bluuebunny/crossref_metadata_2025 huggingface dataset:
Reflections on Health Law and Ethics
Authors: Capron A.M.
Published: June 2007

Major changes are occurring in health law and ethics. Not only are new questions being asked, but new answers are being given, sometimes by new participants. The ferment of the field was very evident during London ‘89, the Second International Conference on Health Law and Ethics, as I hope readers can discern from the essays in this journal. Traditional issues remain, but new themes—such as the place of community welfare alongside values like promoting patient autonomy and serving justice—have emerged with great urgency because of the AIDS epidemic and the constraints on health care spending. Economists and health care planners are looking beyond technical responses and participating more actively in bioethical debates, even as the field seems to be of greater interest to Europeans, Japanese, and people from developing countries, who include a larger number of government officials than is true in most settings in the United States.
The Doctor's Changing Role in Allocating U.S. and British Medical Services
Authors: Lee Robert G. , Miller Frances H.
Published: June 2007

Until the fourth decade of this century, British and American patients who could afford physician services paid for them out of their own pockets; those who could not relied on charity care or simply went without. Doctors functioned as independent contractor private practitioners in both Great Britain and the United States, allocating medical services in response to paying-patient demand — and their own consciences.

Beginning in the 1930s, health care financing on both sides of the Atlantic was restructured in dramatically different directions, and physicians’ allocational roles in their respective countries began diverging. Under the National Health Service (NHS), British general practitioners became essentially gatekeepers to health services, funneling patients to appropriate hospital and specialist care. As time went by they came more to resemble lockkeepers, regulating the queue for secondary and tertiary treatment resulting from governmental limits on health care spending — and from the limitations and inefficiencies of a system of rationing by waiting. In the U.S., on the other hand, efficiency was not at first a concern.
My Annotated Living Will
Authors: Cantor Norman L.
Published: June 2007

Both courts and legislatures have gone a long way toward recognizing individual autonomy to shape the extent of medical intervention in the face of a naturally occurring dying process. This autonomy extends beyond the patient's period of capacity to make decisions on his or her own behalf. That is, a person, while still competent, can express treatment preferences, and those preferences will generally be honored after competence to make medical determinations has been lost. This is the message flowing from judicial emphasis on “substituted judgment” as an important guide in the medical handling of incompetent patients, and from the multitude of “natural death” or “living will” statutes adopted over the last 12 years.

These statutes prescribe a format for a person to issue instructions about medical treatment or non-treatment to be followed if the person becomes incompetent. Such prior instructions designed to guide future medical decisions can be somewhat problematical. If the instructions are not issued proximately to the moment of their utilization, there may be concern that the issuer's preferences have changed over time.
The Role of Physicians in Human Rights
Authors: Nightingale Elena O.
Published: June 2007

For centuries philosophers and writers have reflected on the idea that all human beings, by virtue of being human, are entitled to certain fundamental rights and freedoms. Among these are political and civil rights, as well as economic, social, and cultural rights. Historically, however, how an individual was treated within the boundaries of his own country was not considered the business of any other country. After 1945, as a result of the Holocaust and the atrocities committed by the Nazis against humanity, human rights questions were accepted as international concerns. The nations of the world then agreed that the promotion of human rights and fundamental freedoms were to be one of the principal purposes of the newly-formed United Nations. The Universal Declaration of Human Rights and the Genocide Convention were adopted in 1948. The Universal Declaration of Human Rights sets out common standards that all peoples and all nations should strive for.
Neurologic Syndromes and Prolonged Survival: When Can Artificial Nutrition and Hydration Be Forgone?
Authors: Cranford Ronald E.
Published: June 2007

A recurring lesson in the debate about forgoing life-sustaining treatment for patients with neurologic syndromes is the need to understand the medical realities in such cases. Those of us in the neurological sciences spend a great deal of time working with these cases on a daily basis—trying to define the medical facts and educate ourselves, the public, and the courts. This article will discuss the medical and neurological facts regarding patients with severe and permanent neurological impairment, focusing only on one form of medical treatment: artificially administered nutrition and hydration. The concern of this paper is not the patient's wishes, the family's wishes, or the decision-making role of other key players, but the medical conditions in which it is ethically appropriate to withdraw or withhold artificial fluids and nutrition.
The Process of Dying with and without Feeding and Fluids by Tube
Authors: Schmitz Phyllis
Published: June 2007

The process of dying, ultimately, is an experience that will be common to us all. Considering the current trends in health care, I would guess that most of us give more than a passing thought to how that final phase of life will be played out on a personal level. Undoubtedly, that image is shaped by our attitudes and experiences. In addition each of us recognizes that we have had or are likely to have an impact on the dying in our role as family or friend, health care provider or interpreter of the legal or ethical issues. As a member of a hospice team, I have personally cared for hundreds of terminally ill patients, and based on these experiences, I present the following observations regarding the process of dying, with and without feeding and fluid by tube.

