bluuebunny/crossref_metadata_2025 huggingface dataset:
The Nucleus of a Public Health Strategy to Combat AIDS
Authors: Gostin Larry
Published: June 2007

Since AIDS was first identified in 1981, its rate of spread among a primarily young and vibrant population has chilled the medical and lay communities. Today, the public response is sober and oriented toward the examination of specific policies that could lessen the impact of the disease. After six years' experience it is now feasible to propose a strategy for combatting AIDS. Consensus around the following policies should form the nucleus of the public health strategy to combat AIDS before the intervention of an effective vaccine or treatment.

Unprotected sexual intercourse and use of contaminated needles are intentional activities. Voluntary changes in behavior to avoid a high risk of transmission is currently the overriding public policy objective. The first line of defense in controlling AIDS, therefore, is to inform and educate individuals about high-risk behavior and about methods of altering behavior to protect against transmission of the infection.
AIDS: From Social History to Social Policy
Authors: Brandt Allan M.
Published: June 2007

Despite philosopher George Santayana's famous injunction that those who do not remember the past are condemned to repeat it, history holds no simple truths. Nevertheless, there are a number of significant historical questions relating to the AIDS epidemic. What does the history of medicine and public health have to tell us about contemporary approaches to the very difficult dilemmas raised by AIDS? Is AIDS something totally new, or are there instances in the past that are usefully comparable? Are there some lessons in the way science and society has responded to epidemic disease in the past that could inform our understanding of and response to the current health crisis?

There are obviously no simple answers to such questions. History is not a fable with the moral spelled out at the end. Even if we could agree on a particular construction of past events, it would not necessarily lead to consensus on what is to be done. And yet, history provides us with one means of approaching the present. In this regard, the history of responses to particular diseases can inform and deepen our understanding of the AIDS crisis and the medical, social, and public health interventions available.
AIDS Research: The Ethics of Clinical Trials
Authors: Macklin Ruth , Friedland Gerald
Published: June 2007

Research on AIDS involving human subjects poses in stark form a familiar dilemma: Can the demands of a rigorous scientific research design be met without violating the rights or harming the interests of research subjects? The dilemma is especially troubling in the early phases of drug research, when promising medications showing some signs of success in combatting this fatal disease must be tested for safety and efficacy. The research design using randomized controlled trials, in which an experimental drug is tested against a placebo, highlights the dilemma. Although the use of this research design does not pose the only ethical problem for AIDS research, it is perhaps the most dramatic. Related ethical issues include the question of when an experimental drug that holds out the only present hope may be released for general use; who should be selected to receive experimental drugs that are in short supply; how much information should be released about safety and efficacy while a clinical trial is still in progress; and what factors determine the appropriateness of early termination of a study.
Worldwide Strategies for HIV Control: WHO's Special Programme on AIDS
Authors: Mann Jonathan
Published: June 2007

The acquired immunodeficiency syndrome (AIDS) and the entire spectrum of disease associated with infection by the human immunodeficiency virus (HIV) are the subject of intense international interest and concern. From the viewpoint of the World Health Organization (WHO), HIV is not simply one of a series of newly recognized diseases emerging during the past decade but is a problem with several biological and epidemiological features that justify a unique sense of urgency among public health officials, political leaders, and the general public.

This article describes the evolution of a global perspective and response to HIV, reviews the current international epidemiological situation, explores the principal elements, both conceptual and operational, of WHO's global strategy for HIV control, and discusses the major approaches to HIV prevention in the current global context.
Corporate Restructuring of Tax-Exempt Hospitals: The Bastardization of the Tax-Exempt Concept
Authors: Squiers Mary P.
Published: June 2007

The largest single group of hospitals in the country is composed of private nonprofit hospitals, which are exempt from taxation under the Internal Revenue Code. The second largest group of hospitals consists of for-profit hospital corporations. The third and fourth largest groups are, respectively, municipal hospitals and state and federal specialty hospitals, such as mental health facilities and public health hospitals.

Although the idea of hospitals engaging in business activities used to arouse scorn, the concept has now gained acceptance. This change began in the late 196Os, when the enactment of the Medicare and Medicaid programs forced hospitals to become more so phisticated in handling reimbursement issues, certification-of-need, unrelated business income, and productivity.

By 1981, the percentage of hospital charges reimbursed by the Medicare system had declined to 68.7 percent, from its 1974 level of 75.4 percent. In 1982, with the signing of the Tax Equity and Fiscal Responsibility Art (TEFRA), hospitals were essentially told that they must find their own solution to the problem of inadequate funding.
In Search of the “Lawsuit Crisis”
Authors: Saks Michael J.
Published: June 2007

By now nearly everyone knows about the liability crisis. Municipalities, doctors, businesses, and others are paying soaring premiums for their liability insurance. The unlucky ones cannot find coverage at any price. The result is that services are becoming increasingly scarce and expensive. Curiously, the causes sound even more familiar. A new booklet being circulated by the Insurance Information Institute puts them succintly: “While our judicial system is basically a good one, it has been handicapped by unnecessary lawsuits, … exorbitant awards, and unpredictable results.”

