containment mechanisms commonly used by managed care plans, such as limiting access to services and/or choice of providers, creates a climate ripe for disputes that may end up in court. As dissatisfied patients and providers seek recourse in the courts, tort doctrines are extended and new legal theories emerge as needed. For example, the concepts of direct and vicarious tort liability developed in the hospital context have been extended by courts to encompass HMOs. vicarious liability claims, based on ostensible agency or respondeat superior doctrines, have been brought against HMOs and managed care plans for negligent treatment by physicians selected to provide care to members.
Serious Illness and Private Health Coverage: A Unique Problem Calling for Unique Solutions
Authors: Kinney Eleanor D. , Freund Deborah A. , Camp Mary Elizabeth , Jordan Karen A. , Mayfield Marion Christopher
Published: June 2007

Having a serious illness like breast cancer is a calamity for individuals and families. Along with the pain, discomfort, and dislocation comes the issue of how to pay the medical expenses for the care and treatment of the disease. If the seriously ill person has inadequate or no insurance, these problems are aggravated.

Stories abound about seriously ill people losing private health insurance following diagnosis with a catastrophic disease, remaining in jobs just to maintain health insurance, or facing financial hardship because of gaps in coverage. Yet surprisingly little research has focused on the problems that people with serious illness face with health coverage and, in particular, how concerns about access to health insurance coverage shape their lives.

Further, despite profoundly moving anecdotes of cancer victims and other seriously ill people about their problems with health insurance and despite recent federal and state efforts to reform the private health insurance market in ways discussed below, neither the federal government, states, nor the private sector has crafted comprehensive strategies to enhance health coverage for the seriously ill.
Eliminating Conflicts of Interest in Managed Care Organizations Through Disclosure and Consent
Authors: Gunderson Martin
Published: June 2007

It is often claimed that managed care organizations (MCOs) involve physicians in conflicts of interest by creating financial incentives for physicians to refrain from ordering treatments or making referrals. Such incentives, the argument goes, force the physician to balance the patient's health interests against the MCO's interests and the physician's own financial interest. I assume, for the sake of argument, that such arrangements at least provide reason to believe that physicians in MCOs are involved in conflicts of interest. Two approaches have evolved for dealing with these conflicts. On one approach, MCOs disclose the financial arrangements under which their physicians work so that patients can consent to the managed care plan and thereby to the plan's limitations. The chief proponent of this approach is Mark Hall, whose recent bookMaking Medical Spending Decisionsapplies prior consent to a variety of decisions regarding medical financing and allocation. The other approach is simply to forbid conflicts of interest through regulations.
Genetic Discrimination in the Workplace
Authors: Miller Paul Steven
Published: June 2007

The surge in genetic research and technology, fuelled in large part by the Human Genome Project, has resulted in the continuing expansion of the range of genetic tests and other genetic information available to physicians, insurance companies, employers, and the general public.’ Genetic tests can provide presymptomatic medical information about an individual, including information about an individual's increased risk of future disease, disability, or early death. These tests can reveal information about an individual's carrier status, that is, the likelihood of parents passing on to their children a genetic condition, and about the health of the individual's family members. Although genetic information provides the promise of early detection and treatment of certain illnesses and disorders, it also poses risks. As a result of the increase in genetic testing and information, legal issues regarding employment discrimination on the basis of genetic information are emerging.
Reconsidering Genetic Antidiscrimination Legislation
Authors: Beckwith Jon , Alper Joseph S.
Published: June 2007

Until approximately twenty years ago, advances in the study of human genetics had little influence on the practice of medicine. In the 1980s, this changed dramatically with the mapping of the altered genes that cause cystic fibrosis (CF) and Huntington disease (HD). In just a few years, these discoveries led to DNA-based tests that enabled clinicians to determine whether prospective parents were carriers of CF or whether an individual carried the Huntington gene and, as a result, would almost certainly develop the disease.

Observers interested in the social and economic implications of genetic technology realized that such genetic tests could be used by insurance companies to predict which insurance applicants were likely to become ill or even die from these diseases.
Oocyte Cytoplasm Transfers and the Ethics of Germ-Line Intervention
Authors: Robertson John A.
Published: June 2007

The February 1997 announcement of the birth of Dolly, the sheep cloned from a mammary cell of an adult ewe, has drawn attention to the growing ability to select, alter, or otherwise manipulate the genome of offspring. Prior to Dolly, ethical discussion of genes in reproduction had focused on negative selection: carrier screening, prenatal diagnosis, and abortion or embryo discard. After Dolly, ethical debate will have to consider the direct or positive use of genetic selection or alteration technology.