J.R. was a successful business executive until AIDS intervened; within an eight month period, he was forced to give up both his position and independence because of severe peripheral neuropathy which left him minimally functional and in constant pain.
The Long Dying of Nancy Cruzan
Authors: Annas George J.
Published: June 2007

With the Nancy Cruzan decision, the post-Reagan Supreme Court continued recreating America's legal landscape by transferring traditional rights from its citizens to state legislatures and state officials. Attorneys Bopp and Marzen seeCruzanas a cause for celebration. The more common view is that it is a hollow acceptance of the technological imperative that requires all Americans to engage in extensive damage control. Given the composition of the Court, constituted by President Ronald Reagan to overruleRoe v. Wade,Bopp and Marzen correctly note that the result inCruzanwas “practically inevitable.” But its inevitability does not make its consequences any more desirable than the devastation caused by an inevitable tornado or tidal wave. This article summarizes theCruzancase and suggests ways to contain its potentially destructive force.
Advance Directives Under State Law and Judicial Decisions
Authors: Areen Judith
Published: June 2007

Three years ago I first surveyed state court decisions and laws governing the withholding or withdrawal of medical treatment. The decision of the United States Supreme Court inCruzan v. Director, Missouri Department of Healthon June 25, 1990, makes it timely to review again state law developments because a majority of the Court announced inCruzanthat it will leave to the states the question of what legal requirements may be imposed on decisions to discontinue treatment for incompetent patients. Justice Rehnquist, writing for the majority, explained that the Court's deference to state decision-making is grounded in the fact that “state courts have available to them for decision a number of sources—state constitution, statutes, and common law—which are not available to US.” Although the opinion makes clear that Missouri might have authorized the family of Nancy Cruzan to decide to terminate medical treatment for her, a majority of the Supreme Court refrained from holding that Missouri is constitutionally required to do so.
Does Legislating Hospital Ethics Committees Make a Difference? A Study of Hospital Ethics Committees in Maryland, the District of Columbia, and Virginia
Authors: Hoffmann Diane E.
Published: June 2007

Nationally, the number of hospital ethics committees grew dramatically during the 1980s. The motivation for establishing such committees, however, was not only internal but included court cases, federal regulations and a Presidential Commission report urging the establishment of such committees by hospitals.

While each of these external forces added to the pressures for hospitals to establish their own ethics committees, the establishment of these committees was voluntary in every state until 1987 when the Maryland Patient Care Advisory Committee Act became effective. The Act requires all hospitals within Maryland to establish their own patient care advisory committees or ethics committees, as most hospitals refer to them. Specifically, the Act provides that at the request of a petitioner, these committees must offer advice in cases involving individuals with life-threatening conditions. The committee must consist of at least four members, including a physician, a nurse, a social worker, and a hospital's chief executive officer or designee.
Epidemiology and Ethics
Authors: Last John M.
Published: June 2007

Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control of health problems.

Several terms used in this definition require discussion. “Study” encompasses (a) observations in public health practice, e.g. to investigate outbreaks of food poisoning, identify the source of an epidemic, trace contacts of sexually transmitted diseases; (b) hypothesis-testing observational studies using cross-sectional, cohort and casecontrol methods; and (c) experiments such as randomized controlled trials, in which there is intervention as well as observation, usually with the aim of evaluating a preventive, diagnostic or therapeutic regimen or procedure. “Distribution” refers to time sequences, places of occurrence, and persons affected. “Determinants” are all the physical, biological and behavioral factors that can influence health. “Health-related states or events” include diseases, injuries, deaths, behaviors such as tobacco addiction, and reactions to preventive, diagnostic or therapeutic regimens or procedures.
Children in HIV/AIDS Clinical Trials: Still Vulnerable after All These Years
Authors: Levine Carol
Published: June 2007

“All things considered, I chose what was best for my children, or what I thought was best…” confessed Jean- Jacques Rousseau in 1782. What more can one expect from a parent or a professional entrusted with decisions about children? What Rousseau thought was “best” for each of his five infants, however, was to dispatch them to foundling homes in Paris, without even keeping a record of their birthdates, thus leaving them to an unknown but probably dismal fate.