Thus, the liability crisis is seen as a lawsuit crisis. The press and industry lobbyists overflow with stories of frivolous lawsuits, out-of-control damage awards, and a nation turned litigious. Accordingly, state legislatures around the country are preparing to solve the problem by modifying the laws that permit injured plaintiffs to seek compensation for their injuries through the courts.

If the lawsuit crisis exists, serious evidence of it should not be too difficult to find. in fact, the more awful the problem, the more plentiful and glaring should be the evidence. I have begun such an inquiry, but so far the hard evidence has been, to put it mildly, elusive.
AIDS: Legal and Policy Implications of the Application of Traditional Disease Control Measures
Authors: Curran William J. , Clark Mary E. , Gostin Larry
Published: June 2007

Public health is fundamentally about the values of community, the shared interests in life, health, and security. How the community perceives disease is not solely an issue of medical knowledge, but a function of the interrelated economic, social, and moral beliefs of the society. Our response to particular diseases will be colored to some extent by our image of the individuals or groups most directly affected by that disease.

Acquired immunodeficiency syndrome (AIDS) clearly poses a considerable threat to public health. The disease is thus far medically uncontrollable, and always fatal. The grim prognosis for persons with AIDS has intensified the urgency of developing a program to control and prevent the spread of the syndrome.
Patients' Interests and Clients' Wishes: Physicians and Lawyers in Discord
Authors: Dickens Bernard M.
Published: June 2007

It is intended that this exploration of different interfaces of law and medicine will present a general overview. These reflections on some comparisons of and, particularly, contrasts between the health professions and the legal profession do not aspire to the profundity, moderation, or elegance of, for instance, Prof. William Curran's recent learned discourse. They are self-consciously more polemical than a truly scholarly study should be, and include some crude or simplistic characterizations. Their purpose is to provoke reaction, however, and thereby to contribute to health professionals' and lawyers' consideration of their experience of each other.

It is trite to observe that the two inevitabilities of modern existence are death and taxes. It is more interesting to observe the consequence, however: that the professional mediators of death and taxes—namely, health professionals and lawyers—are equally inescapable. Members of these professions are not necessarily propelled into each other's arms, but in their professional and personal lives they cannot extricate themselves from each other's disciplines.
Insurers, Consumers, and Testing: The AIDS Experience
Authors: Hiam Peter
Published: June 2007

At the end of 1987, the insurance industry could breathe a sigh of relief. By a combination of good luck, astute planning, and nerve, life and health insurers had managed to impose HIV-testing requirements on insurance applicants while making few concessions to the gay community or insurance regulators. To a greater degree than almost anyone had thought possible, the insurers had deflected most of the expected health costs from the AIDS epidemic onto the nation’s taxpayers, and had taken steps to deny life or health insurance to anyone they considered to be at risk of AIDS.

The use of blood tests to determine if an individual is infected with the human immunodeficiency virus (HIV) that causes AIDS has been a matter of considerable controversy. Yet to date only a handful of states have restricted the use of HIV testing by companies offering life or health insurance.
Trying Not to Talk Forever: A Tool for Change
Authors: Wolf Susan M.
Published: June 2007

George Annas’ review finds most of what is in the Hastings Center’sGuidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying“solid.” He takes no issue with the major substantive points. The fundamental premise of the book—that patients’ interests must be protected and their decision-making authority defended—is a view Professor Annas has long championed as well.

Despite this basic agreement, Annas’ criticisms would be significant ones if theGuidelineswere what he presents them to be. But they clearly are not. As theGuidelinesthemselves state: These are ethics guidelines; they are not legal guidelines. They are an attempt to offer practical and reasonably concise suggestions for how to make decisions; they are no substitute for the literature on the pros and cons of different approaches to the termination of treatment. They are meant to provoke a necessary process of debate within a health care institution; they are not the final moral truth.
Legislative Approaches to Surrogate Motherhood
Authors: Charo R. Alta
Published: June 2007

By the beginning of 1988, nearly six hundred babies had been born through surrogate mothering arrangements. Although there have been a number of lawsuits concerning custody or challenging adoption laws that appear to prohibit payments to surrogates, the majority of surrogacy arrangements proceed without judicial involvement. Nevertheless, surrogate mothering has engendered considerable activity in state legislatures, as well as two bills in Congress to ban the practice (H.R.2433 and H.R. 3264) and hearings by the House Committee on Energy and Commerce and the Subcommittee on Transportation, Tourism, and Hazardous Wastes. Most recently, the Congressional Office of Technology Assessment (OTA) released a report,Infertility: Medical and Social Choices. That report included the results of a survey of surrogate-mother matching services active in the United States in late 1987.
The Case of Baby M: Love's Labor Lost
Authors: Smith George P.
Published: June 2007

It has been estimated that in the United States some twenty thousand babies are born through artificial insemination by donor (AID) each year. With the startling new advances in reproductive technology, or what has been termed collaborative conception, it is now possible for a child to have up to five parents: an egg donor, a sperm donor, a surrogate mother who gestates the fetus, and the couple who actually raises the child. What we now face, then—not only in considering the New Jersey Supreme Court's decision In re Baby M but in the whole area of the new reproductive biology—is, in the words of a popular columnist, a mess.

