Lawyers and bioethics: balancing being lawyers and conferring with medical ethics advisors.

WITH INCREASING frequency health law lawyers are asked to participate in discussions that intertwine legal, clinical and medical-ethical concerns. These "bioethical" issues are related to, but distinct from, purely legal questions. For example, in-house hospital counsel routinely wrestle with complicated and painful issues involving end-stage life decision making, do not resuscitate orders, advance directives, maternal-fetal issues, so-called futile treatments, and conflicts between family members and health professionals. Health law lawyers also are involved integrally in developing and reviewing institutional patient care policies that involve ethical problems and dilemmas. Health law lawyers frequently play a role in ensuring that health care institutions conform to Joint Commission for the Accreditation of Healthcare Organizations standards, as well as to and federal fraud and abuse, anti-self referral, and anti-kickback regulations. (1) All these duties necessarily involve issues of law bioethics. Bioethical issues sometimes arise when attorneys represent individual patients in a health care setting. Here, too, health law lawyers may be asked to perform functions beyond the purely technical legal role. (2) The overlap between medical law and medical ethics is becoming so commonplace that lawyers who practice in a medical setting must come to terms with the fundamental question: "What does it mean to practice bioethics and the law?" This question is not merely a topic for professional or academic enrichment. It is a complex question involving rapidly changing legal and medical environments and doctrines, shifting inter-professional relations, and multiple and interlocking personal and professional commitments and duties. The relationship between bioethics and law is so important and complicated that lawyers' professional ethics obligations require that those who are likely to deal with these issues have a clear view of the nature of their various roles and how those roles interact before they face these issues in practice. Just as important, health law lawyers must be able to help the non-lawyers with whom they work understand the multifaceted nature of bioethics and the law. CONCEPTS AND RELATIONSHIPS Medical ethics or bioethics is the examination of how to make morally right choices in medical practice and health care delivery. It is a branch of applied ethics--what is right and what to do about it. Bioethics includes the examination of issues in health care economics, especially the distribution of scarce medical and financial resources. For example, medical ethicists have examined the fairness of attempts to control costs, such as managed care, and have analyzed the increased emphasis on market principles to distribute medical resources. Bioethics also attempts to resolve conflicts between society and individuals. For example, parents sometimes refuse effective treatments for their children on religious or other grounds. These decisions raise questions regarding the right of the medical community and the state to intervene in medical decision making. (3) In many respects, the professional duties of lawyers who practice medical law are relatively clear. Of course, they are required to provide competent legal advice and are bound to protect the interests of their clients. In this regard, they are no different from other working legal professionals. Whatever else they are asked to do, they are bound to perform to these standards. Much of the legal work related to bioethics is within traditional provinces of contract, tort, insurance, and constitutional and regulatory law. (4) In this respect, too, their responsibilities are no different from those imposed on other lawyers, although it is becoming increasingly difficult to keep abreast of the health law generated by courts, legislatures and new health care arrangements. This current dynamic environment is what makes health law one of the most intellectually exciting, yet daunting, areas of practice. …