Acting from moral and often legal obligations to protect vulnerable persons from harm and to enhance their welfare, adults daily make decisions about and for children. Professionals and policy makers fulfill their social responsibilities by creating and implementing policies and practices that enable children's caregivers to fulfill these same goals.
Recent Developments in Abortion Law
Authors: Boland Reed
Published: June 2007

This is the first in a projected series of periodic reports on international legal developments relating to reproductive health. It follows an introductory essay on abortion law developments in the industrialized world, which appeared in the Winter 1990 issue ofLaw, Medicine & Health Care.The major focus of this report is again abortion, the reproductive health issue with the highest international legal profile. Like its predecessor, it discusses the consequences of the withering away of Communism in Eastern Europe—in this case Czechoslovakia, the German Democratic Republic, and Poland—as well as the effects of major liberalization of abortion law in Belgium and Canada and the approval by France of use of the abortion-inducing drug RU-486.
The Moral Standing of Animals in Medical Research
Authors: Beauchamp Tom L.
Published: June 2007

Major segments of the news media, as well as many scientific journals, have produced innumerable articles and stories that polarize issues about proper protections for animals involved in research. The prevailing exposition of the issues is the following: On the one hand, animal lovers make emotional appeals to the public's attachment to animals and use clever tactics to increase the vulnerability of universities and institutions of research. On the other hand, arrogant scientists refuse to respond to public controversy, have an inherent conflict of interest in reviewing research involving animals, and are out to advance their careers and interests, callously using animals as means to that end. As a result, journalists warn NIH officials that they “can expect continuing criticism from two disparate and opposing groups—animal welfare activists, who consider NIH the fox guarding the chickens … and scientists and administrators from the research community, who regard tighter restrictions as unnecessarily burdensome.”
Some Ethical Costs of Rationing
Authors: Menzel Paul T.
Published: June 2007

The escalating cost of health care has forced people to confront the possibility of rationing—forgoing beneficial care for patients so that the resources might be used either for other current or prospective patients or for entirely different things in life than health care. Rationing of some sort makes eminent sense, not just economically; only those who are fanatics about health and medicine would urge that everything possible be spent on health care for even the slightest marginal benefit. Yet actual rationing of health care is usually thought to exact high, or at least disturbing, ethical costs.

I will examine four of these costs here: (1) the sacrifice of physician loyalty to patients, (2) the substitution of misleading and discriminatory numerical measurements of medicine's human benefit for more sensitive qualitative judgments, (3) the unfair bite that rationing is likely to take first out of poor people's care before it affects wealthier patients, and (4) the general Substitution of public, group standards about life and health for the values and decisions of individuals.
Ethical Dilemmas in HIV Infection: What Have We Learned?
Authors: Lo Bernard
Published: June 2007

The acquired immunodeficiency syndrome (AIDS) has raised perplexing ethical and public policy dilemmas. Early in the epidemic, closing of bathhouses, testing blood donors for human immunodeficiency virus (HIV) infection, and notifying seropositive blood donors evoked passionate controversies. Current dilemmas include testing and using promising new treatments, notifying partners of seropositive persons, and, most recently, restricting the clinical activities of seropositive health,care workers who perform invasive procedures.

These dilemmas about HIV infection involve scientific judgments, cultural norms, and social values. In the HIV epidemic, public rhetoric and political pressure have been prominent. On the one hand, some persons have launched moralistic crusades against homosexuals and injection drug users. For these persons, AIDS symbolizes the breakdown of traditional family values and the social order. On the other hand, some advocates for persons with HIV infection have used confrontational tactics such as sit-ins and disruptive demonstrations.
Special Ethical Issues in the Management of PVS Patients
Authors: Brody Baruch
Published: June 2007

The patient in a persistent vegetative state (hereafter, the PVS patient) has played a central role in recent American bioethical discussions and in recent litigation involving bioethical issues. From Quinlan’ to Cruzan and Wanglie, some of the most important cases involving ethical issues at the end of life have involved PVS patients. Major American medical groups such as the AMA and the American Academy of Neurology have adopted important policy statements on the care of such patients, statements that have been followed by at least one European group.

I have always found this activity a bit of a mystery. There is, after all, a relatively clear consensus about decision-making at the end of life, a consensus embodied in such documents as a report from the President's Commission and a report from the Hastings Center.
Antiprogestin Drugs: Research and Clinical Use in Sweden
Authors: Bygdeman Marc , Swahn Marja-Liisa
Published: June 2007

Progesterone is essential both for ovulation and for the formation of the secretory endometrium which is required for nidation: it plays a central role in the establishment and maintenance of pregnancy. Given the multifaceted role of progesterone in the reproductive process, an anti-progestational compound such as RU 486 (Mifepristone, Roussel-Uclaf, Paris, France) could be expected to have a number of potential clinical applications in human fertility regulation including termination of pregnancy, induction of missed menses, postcoital contraception and inhibition of ovulation and implantation.