Interestingly, the enormity of this complex, multiparent scenario—which Kerns to be on its way to becoming a reality with Baby M and its anticipated progeny—was totally lost on Mary Beth Whitchead. I just can't see how four peeple loving [Baby M], five people loving her, can hurt her, she said recently.
Intentional Injury: Are There No Solutions?
Authors: Hawkins Darnell F.
Published: June 2007

Injury control has gained gradual acceptance as both a public policy concern and the focus of scholarly research during the last decade. Observers have noted the costs to American society of both intentional and unintentional injuries and have sought to identify preventive intervention strategies that can reduce their incidence and impact. Although many of these intervention efforts have just begun, researchers have been far more successful at identifying potential strategies for the prevention of unintentional than for intentional injury. Indeed, many observers have asked whether the majority of intentional injuries can be prevented at all. In this paper I examine the various problems associated with the prevention of intentional injuries such as homicide, assaultive violence, and suicide. Homicide among blacks is used to illustrate the variety of theoretical, ideological and practical concerns that must be confronted in efforts to successfully prevent intentionally induced injury.

Proponents of efforts to designate injury, both intentional and unintentional, as a health concern have suggested that one result of such a designation will be the development of more effective strategies for the prevention of injuries.
Motor Vehicle Injuries: The Law and the Profits
Authors: Robertson Leon S.
Published: June 2007

Motor vehicle injury in the United States constitutes the leading cause of death during more than half of the normal lifespan: from a few months after birth until 40 years of age. The number of deaths from motor vehicles in the U.S. annually during the 1980s has ranged from 5 1,000 to 43,000, approximately equal to the total deaths of U.S. combatants in the entire Vietnam War. In addition, millions of people each year are the victims of nonfatal motor vehicle injury and thousands become permanently disabled and dependent for the remainder of their lives as a result of brain, spinal cord and other damage incurred in motor vehicle crashes.

During the first half of this century, the manufacturers of motor vehicles successfully evaded responsibility for the damage done by their products. Although the increased risk of motor vehicle travel compared to horse-drawn vehicle and train travel was recognized by 1905, vehicle manufacturers and “safety experts” (often allied in symbiotic associations) managed to define the problem as mainly one of errant drivers.
The Chain Saw and the Regulator: Inching toward Safety
Authors: Furrow Barry R.
Published: June 2007

The chain saw emerged in the marketplace as a powerful and useful new consumer product in the 1960s. Once a massive and awkward professional logging tool, the device has been transformed into a hand held tool that a casual user can easily use to cut trees and branches. By 1970, 2.3 million saws had been sold; by 1979, 3.5 million. From 1973 to 1977 sales of gasoline chain saws grew at an average rate of 1 2 percent per year, and electric saws at 37 percent per year. The largest increase in sales occurred in the lower priced saws. By 1986 22 million chain saws could be found in American households, the result of an expansion in the market due to both the energy crisis of 1970 and aggressive marketing and price cutting by manufacturers. During the calendar year 1987 an estimated 1,350,ooo chain saws were shipped to dealers, the same level as 1986, and manufacturers anticipate that 1988 shipments may increase 2 percent. The market has softened considerably, but is still expanding.
Community Care and the Discharge of Patients from Mental Hospitals
Authors: Bean Philip , Mounser Patricia
Published: June 2007

In Britain the movement towards “Community Care” gathers apace. Segregation techniques in their traditional forms are steadily losing ground to newer community based alternatives. Both America and Britain have seen a massive reduction in the register of patients resident in mental hospitals; specifically in America from a peak of 560,000, and in Britain 165,000 in 1955, to some 273,000 and 70,000 respectively. And how has this been achieved? Through the rhetoric of “community care,” whose influence over policy in hospital admissions and discharges has been particularly remarkable, according to Peter Sedgwick, in that it does not in reality exist. America has been swift to adopt this new panacea “community care” where the emptying of asylums has turned out to have unforeseen problems. Creedmoor asylum for the borough of Queens in New York released 3,000 patients within a few months. Britain has been rather slow to follow—perhaps a little less ruthless—but the reduction of beds continues.
Refusing Treatment, Refusing to Talk, and Refusing to Let Go: On Whose Terms Will Death Occur?
Authors: Meisel Alan
Published: June 2007

The wish of many to die with dignity in the face of medical technology, which holds out the hope of continued life but can dehumanize those whom it sustains, is played out countless times in hospitals and nursing homes every day. Each day, hundreds, if not thousands, of decisions must be made about administering or withholding life-sustaining treatment for critically ill patients. Occasionally it spills over into the courtroom and the press, creating the impression that there is a large volume of such litigation. In fact, the number of litigated cases is relatively small–approximately 50 reported cases since the Quinlan case in 1975, and possibly a few times that number in unreported cases.