The principal use of genetic selection techniques in human reproduction (reprogenetics) likely will be to treat or prevent disease in offspring. In the future, however, such techniques might also be used to enhance or even diminish expected characteristics of progeny. Techniques to accomplish these goals are likely to include: selection of the nuclear genome, as occurs in somatic cell cloning; chromosomal transplants; or direct insertion or deletion of specific genes.
The Supreme Court Confronts HIV: Reflections onBragdon v. Abbott
Authors: Parmet Wendy E.
Published: June 2007

The most remarkable thing about the U.S. Supreme Court's 1998 decision inBragdon v. Abbottwas that it was necessary at all. Seventeen years into the epidemic of the acquired immunodeficiency syndrome (AIDS), the Supreme Court, by a mere 5-4 majority, finally affirmed what most public health officials, health providers, and lawyers working with people with human immunodeficiency virus (HIV) believed all along: that individuals with HIV infection are entitled to the protections of antidiscrimination law, and that health care providers must respond to a patient's infection based on reason and science, not fear and prejudice. For individuals with HIV, and for those with other disabilities, the Court's ruling was a critical victory. But the very fact that the issues had to be decided by the Supreme Court and that only five justices joined the majority, shows the fragility of legal rights pertaining to HIV as well as the wide gulf between the perspectives of public health and those of public law.
Center Stage on the Patient Protection Agenda: Grievance and Appeal Rights
Authors: Miller Tracy E.
Published: June 2007

Responding to mounting public concern about the shift to managed care, legislation to grant patient protections has dominated the health policy agenda over the past two years. Although some policies, such as laws on maternity length of stay, can be easily dismissed as “body part by body part” micromanagement of medical practice, other initiatives offer substantive, new rights to patients across the spectrum of care. At both the state and the federal levels, the right of enrollees to appeal a denial of treatment or to file grievances about other plan decisions has emerged as a centerpiece of patient protection legislation. Grievance and appeal rights have been embraced as a way to empower patients, to enhance access to treatment, and to improve the quality of care by providing an external mechanism to review treatment denials.
Private Health Care for Canada: North of the Border, an Idea Whose Time Shouldn't Come?
Authors: Schrecker Ted
Published: June 2007

Toronto physician Brian Goldman had thought about “joining the camp that favours private health care for Canada.” Writing in theCanadian Medical Association Journal,he tells us that he changed his mind after one of his cats experienced a series of illnesses and misadventures that resulted in a Can$3,101 medical bill. “I’m just glad,” he says, “that the cost of health care never entered my deliberations.”’

Canadian citizens and permanent residents are similarly free from most worries about the direct costs of their own medical care, and have been for more than a generation. This reflects a fundamental difference between the Canadian and United States contexts for health policy. Since the failure of President Clinton's first-term efforts to provide something approximating universal health insurance, reforms to the existing regime of providing and financing health care in the United States have been incremental, and primarily responsive to the changing nature of the health care marketplace. In Canada, universal publicly funded first-dollar coverage for most physicians’ and hospitals’ services has been a reality since the early 1970s.
Pain Management and Palliative Care in the Era of Managed Care: Issues for Health Insurers
Authors: Hoffmann Diane E.
Published: June 2007

The problem of inadequate pain management for both terminally ill patients and patients with chronic pain has recently been documented by a number of authors and studies. A 1997 report by the Institute of Medicine (IOM), for example, states that “a significant proportion of dying patients and patients with advanced disease experience serious pain, despite the availability of effective pharmacological and other options for relieving most pain.” There are particularly impressive data that pain associated with cancer is not adequately treated.

The problem has been attributed to (1) inadequate education of physicians on approaches to pain management and an often misguided belief that prolonged therapy with certain pain medication will lead to addiction; (2) legal obstacles, such as physicians’ fear of criminal prosecution and other disciplinary actions by state licensing boards for overprescribing narcotics; and (3) inadequate insurance coverage as a result of narrow eligibility criteria for hospice care for Medicare beneficiaries, and inadequate reimbursement more generally for pain management and palliative care.
Public Financing of Pain Management: Leaky Umbrellas and Ragged Safety Nets
Authors: Jost Timothy S.
Published: June 2007

The United States, unlike all other industrialized nations, does not have a comprehensive public system for financing health care. Nevertheless, the magnitude of America's public health care financing effort is remarkable. Of the one trillion dollars the United States spent on health care in 1996, almost half, $483.1 billion, was spent by public programs. In 1995, Medicare—our social insurance program for persons over sixty-five and the long-term disabled—overed 37.5 million Americans; Medicaid—our program for indigent elderly and disabled persons and indigent children and their families—covered 36.3 million. In 1996, Medicare and Medicaid spent $203.1 and $147.7 billion, respectively. The payment policies of these massive public health care programs have a profound effect on the provision of health care.