Our research and clinical evaluation have mainly been directed to termination of pregnancy and to inhibition of implantation. The aim of this presentation is to summarize briefly our experience with the use of RU 486 in these areas.
RU486/Prostaglandin: Considerations for Appropriate Use in Low-Resource Settings
Authors: Holt Renee
Published: June 2007

Antiprogestins represent a new class of promising drugs in fertility regulation, especially in early termination of pregnancy. RU486 (mifepristone), manufactured by Roussel-Uclaf and marketed under the international trade name Mifegyne, is an antiprogestin tablet that is used sequentially with a prostaglandin for non-surgical termination of pregnancy. It has been chosen as a pregnancy termination method by over 100,000 women in France since its regulatory approval there in 1988. In addition, RU486/prostaglandin was approved in July 1991 for use in the United Kingdom and an application for approval is being considered in Sweden. In Western Europe, it seems, RU486/prostaglandin is increasingly accepted by medical experts, regulatory officials and women as an alternative to vacuum aspiration or dilation and curettage (D&C) for early pregnancy termination.

As the use of RU486/prostaglandin becomes more established, health practitioners and women's health advocates are beginning to consider the feasibility of using this method for pregnancy termination in low-resource settings.
RU 486: What Physicians Know, Think and (Might) Do—A Survey of California Obstetrician/Gynecologists
Authors: Heilig Steve L.
Published: June 2007

Although RU 486 has been the subject of extensive research and media coverage, in the United States the actual clinical use of the drug remains largely a theoretical possibility. California is the site of the only American clinical research on the use of RU 486 for termination of early pregnancy, and the California state legislature has adopted a strongly-worded resolution in favor of the testing and use of RU 486 in the state. However, the degree of physician awareness, the nature of physician opinion and the potential use patterns of this drug remain speculative.

To gain a better picture of what the physicians most likely to utilize RU 486 think about the drug, licensed California obstetricians and gynecologists were surveyed regarding their opinions about RU 486. The physicians were queried about their general awareness of the history of RU 486, their level of confidence in the existing data regarding the drug and their possible plans to administer the drug clinically if it were to become available.
Acceptability of Mifepristone for Early Pregnancy Interruption
Authors: David Henry P.
Published: June 2007

Traditionally, fertility regulating methods were devised and offered in accord with the convenience of service providers and/or with their perceptions of the convenience of the population served. Generally, the focus was on a method's safety, efficacy, and affordability. It was not until a June 1972 planning meeting of the World Health Organization Human Reproduction Unit that the concept of acceptability was adopted as an additional criterion. The purpose was “to modify technology and programs to fit people, rather than modifying people to fit technology and programs.” A WHO Task Force on the Acceptability of Fertility Regulating Methods was established in January 1973 within what has now become the WHO Special Programme of Research, Development, and Research Training in Human Reproduction. Research conducted in the subsequent 17 years has had a profound effect on the field.

It is the purpose of this article to review the current status of early pregnancy interruption with mifepristone (RU 486) combined with a prostaglandin analogue from the standpoint of its acceptability to women.
“Inducing a Miscarriage”: Women-Centered Perspectives on RU 486/Prostaglandin as an Early Abortion Method
Authors: Berer Marge
Published: June 2007

In countries where abortion is performed safely in medical settings, the vast majority of up to several generations of women have come to identify early abortion as a surgical experience—whether on an inpatient or outpatient basis, whether with local or general anesthetic or whether in a freestanding clinic or a hospital.

In this context, the introduction of RU 486 with prostaglandin (RU 486/PG) as an alternative method of early abortion will once more alter women's experience of abortion.

The first part of this paper explores the similarities and differences between an abortion with RU 486/PG and vacuum aspiration from a women-centered perspective. This comparison is limited by the fact that only women in France have so far had access to both methods, along with those who have participated in clinical trials, and that very few in-depth women's experiences and reactions to this method have been published.
Benten v. Kessler: The RU 486 Import Case
Authors: Pine Rachael N.
Published: June 2007

On July I, 1992, I received a phone call from a reporter asking for my response to Leona Benten's choice to defy the U.S. Food and Drug Administration's ban on RU 486 by bringing a single personal dose of the abortifacient drug into the U.S. on a flight from Europe. By the end of the day, my colleagues and I at the New York-based Center for Reproductive Law and Policy had been asked and had agreed to represent Leona and her companions, Dr. Louise Tyrer and Lawrence Lader, in their legal challenge to the import ban and, more urgently, in their effort to retrieve the RU 486 pills that were confiscated from Leona by U.S. Customs officials at the airport. Leona, who was 6 weeks pregnant and who desperately wanted to terminate her pregnancy by a non-surgical abortion method, had only two more weeks in which to use the drug according to prevailing medical protocol.
Avoiding “Cloudcuckooland” in Ethics Committee Case Review: Matching Models to Issues and Concerns
Authors: Cohen Cynthia B.
Published: June 2007

Two Athenians set out to found a city free from the sophistry, power struggles, and litigiousness of Athens in Aristophanes’ play, The Birds. Their creation is to stand as a shining example of a virtuous demos in which reasoned discourse will give birth to goals beneficial to the individual and the community. The city that emerges, “Cloudcuckooland,” turns out to be a replica of Athens, driven by a morality of self-interest and the lust for world conquest. Its founders’ dream fades in a maze of doubtful arguments, crippling red tape, and insatiable litigiousness. Even so, Aristophanes hints, the dream survives, for no Athenian can escape from the restless hubris that leads to daring creation.