Betty's case did not wind up in the courts, though it is the kind that could have, given the combination of her physicians not talking to Betty and her family, not listening to them, and not hearing them, and their apparent unwillingness to let Betty die peacefully without aggressive treatment.
The Road to Moderation: The Significance of Webster for Legislation Restricting Abortion
Authors: Wardle Lynn D.
Published: June 2007

One thing is certain about the Supreme Court's decision in Webster v. Reproductive Health Services: It will stimulate state legislatures to enact more legislation regulating abortion. Justice Blackmun candidly described the main opinion, written by Chief Justice Rehnquist (part majority, part plurality), as an “implicit invitation to every State to enact more and more restrictive abortion laws, and to assert their interest in potential life as of the moment of conception.” For many pro-choice advocates, this is an ominous development; for some, it is extremely frightening. For most pro-life advocates, however, this is a hopeful result; some enthusiastically perceive the prospect to reenact the 19th century abortion prohibition. But the most passionate activists on both sides are mistaken; both those who are frightened about “dark ages” abortion prohibitions and those who are gloating about turning back the clock misunderstand the significance and holding of Webster. Webster is a victory for moderation; it signifies the revival of a long-term process of political give-and-take, public education and debate, and legislative compromise.
International Dimensions of the Department of Justice Arguments in theWebsterCase
Authors: Cook Rebecca J.
Published: June 2007

In the Brief for the United States asAmicus Curiaesupporting the Attorney General of Missouri in theWebstercase, the Department of Justice invoked a favorable image of European legislative responses to the practice of abortion in order to argue the appropriateness of locating legislative control at the state level, as opposed to the level of federal law. It was further claimed that it was necessary for the Court to set aside its 1973 decision inRoe v. Wadein order for legislation in the U.S. to be consistent with the laws of other countries with which the U.S. “shares a common cultural tradition.”

The foundation on which these arguments were based is fundamentally flawed. The Department's brief omitted reference to the setting of Western European national legislation within the framework of international law , and in particular of the European Convention on Human Rights and Fundamental Freedoms.
Abortion and Distortion of Justice in the Law
Authors: Dickens Bernard M.
Published: June 2007

Opinions differ about whether the legality of induced abortion isthemost divisive social issue of the present time, but all agree that it is a strong contender for that status. The argument about which form of legislation would lower or raise the incidence of abortion has an empirical dimension, but many of the opposing arguments concern values and ideologies. The value of human life and the respect to which it is entitled, represented in the sympathetic form of the human fetus, are pitted against the value of women's self-determination and well-being, and the respect and status that women enjoy as decision-makers over their bodies and destinies.

The very language in which different persuasions are expressed often resonates with values. The pro-life/pro-abortion distinction incorrectly suggests that those who favor women's choice prefer that it be made in favor of abortion, whereas the pro-choice/anti-choice distinction incorrectly suggests that opposition to abortion rests on hostility to self-determination rather than on the assertion of more positive values, notably the sanctity of human life at all stages of development. The practice adopted below will be to give protagonists of different views the descriptions they give themselves, namely pro-choice and pro-life, although the author will not attempt to conceal a personal pro-choice preference.
Refusals of Medical Care in the Home Setting
Authors: Dubler Nancy Neveloff
Published: June 2007

The home setting presents particular problems in assessing a client/patient's ability to refuse suggested medical care. Home is familiar; it is associated with relaxation and not with the mobilization required to combar anxiety, uncertainty, illness and pain. In the home family members may be overly involved or controlling. Especially in the situation of elderly siblings with long combined histories, there may be shared peculiarities or even shared personaliry disorders which complicate an individual's choice of care. The home, because it is familiar, may maximize patient orientation but may also support denial of illness; the patient/client may reason “If I'm home, I'm really not ill.” In contrast, hospitals and long-term care facilities are intimidating and infantilizing institutions that tend to undercut personal resolve and challenge denial.
HIV Screening: Nosocomial Epidemiologic Risks and Decision Analysis
Authors: Pauker Stephen G.
Published: June 2007

Acquired immunodeficiency syndrome continues to expand exponentially, although the rate of growth in some sectors of the population has been slowing. Unfortunately, these clinically manifest cases constitute only a tiny fraction of the population infected with the human immunodeficiency virus. Epidemiologic data provide only crude estimates of the prevalence of asymptomatic viral infection, although more specific information is available for certain groups, most often defined by demographic, behavioral and medical information. Those data suggest that the prevalence of virus varies some 5000-fold from as low as 0.01 percent up to 50 percent.