Many of the recipients of Medicare and Medicaid suffer pain. In 1994, 376,200 Americans over age sixty-five died of cancer. Virtually all of these would have been Medicare recipients, and as many as 70 percent of them died in unrelieved pain. Nearly four million Americans over sixty-five endured the pain of inpatient surgery in 1995, again nearly all of whom were Medicare recipients.
The Potential for Unintended Consequences from Public Policy Shifts in the Treatment of Pain
Authors: Haddox J. David , Aronoff Gerald M.
Published: June 2007

Recently, due to a number of converging factors, there have been significant shifts in public policy regarding the legitimacy of treating chronic pain with opioids. Traditional tenets handed down in medical, dental, nursing, and pharmacy education created a distinct reluctance on the part of practitioners to prescribe opioids on a continual basis. Much has been written about the reasons for these attitudes. One of the barriers that is very consistently reported by prescribers is the fear of regulatory and legal repercussions to ongoing prescription of this class of medications. It is in this arena that sentinel changes have occurred, the most recent of which is the promulgation of a document prepared by the Federation of State Medical Boards (FSMB), which suggests a set of guidelines meant to be endorsed or adopted by individual medical licensing boards on how to approach this particular aspect of practice. These guidelines, representing a broad consensus from a wide constituency, were developed in a relatively open forum and detail a balanced approach to the prescription of opioids for chronic pain.
Ethical Issues and Practical Problems in Preimplantation Genetic Diagnosis
Authors: Botkin Jeffrey R.
Published: June 2007

Preimplantation genetic diagnosis (PGD) is a new method of prenatal diagnosis that is developing from a union of in vitro fertilization (IVF) technology and molecular biology. Briefly stated, PGD involves the creation of several embryos in vitro from the eggs and sperm of an interested couple. The embryos are permitted to develop to a 6-to-10-cell stage, at which point one of the embryonic cells is removed from each embryo and the cellular DNA is analyzed for chromosomal abnormalities or genetic mutations. An embryo or several embryos found to be free of genetic abnormalities are subsequently transferred to the woman's uterus for gestation. Embryos found to carry a genetic abnormality are discarded or frozen. Extra normal embryos may be frozen for future transfer or donation to another couple.
Killing and Allowing to Die: Another Look
Authors: Sulmasy Daniel P.
Published: June 2007

One of the most important questions in the debate over the morality of euthanasia and assisted suicide is whether an important distinction between killing patients and allowing them to die exists. The U.S. Supreme Court, in rejecting challenges to the constitutionality of laws prohibiting physician-assisted suicide (PAS), explicitly invoked this distinction, but did not explicate or defend it. The Second Circuit of the U.S. Court of Appeals had previously asserted, also without argument, that no meaningful distinction exists between killing and allowing to die. That court had reasoned that if this were so, it would be discriminatory to allow persons on life support to end their lives by removing such treatment, while those who are not connected to life support would be denied similar access to death.
The Doctor-Proxy Relationship: Perception and Communication
Authors: Zeleznik Jomarie , Post Linda Farber , Mulvihill Michael , Jacobs Laurie G. , Burton William B. , Dubler Nancy Neveloff
Published: June 2007

Health care decision making has changed profoundly during the past several decades. Advances in scientific knowledge, technology, and professional skill enable medical providers to extend and enhance life by increasing the ability to cure disease, manage disability, and palliate suffering. Ironically, the same interventions can prolong painful existence and protract the dying process. Recognizing that medical interventions, especially lifesustaining measures, are not always medically appropriate or even desired by a patient or family, health care professionals endeavor to determine who should make health care decisions and according to what standards. The importance that Western culture places on individual rights and self-determination is reflected in the growing advocacy for patient autonomy and the discrediting of physician paternalism. However, the question of autonomy becomes more complex when patients lack the capacity to decide for themselves.

Advance directives represent one response to the dilemma of decision making for incapacitated patients. The original advance directive, the living will, is a written list of instructions reflecting the individual's wishes about care, usually at the end of life.
The Legal and Functional Status of the Medical Proxy: Suggestions for Statutory Reform
Authors: Sabatino Charles P.
Published: June 2007

Medical technology, specialization, and the corporatization of health delivery systems in the late twentieth century have all helped give birth to an unwelcome but unavoidable responsibility for individuals with family or friends—serving as a health care proxy. The responsibility comes without monetary compensation, is often involuntary, and lacks any real guidelines beyond the duty to make life-and-death decisions in circumstances over which the proxy has little control.

The parameters of the proxy's job have evolved somewhat awkwardly in statutes and case law, as lawmakers and judges have tried to apply conventional concepts to novel circumstances. This article examines the legal and functional status of the proxy, as well as the strengths and weaknesses of current public policy as reflected by state advance directive and surrogate decision-making laws. The first section of the article provides a historical perspective of our current notions of agency law as relevant to health care proxies.