Special committees have been created in recent years to address difficult ethical issues in clinical care free from the bureaucratic amorality, professional friction, and litigiousness that can characterize problem-solving within health care institutions.
Medical Futility: Legal and Ethical Aspects
Authors: Grant Edward R.
Published: June 2007

I welcome the long-overdue recognition of medical futility represented by the contributions of Koch, et al., Miles, and Dew, although I would be more comfortable with using the more global (and optimistic) term of “beneficence.” However labeled, the notion that medical treatment decisions are primarily that—medical decisions—is a far more appropriate starting point in both law and ethics than the customary departure point of patient autonomy. This is particularly true in cases in which the patient is not competent, and prior expressions of intent are remote, vague, or otherwise unreliable. Despite such flaws, prior statements have been invested with a talismanic quality, permitting avoidance of the genuine moral issues of duty and benefit that are presented by every severely ill and incompetent patient.

The rise of patient autonomy may actually have had less to do with genuine concern for the liberty of the patient than with the moral vacuum created by an excessively pluralistic view of medical ethics. Courts in particular have fallen out of the habit of a priori moral reasoning, replacing this discipline with balancing tests of asserred personal and governmental power.
A Retrospective onCruzan
Authors: Meisel Alan
Published: June 2007

In 1990, the United States Supreme Court issued a decision in theCruzancase, the first “right-to-die case” to reach that court. Prior to the Court's decision, there was widespread speculation as to what it would decide and what the impact of the decision would be. Speculation about the impact of the decision intensified after it was announced, with many suggesting that it would prove to be a serious setback to the consensus about the legality of terminating life-sustaining medical treatment that had evolved in the state courts since the Karen Quinlan case ushered in the era of right-to-die litigation in 1976.

This article examines a number of aspects of the legal consensus about forgoing life-sustaining treatment that emerged prior toCruzanand discusses their viability in light both of whatCruzandid and did not decide and in light of subsequent judicial decisions in right-to-die cases. Two years after the Supreme Court's decision, it is apparent that the pre-Crtrzan legal consensus is stronger than ever.
Treatment Decisions for Terminally Ill Patients: Physicians' Legal Defensiveness and Knowledge of Medical Law
Authors: Van McCrary S. , Swanson Jeffrey W. , Perkins Henry S. , Winslade William J.
Published: June 2007

Wanzer, et al., have noted that “all too frequently, physicians are reluctant to withdraw aggressive treatment from hopelessly ill patients, despite clear legal precedent.” Our collective clinical experience confirms that this reluctance persists among some physicians. In this study, we investigated physicians’ attitudes, knowledge, and reported practices regarding the effects of perceived legal constraints on the abatement of life-sustaining treatment from patients who are clearly dying. A factor in assessing these issues is the concept of defensive medicine-that is, the perception that doctors are being forced to order every possible laboratory test and second opinion, or to continue providing non-beneficial life-sustaining treatment, solely to protect themselves from future legal claims. This perception appears widespread among practicing physicians. However, we believe that defensive medicine represents only part of a complex constellation of factors that comprise physicians’ reluctance to abate treatment. This phenomenon encompasses medical, ethical, legal, social, psychological, and spiritual factors interacting in ways that are not fully understood.
The “Gag Rule” Revisited: Physicians as Abortion Gatekeepers
Authors: Bloche M. Gregg
Published: June 2007

To the surprise of many and the dismay of some, the U.S. Supreme Court took it upon itself last term to proclaim a national compromise on the question of abortion. The Court's announced truce, an elaboration on Justice O’Connor's “undue burden” idea, is pragmatic in design but unlikely to prove stable in practice. The three justices who spoke for the Court disparaged Roe with reluctant praise, then upheld its outer shell on the ground that social expectations and the need to sustain the appearance of the rule of law made it impolitic to do otherwise. This awkward doctrinal invention seem unlikely to yield a lasting peace. However artful as political brokerage, it is unpersuasive as principled jurisprudence. Its explicitly political calculus invites skepticism about its authors’ commitment to principled method even as it purports to preserve public regard for judicial legitimacy. Moreover, there is an unexplained “disconnect” between the opinion's avowed preservation of Roc's “essential holding” and its abandonment of Roe's commitment to reproductive freedom as a compelling interest.
Health Priorities in Developing Countries
Authors: Delph Yvette M.
Published: June 2007

Developing countries are faced with the mutually perpetuating obstacles of poverty and inadequate development. Their needs are often so vast that their scarce resources prove too meager even to begin to address the problems.