The extraordinary and relatively unmodifiable consequences of HIV infection provoke increasing concern among health care workers about the possibility of nosocomial infection. For nosocomial transmission to occur: 1) the patient must be infected; 2) parenteral exposure to blood or certain other body fluids must occur; and 3) the virus must be transferred (with the latter likelihood being proportional to the quantity of exposure).
AIDS-Related Legislation in the Context of the Third AIDS Pandemic
Authors: Jayasuriya D. C.
Published: June 2007

The first AIDS-related legislation was enacted in 1983. By this time, policy-makers as well as legislators in several countries had set in motion the process of formulating legislative measures to deal with a new and critical problem about which very little was known. This process gathered momentum over the years, partly as a response to the recognition that the problem of discrimination against AIDS patients and persons with HIV infection, which first began with homosexuals and persons of Haitian and African origin, will assume more critical dimensions with devastating social, economic, political and cultural implications and reactions. It is these implications and reactions which have come to be described as the “Third AIDS Pandemic:”

The third epidemic closely follows the first two, of HIV infection and AIDS. It is the epidemic of economic, social, political and cultural reaction. In the words of Javier Perez de Cuellar,… “AIDS raises crucial social, humanitarian, and legal issues threatening to undermine the fabric of tolerance and understanding upon which our societies function.”
The “Crisis” in Medical Malpractice: A Comparison of Trends in the United States, Canada, the United Kingdom and Australia
Authors: Danzon Patricia M.
Published: June 2007

As the sense of crisis in medical malpractice reemerged in the United States in the early 1980s, other countries previously thought immune to liability problems were experiencing similar difficulties. In fact, the frequency and severity of malpractice claims and the cost of malpractice insurance have risen as dramatically in Canada and the U.K. as in the United States, despite legal systems in the U.K. and Canada that are generally less favorable to potential plaintiffs. The absolute level of claims and insurance costs are still lower in the U.K. and Canada than in the U.S., but the gap is narrowing. This paper reviews the evidence on recent trends in claims, awards and insurance premiums in these three countries and comments on the lessons that can be learned from this cross-national comparison.
Neocortical Death and Human Death
Authors: Devettere Raymond J.
Published: June 2007

Proposals to make neocortical death, sometimes called cerebral death, a medical and legal indication of human death are becoming more common. Increased sensitivity to the futility and costs of providing life support for patients long after they could be considered dead guarantees that interest in the proposals will continue for some time. Neocortical death would be an acceptable indication of human death if 1) it is consistent with our concepts of human death, 2) it can be diagnosed with certainty and 3) it is sufficiently understood by the general public to be accepted as public policy.

In this paper the phrase “neocortical death” will refer to permanent loss of consciousness due to the irreversible cessation of whatever chemical and biological functions of the brain are needed to support consciousness. By consciousness is meant “the state of awareness of the self and the environment.”
Procedural Paternalism in Competency Determination
Authors: Van McCrary S. , Walman A. Terry
Published: June 2007

In recent years, the competency of patients to refuse life-sustaining treatment has been widely discussed. Generally, competence has been recognized to be a legal concept, holding that the patient is presumed competent unless a court declares the person incompetent and designates a guardian. It has been noted, however, that clinical medical practice often diverges markedly from this standard. Some authors have suggested that in many cases the implicit medical presumption may be that many persons, particularly the aged, are presumed incompetent to refuse treatment until they demonstrate to their physician's satisfaction that they are competent. This gap between legal theory and medical practice presents numerous difficulties to both legal and medical professionals seeking to accommodate the competing values of patient self-determination and best interests.

This paper will present and discuss a case exemplifying a particular problem that can arise in the competency evaluation process.
Detention without Trial, Hunger Strikes and Medical Ethics
Authors: Benatar S. R.
Published: June 2007

Racism, which has pervaded and debased life in many countries, was given little attention by the international community before the Second World War when international law only governed relationships between states; the way in which individuals were treated within their own states was considered to be a purely domestic affair. The revulsion engendered by the Nazi atrocities however had a profound effect on world opinion, and in 1945 the “United Nations” grew out of the League of Nations with the hope that this body could contribute to the maintenance of international peace and encourage worldwide respect for human rights and fundamental freedoms. Three years later, in 1948, the Nationalist Party came into power in South Africa and the racial attitudes of the time were committed to the statute books in this country.
Abortion Law in England: The Medicalization of a Crime
Authors: Grubb Andrew
Published: June 2007

Abortion is the most divisive issue in American society today, but that is not unique because the issue troubles many other Western countries as well. Acrimonious debate has ensued in America in the wake of the Supreme Court's latest pronouncement in Webster v. Reproductive Health Services. Anxiety about the future of the law in America has been widely expressed by pro-life and prochoice groups alike. These could well be the visible skirmishes of the abortion battle and the conflict over the existence of a woman's right to choose in almost any Western jurisdiction. Perhaps only the intensity of debate and venue of battle vary.

In the wake of Roe v. Wade the American battle fronts have mainly been in the courts. A plethora of cases in both state and federal courts has tested the constitutionality of legislation passed by State legislatures restricting the availability of abortion.
The HIV-Infected Health Care Professional: Employment Policies and Public Health
Authors: Barnes Mark , Rango Nicholas A. , Burke Gary R. , Chiarello Linda
Published: June 2007

In July 1990, the federal Centers for Disease Control (CDC) reported the first case of possible transmission of the Human Immunodeficiency Virus (HIV) to a patient from an HIV-infected health care worker. The transmission may have occurred during an invasive dental procedure performed on her by a dentist who had AIDS, and in January 1991, the CDC reported possible HIV transmission during dental procedures to two other patients of the same dentist. Further, the recent revelation that a respected surgeon at a major medical center performed many surgical procedures while infected with HIV created substantial public concern. These cases call into question the prudence of allowing infected workers to continue performing medical and dental procedures that involve some risk, however slight, of transmitting HIV infection to patients. Whether HIV-infected workers should be excluded from practice of their profession because of a remote risk to patients relates directly to levels of tolerable risk in health care delivery and in social policy.
Identifying Appropriate Decision-Makers and Standards for Decision
Authors: Pollock Stewart G.
Published: June 2007

Judges, like lawyers, love to make disclaimers. So, at the outset, I disclaim any expertise in medicine or bioethics. My views are those of a generalist, a judge who has been required to decide cases involving bioethical questions such as the termination of medical treatment.

As Chief Judge Wachtler has explained, the New York Court of Appeals, like the Supreme Court of Missouri in Cruzan, has decided to require clear and convincing evidence before permitting the termination of life-sustaining treatment for an incompetent patient who is not terminally ill. Other courts, including the New Jersey Supreme Court, have reached a different conclusion.

It is not my purpose today to persuade you that the position of our court is correct. Instead, I propose to look at the Cruzan case to see what it does and does not tell us about the identity of the decision-maker and the standard for decision-making in the termination-of-medical-treatment cases.
The Authority of Families to Make Medical Decisions for Incompetent Patients after theCruzanDecision
Authors: King Patricia A.
Published: June 2007

I want to approach this difficult topic not from the professional perspective of a lawyer, but rather as the person I am in multiple relationships: wife, mother, step-mother, daughter, and step-daughter. I would suggest to you that none of us can avoid thinking about the role of families in making decisions for incompetent patients without viewing the questions that arise through lenses created by the roles we play in multiple relationships. I would also suggest to you that none of us can avoid thinking about the possibility of becoming incompetent ourselves without thinking about the relationships we have with our families.

My remarks here will be addressed primarily to theCruzandecision, so they will be most obviously applicable to patients in a persistent vegetative state. However, I intend for my reflections to apply to decision-making about all incompetent adult patients.
Issues in Preparing Ethical Guidelines for Epidemiological Studies
Authors: Dickens Bernard M.
Published: June 2007

The Nuremberg Code of 1947 is often taken to mark the beginning of the modern age of ethical codes for medical and health-related research with human subjects. The 1947 Code was fashioned in response to inhumane medical experimentation revealed at the Nuremberg War Crimes Tribunal. The fact that, prior to 1939, Germany had an ethical code for human research in medicine that appears sensitive and sophisticated even by current standards indicates that codes in themselves do not assure ethical conduct. Nevertheless, calls continue for the preparation of codes of conduct to guide the exercise of ethical judgment in health-related research.

Medical research concerned with individual subjects as such now possesses codes or guidelines at many levels, including funding agency, research institutional, national and international levels. The World Medical Association's Helsinki Code is now in its fourth version, and the Guidelines proposed in 1982 by the World Health Organization affiliate, the Council for International Organizations of Medical Sciences (CIOMS) is about to be revised to take account of a decade of significant developments.
Case Studies of Expedited Review: AZT and L-Dopa
Authors: Kaitin Kenneth I.
Published: June 2007

The HIV epidemic has led to a reassessment of attitudes regarding public access to new therapeutic agents for the treatment of life-threatening and severely debilitating diseases. People with AIDS and their advocates have relentlessly attacked the process by which new drugs are developed and approved for marketing in this country, a process characterized as overly conservative, risk-averse, and paternalistic. In response to growing pressure to accelerate access to important new therapeutic agents, the Food and Drug Administration (FDA) has issued several bold initiatives designed to facilitate the development of experimental drugs used in the treatment of serious or immediately life-threatening diseases.