It is estimated that close to 2.2 billion people live in a state of severe poverty. The precarious housing and health of these people, 60 percent of the population of developing countries, are compounded by hunger and dangerous environmental conditions. Generally, they have large families and their incomes are extremely low. Malnutrition is widespread despite the fact that 80 percent of their earnings are spent on food.
Women's Health: An Ethical Perspective
Authors: Macklin Ruth
Published: June 2007

If there is one ethical concept considered to be central to human social life it is the idea of justice. Although there are several competing principles of justice, the core concept of justice embodies the obligation to treat like cases alike, in relevant respects. Women may differ from men in some respects, but the fact that women get sick, become injured, and die from preventable causes renders them similar to men in the need to carry out biomedical research, develop therapies, and attend to health problems specific to women. An ethical perspective on women’s health begins and ends with principles of justice. Although particular circumstances and conditions differ in developed and less developed countries, the ethical conclusions regarding justice are the same for women in all societies.
The Impact of the Patient Self-Determination Act's Requirement That States Describe Law concerning Patients' Rights
Authors: Teno Joan M. , Sabatino Charles , Parisier Lauren , Rouse Fenella , Lynn Joanne
Published: June 2007

As of December 1991, the Patient Self-Determination Act (PSDA) mandated that health care institutions which receive funding from Medicare or Medicaid provide written information about persons rights to participate in medical decision-making and formulate advance directives. The PSDA required each state

…acting through a State agency, association, or other private nonprofit entity develop a written description of the law of the State (whether statutory or as recognized by the courts of the State) concerning advance directives that would be distributed by providers or organizations under the requirements of [the Act].
Genetic Testing and the Social Responsibility of Private Health Insurance Companies
Authors: Jecker Nancy S.
Published: June 2007

Over the next 15 years, the government-funded human genome project will map and sequence each of the human cell’s estimated 100,000 genes. The project’s first fruits will be a vast quantity of information about genetic disease. This information will contribute to the design of quicker, cheaper and more accurate tests for identifying deleterious genes in individuals. Because genetic conditions are often regarded as “immutable, heritable taints that intrinsically implicate the bearer’s identity,” overly-deterministic interpretations of genetic information can readily distort genetic risk and become enshrined in institutional policies of social isolation and discrimination.
Quality Control in Health Care: Developments in the Law of Medical Malpractice
Authors: Furrow Barry R.
Published: June 2007

Physicians and institutional providers face expanding liability exposure today, in spite of state tort reform legislation and public awareness of the costs of malpractice for providers. Standards of practice are evolving rapidly; new medical technologies are being introduced at a rapid rate; information is proliferating as to treatment efficacy, patient risk, and diseases generally. Tort standards mirror this change. As medical standards of care evolve, they provide a benchmark against which to measure provider failure. The liability exposure of physicians is affected by (1) the generation of data, including outcomes data usable to profile physician practice, and statistical data that allows for predictions as to treatment efficacy, and patient prognosis; (2) obligations to inform patients and third parties of risk created by contagious disease and other sources of harm; (3) obligations of physicians to disclose risks that the provider creates for the patient; (4) obligations to disclose conflicts of interest arising out of the practice setting; and (5) duties arising from new epidemiological knowledge.
The Single Disease Hospital: Why Tuberculosis Justifies a Departure That AIDS Does Not
Authors: Rothman David J.
Published: June 2007

Although HIV disease has set a new model for resolving the tensions between civil liberties and public health interests, with an unprecedented commitment to individual privacy and autonomy, the resurgence of tuberculosis has sparked new and troublesome concerns. One particularly intense controversy has emerged around the value and appropriateness of single disease hospitals. In HIV disease, the single hospital turns out to be an altogether unsuitable and unnecessary innovation. In the instance of tuberculosis, however, it appears to have a critical and legitimate role, particularly for involuntary commitment of patients who have been non-compliant with treatment regimens. To be sure, that role must be carefully circumscribed and the facilities themselves closely monitored. But a hospital dedicated to tuberculosis now occupies a central place in public policy that is not to be found for HIV disease. What considerations promote this difference, and how a single disease hospital for tuberculosis may avoid the pitfalls that make it so inapposite for HIV, are the two questions this essay will be exploring.
Tuberculosis in Correctional Facilities: The Tuberculosis Control Program of the Montefiore Medical Center Rikers Island Health Services
Authors: Safyer Steven M. , Richmond Lynn , Bellin Eran , Fletcher David
Published: June 2007

“Recognizing that prisons disproportionately confine sick people, with mental illness, substance abuse, HIV disease among other illnesses; and that prisoners are subject to further morbidity and mortality in these institutions, due to lack of access and/or resources for health care, overcrowding, violence, emotional deprivation, and suicide.…(APHA) condemns the social practice of mass imprisonment.”

After decades of steady decline, tuberculosis has emerged as a significant public health threat in the United States. The rising rates of tuberculosis cases, an increasing proportion of which are resistant to standard chemotherapies, are linked to the many scourges threatening our communities: the explosion of poverty, drug use, violence, the HIV epidemic, and the concomitant rise in congregate housing including homeless shelters, residential drug treatment programs and incarceration facilities. Jails and prisons have disproportionately high rates of tuberculosis infection and have been implicated as points of tuberculosis spread and, as such, are a critical point for tuberculosis control interventions.
Catalysts for Conversations About Advance Directives: The Influence of Physician And Patient Characteristics
Authors: Sugarman Jeremy , Kass Nancy E. , Faden Ruth R. , Goodman Steven N.
Published: June 2007

Recent legislation, such as the Patient Self-Determination Act, establishes advance directives as an acceptable procedural means of incorporating patients’ preferences for life-sustaining treatments into their medical care. Advance directives can enhance medical decision making since they provide patients with an opportunity to communicate their preferences before suffering from an acute illness that may preclude their ability to do so.

Although patients expect discussions about life-sustaining therapies to be initiated by their physicians, very little is known about what prompts physicians to discuss advance directives with their patients. As in other areas of clinical decision making, there is evidence that patients’ sociodemographic factors influence whether discussions about advance directives occur between patients and their physicians. In one study of persons with the acquired immunodeficiency syndrome (AIDS), those who had not had discussions about advance directives with their physicians tended to be non-white, have no prior hospitalization, and were more likely to have been cared for in a health maintenance organization than in a teaching hospital.
Health and Education: A Tale of Two Crises
Authors: Parmet Wendy E. , Enrich Peter
Published: June 2007

This is a tale of two social structures, health care and education. Both systems are undeniably critical to our social fabric, and even to our national prosperity. Both systems also provide services that are uniquely personal and vital to individual well-being. And both systems are now widely perceived as being in “crisis,” as needing “fundamental reform.”

At the same time, there are fundamental differences in the ways the two sectors are organized and understood. Health care is essentially a system of private relationships; education a system of public responsibilities. Although each system is extraordinarily complex and contains elements that defy neat categorization, by highlighting the contrasting visions and structures of the two, one gleans useful insights both into the distinctive failings of each and into potential directions for reform.
Review Essay: Herding Cats and Reforming the American Health Care System
Authors: Stell Lance K.
Published: June 2007

A recentNew York Times/CBS poll shows that nearly 80 percent of respondents think the American “health care system is headed toward a crisis because of rising costs.” Indeed, the public has become well acquainted with ominous-looking graphs that detail the nation’s health care spending. The increasingly steep slope of the graph showing the percentage of gross domestic product spent on health care invites tongue-in-cheek projections for when health care spending will finally consume it all.

High aggregate health care expenditures result from the low prices individuals pay for coverage. On average, patients pay only five cents out-of-pocket for every dollar of hospital charges they generate. The remainder is paid by private or public health insurance. Patients pay slightly more for physicians’ services—nineteen cents on each dollar. For health care of all types, patients pay approximately twenty-four cents on each dollar. With individuals paying what amount to fire sale prices for health care, it should come as no surprise that they purchase a great deal of coverage.
Interdisciplinary Health Care Teams and Health Care Reform
Authors: Purtilo Ruth B.
Published: June 2007

The purpose of this paper is to encourage reflection about the harm that could result if the positive aspects of team-organized health care are compromised during the health care reform process. While other models of health care delivery could replace teamwork and serve patients as well or better, the interdisciplinary health care team (IHCT) probably will not be abandoned. However, one or more disciplines whose members play important roles on various teams may be sacrificed in the hasty effort to define essential health care. Moreover, a significant proportion of the types of IHCTs in existence could be rashly eliminated from health plans. These changes should not take place randomly or by default.
Research on “Big Ticket” Items: Ethical Implications for Equitable Access
Authors: Veatch Robert M.
Published: June 2007

“Big ticket” items in medicine pose a moral puzzle. We can call it the “Coby Howard puzzle,” after the boy whose need for an expensive bone marrow transplant forced Oregonians to reassess their policy of prohibiting this and other expensive “big ticket” procedures in favor of more low-tech, apparently cost-efficient interventions. The Oregon rationing debate was stimulated by the concern that expenditures on “big ticket” medical treatments for life-threatening disease were coming at the expense of low-tech, preventive “basic” care like immunizations, wellbaby clinics, and prenatal care.