The clinical testing and regulatory review of new therapeutic agents in the United States are lengthy processes. A recent analysis of new chemical entities (NCE) approved by the FDA in 1987,1988, and 1989 has revealed that, on average, the clinical development phase for new drugs exceeds five years (63 months).
Justice, Politics and Community: Expanding Access and Rationing Health Services in Oregon
Authors: Garland Michael J.
Published: June 2007

In 1989 the Oregon Legislature voted not to wait any longer for national leaders to serve up a solution to the problem of the millions of Americans (450,000 in Oregon) who are uninsured for health care. Under the leadership of Senator John Kitzhaber, President of the Oregon Senate, the lawmakers put together a package of bills designed to bring every Oregonian the security of third party financing for needed health care. The Oregon Plan's key innovation is the idea that, from a societal perspective, some health services can be declared more important than others. From that central idea came the thought that the whole range of health services could be arrayed to reflect social priorities relevant to Medicaid budgeting and the design of new health insurance programs for “the uninsured.”
Introduction of Abortion Technologies: A Quality of Care Management Approach
Authors: Greenslade Forrest C. , Winkler Judith , Leonard Ann H.
Published: June 2007

The development of antiprogestins and their use for early legally induced abortion have caused considerable heated debate concerning the appropriateness of this new technology for introduction into health care settings around the world. This debate is obviously complicated by broader issues such as abortion itself, women's rights and reproductive freedom, hormone-related medications, and other controversies. While these issues cannot be completely separated, this paper focuses on the management challenges that surround the introduction of new reproductive health technologies. This problem is central to the availability, accessibility, and applicability of new abortion technologies such as the RU 486/Prostaglandin combination.

Introduction of new contraceptive and abortion technologies has yielded important lessons that can guide decision-making regarding RU 486/Prostaglandin. Specifically, these experiences have highlighted the need to concentrate on quality of care concerns in introducing technologies, to ensure new services’ acceptability and, thereby, their effectiveness.
Futility: A Concept in Search of a Definition
Authors: Cranford Ronald , Gostin Lawrence
Published: June 2007

In the landmark case of Crzan v. Director, Missouri Department of Health; the United States Supreme Court went out of its way to emphasize that the state was paying for Nancy Cruzan's care. The court refused to allow removal of the artificial nutrition and hydration that was maintaining Nancy Cruzan in a persistent vegetative state (PVS). What if, instead of the state's paying for the care, the parents had to “spend down” in order to be eligible for Medicaid? Could the state opt for life and require the family to pay for the care? If not, do constitutional rights depend on who can or will pay the cost of care?

Now turn the facts of Cruzan around and assume that the parents want to keep the child alive. Could the parents force the state to bear the cost of keeping a PVS patient alive indefinitely? If not, why should the state, but not the parents, have a constitutional right to preserve life? Do constitutional rights boil down to dollars?
Required Reconsideration of “Do-Not-Resuscitate” Orders in the Operating Room and Certain other Treatment Settings
Authors: Cohen Cynthia B. , Cohen Peter J.
Published: June 2007

Incoming patients across the country, as a requirement of the Patient Self-Determination Act,’ are met on the threshold of hospitals and informed of their right to accept or refuse treatment. They are also offered information about formulating advance directives to govern the use of lifesustaining treatment should they lose decision-making capacity. It is generally assumed that instructional directives covering specific treatment interventions must be followed in every setting within the hospital.’ This assumption is reinforced by the requirements of the Patient Self-Determination Act, since options accepted by patients at the portals of a health care institution are likely to be perceived as in force throughout the facility.

The “Do-Not-Resuscitate” (DNR) order is a specific directive mandating that cardiopulmonary resuscitation (CPR), a dramatic intervention that can restore breathing and heartbeat to patients who have experienced cardiac arrest, should not be performed on patients. Patients or their surrogates who agree to the entry of DNR orders into their medical records usually do so because they believe CPR would be useless or disproportionately burdensome.
Empowerment of Advanced Practice Nurses: Regulation Reform Needed to Increase Access to Care
Authors: Inglis Antoinette DeBois , Kjervik Diane K.
Published: June 2007

As the millennium approaches, the United States is on the verge of major health care reform. While swallowing scarce national resources, our health care system produces unenviable results and major inconsistencies. In 1992, $838.5 billion were spent on health care, biting more than 14 percent out of our gross national product. From 35 to 37 million Americans, or approximately 14 percent of the populationn, are uninsured. Our health care system is inherently inconsistent: We have the highest birthweight-specific survival rate of any country in the world, yet we rank 19th worldwide in infant mortality rate, i.e., state-of-the-art medical technology allows us to save a 500-gram infant, yet the mother of that infant may not have had access to basic, minimal prenatal care.
How Physicians Talk about Futility: Making Words Mean Too Many Things
Authors: Solomon Mildred Z.
Published: June 2007

“There's glory for you!”