Another recent example was the public controversy over expenditures of over $1,800 per day on a project to try to separate Siamese twins conjoined at the heart. The physicians, prior to the procedure, claimed there was a one percent chance of success. It was reported that 50,000 children in Philadelphia could be immunized at the cost of that innovative therapy. Cost-benefit analysis suggests that much greater good would be done in the long run if we ignored the expensive, long-shot, high-risk projects and focused on basic medical needs.
Collective Decisions About Medical Futility
Authors: Spielman Bethany
Published: June 2007

The debate about medical futility is no longer in its infancy. Scholarly literature on this seemingly intractable problem is voluminous. The list of widely publicized cases in which physicians have wanted to discontinue life-sustaining medical treatment that families demand has grown to include not just Helga Wanglie, but also Baby Rena, Baby L, Jane Doe, Joseph Finelli, Baby K, and Teresa Hamilton. A futility case has now been decided at the appellate court level.

Commentators have generated three kinds of proposals for resolving these conflicts. One group contends that the problem can be solved within the physician-patient-family relationship. While some in this group view professional authority broadly enough to warrant unilateral judgments by physicians that interventions desired by the patient or family should not be provided, others contend that physician authority does not extend that far, and that any resolution must be constrained by informed consent requirements.
An Overview of Prescription Drug Misuse and Abuse: Defining the Problem and Seeking Solutions
Authors: Wilford Bonnie B. , Finch James , Czechowicz Dorynne J. , Warren David
Published: June 2007

Each year, millions of individuals in the United States are treated for a variety of serious medical conditions with prescription drugs whose therapeutic benefits are well known. The vast majority of these medications are used to treat medical and psychiatric illnesses. Generally, they are used as prescribed, and contribute to a better quality of life for persons suffering from debilitating or life-threatening disorders.

The fact that a small portion of these medications is diverted by those who seek their psychoactive effects raises the important policy issue: how to make drugs easily available for medical use while limiting access for purposes of abuse.

Such a responsibility poses challenges very different from those of the so-called “war” on illicit drugs, because this control must be achieved without impeding patients’ access to medical care. A rational public policy would attempt to achieve a balance between the need to minimize abuse and the need to provide relief.
An Open Letter to Physicians Who Have Patients with Chronic Nonmalignant Pain
Authors: Snyder Cynthia A.
Published: June 2007

“It was the best of times. It was the worst of times.” Charles Dickens easily could have been describing our time and the dilemma in which victims of nonmalignant chronic pain find themselves.

I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life.

The morning of February 1983 severed my life into “before” and “after,” as clearly as if it has been cut by a sharp knife. The “before” included my career as an oncology nurse, a college nursing professor, and a writer; but that was abruptly ended by the catastrophic rupture of a deep cerebral aneurysm. Surgery saved my life, but something unforeseen occurred during the procedure; and so, in the “after,” I have had to live with a serious seizure disorder and memory loss.
The Treatment of Anxiety: Realistic Expectations and Risks Posed by Controlled Substances
Authors: DuPont Robert L. , DuPont Caroline M.
Published: June 2007

We can think about the use of controlled substances in the treatment of anxiety disorders in two simple but diametrically opposed ways. First, we can say that anxiety disorders are trivial and require only acts of willpower, or, if anxiety disorders do require treatment, they are better treated without the use of benzodiazepines (BZs). When BZs are used to treat anxiety, they pose grave risks of addiction to the patients to whom these medicines are prescribed; they relieve patients’ symptoms, but are the equivalent of a pharmacological “roach motel,” a haven into which many unsuspecting patients enter, but from which few emerge without becoming addicted. Patients must then face terrible struggles to free themselves of dependence on BZs, and this compounds the problem for which they sought treatment. Furthermore, the large number of prescriptions for BZs are a threat to the public health because these drugs are widely abused by alcoholics and drug addicts.
Freedom of Conscience, Professional Responsibility, and Access to Abortion
Authors: Dresser Rebecca S.
Published: June 2007

Access to abortion is becoming increasingly restricted for many women in the United States. Besides the longstanding financial barriers facing low-income women in most states, a newer source of scarcity has emerged. The relatively small number of physicians willing to perform the procedure is compromising the ability of women in certain parts of the country to obtain an abortion.

Do physicians have a duty to respond to this situation? Do they have a professional responsibility to ensure that abortions are reasonably available to the women who want to terminate their pregnancies? Or, is abortion so morally and socially controversial as to remove any professional obligation to provide reasonable access?

Both law and medical ethics have traditionally protected physicians’ freedom to refuse to perform any procedure, including abortion, that conflicts with their religious or other moral beliefs.