“I don't know what you mean by ‘glory,’ ” Alice said.

Humpty Dumpty smiled contemptuously. “Of course, you dont—till I tell you. I meant ‘there's a nice knock-down argument.’”

“But ‘glory’ doesn't mean a ‘nice knock-down argument,” Alice objected.

“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”

“The question is,” said Alice, “whether you can make words mean so many different things.”

“The question is,” said Humpty Dumpty, “which is to be master, that's all.”

When applied bioethics confronts the topic of futility, the question of who is to be master turns out to be central. Indeed, much of the literature on futility has focused on exactly this question: who gets to define the terms of the debate? Who gets to decide that treatment is “futile” and therefore allowably withheld or withdrawn?
Psychosocial Issues in the Management of Patients with Tuberculosis
Authors: Fullilove Mindy Thompson , Young Rebecca , Panzer Paula G. , Muskin Philip
Published: June 2007

The resurgence of tuberculosis in the United States is due, in part, to the dismantling of large-scale treatment systems that were a critical part of the disease control effort for the better part of the twentieth century. As the number of cases grows, clinicians, politicians, public health officials and community advocates have grappled with the difficult problem of building systems to care for infected people that are consonant with current knowledge and beliefs about quality care. As an example, the United Hospital Fund’s 1992 report, The Tuberculosis Revival: Individual and Societal Obligations in a Time of AIDS, discussed policies to guarantee adequate treatment that protects patients’ civil rights, needs for special facilities for care of TB patients, and the special problems faced by infected prisoners. This thoughtful report highlighted many areas of social policy that require further examination.
Rebuilding the Public Health Infrastructure: The Challenge of Tuberculosis Control in New York City
Authors: Hamburg Margaret A.
Published: June 2007

Nowhere in this nation is the return of tuberculosis more visible or more pronounced than in New York City. Fueled by poverty, homelessness and AIDS, tuberculosis has again reached epidemic proportions. New York City is at the forefront of the battle against this advancing disease. For this reason, and because the dynamics at work in New York City are a microcosm of those same forces at work in the larger society, what transpires here often foreshadows the direction that other urban centers will take. It is in this context that our New York experience provides a valuable framework for learning and for action.
Homelessness and TB: A Study in Failure
Authors: Brudney Karen
Published: June 2007

Homelessness has existed in America since colonial times, and the attitudes, analyses and solutions offered through the succeeding centuries have evolved far less radically than recent media attention might suggest. From the building of the first poorhouse in Boston in 1664, to the conversion of massive armories into latter day poorhouses in New York City in the 1980s, our society has had ambivalent feelings towards the poor and the homeless. The outbreak and progression of tuberculosis in such settings—a seeming mystery at best, a reality denied at worst—reflects both society’s ambivalence towards this population, as well as a misguided belief that modern medicine can be viewed in the abstract as curative and divorced from the social context to which all disease is inextricably bound. Unless and until these beliefs are addressed and altered, TB among the homeless will continue unabated.
Thoughts on the Law and the Public's Health
Authors: Burris Scott
Published: June 2007

One understanding of health conceives of it as a state of freedom from pathology, achieved by an individual, through the mediation of a doctor. On this view, improvements in health flow from the application of science to specific ills of the body, and access to medical care is the chief determinant of health. This “medicalized” view of health underlies the current debate over medical care payment reform. This is the dominant way of talking about health.

An alternative is the view of health commonly associated with the practice of public health. On this view, health is an attribute of communities in social and physical environments. Health takes its shape in large numbers—in morbidity and mortality statistics—and, ideally, includes not just a high level of well-being for some, but also its even distribution throughout a society. Improvements in health are seen to arise from healthful changes in the environment.
Nothing to Fear But Fear itself: HIV-Infected Physicians and the Law of Informed Consent
Authors: De Ville Kenneth A.
Published: June 2007

On March 9, 1993, in the first ruling of its kind, the Maryland Court of Appeals declared that physicians and hospitals may be sued for failing to inform patients of a practitioner’s human immunodeficiency virus (HIV) status. What is more significant, these suits may be pursued even in instances when the physician has followed universal precautions and the patient did not contract the virus that causes acquired immunodeficiency syndrome (AIDS). The Maryland court addressed two central questions inFaya v. Almaraz. First, do HIV-infected physicians have a legal duty to inform their patients of their HIV status? And, second, can patients recover damages for fear induced by a physician’s conduct? While one finds numerous precedents that authorize actions to recover damages based purely on fear of disease and emotional distress, theFayacourt’s holdings on the issue significantly expand the scope of potential liability. Moreover, the court’s analysis of the informed consent and HIV-infected physician issue is incomplete, inconsistent, and represents an unjustified and unwise departure from traditional informed consent theory. It, and its progeny, may have widespread and dire repercussions.