Health Law and Policy Commons^™

Medicine And Human Rights: Reflections On The Fiftieth Anniversary Of The Doctors’ Trial, George J. Annas, Michael A. Grodin

Faculty Scholarship

1996 marks the fiftieth anniversary of the commencement of the trial of Nazi physicians at Nuremberg, a trial that has been variously designated as the "Doctors' Trial" and the "Medical Case." In addition to documenting atrocities committed by physicians and scientists during WWII, the most significant contribution of the trial has come to be known as the "Nuremberg Code," a judicial codification of 10 prerequisites for the moral and legal use of human beings in experiments. Anniversaries provide us with an opportunity to reflect upon the past, but they also ena ble us to renew our efforts to plan for …

Cowboys, Camels, And The First Amendment: The Fda's Restrictions On Tobacco Advertising, George J. Annas

Faculty Scholarship

The Marlboro Man and Joe Camel have become public health enemies number one and two, and removing their familiar faces from the gaze of young people has become a goal of President Bill Clinton and his health care officials. The strategy of limiting the exposure of children to tobacco advertisements is based on the fact that almost all regular smokers begin smoking in their teens. This approach is politically possible because most Americans believe that tobacco companies should be prohibited from targeting children in their advertising.

Facilitating Choice: Judging The Physician's Role In Abortion And Suicide, George J. Annas

Faculty Scholarship

When I was invited to give this talk I thought, "I'll just give my standard slide show on death in America." I thought I would just talk about the right to die, something I can do in my sleep, and everybody would be happy. And you probably would, since it's a pretty good speech. I am going to give it at a Pennsylvania Judges Conference in a couple of weeks, and they will like it. But it is not very challenging, either for me or for you. So, what I want to explore with you today is how judges have …

The Promised End: Constitutional Aspects Of Physician-Assisted Suicide, George J. Annas

Faculty Scholarship

The debate over physician-assisted suicide has dramatically shifted to a discussion of constitutional issues. This spring, within a month of each other, U.S. Circuit Courts of Appeals on both coasts ruled that state prohibitions of assisted suicide are unconstitutional when applied to physicians who prescribe lethal medication for terminally ill, competent adults who wish to end their lives. The Ninth Circuit includes Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, and Washington, and the Second Circuit includes New York, Connecticut, and Vermont. Both courts reached the same conclusion but for different legal reasons.

Aids Phobia, Public Health Warnings, And Lawsuits: Deterring Harm Or Rewarding Ignorance?, Wendy K. Mariner

Faculty Scholarship

Courts in more than a dozen states have decided cases in which a person has claimed money damages for his or her fear of getting acquired immunodeficiency syndrome (AIDS). Although most courts have rejected such claims in the absence of actual exposure to the human immunodeficiency virus (HIV), their reasoning has varied slightly from state to state. This article argues that negligence law should not permit people who are HIV negative to recover damages for an unfounded fear of AIDS. Public health statements intended to educate the public about preventing HIV transmission may have encouraged some fear-of-AIDS lawsuits against health …

Business Vs. Medical Ethics: Conflicting Standards For Managed Care, Wendy K. Mariner

Faculty Scholarship

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, fee-for-service (FFS) medical practice creates incentives to provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, …

Nonprofit Hospital Mergers And Section 7 Of The Clayton Act: Closing An Antitrust Loophole, Laura L. Stephens

Faculty Scholarship

Nonprofit hospitals developed out of the charitable hospital movement, which began in the mid-nineteenth century.' The early voluntary hospitals depended upon local benefactors for financing.² Originally conceived as charitable institutions providing long-term care, these hospitals began to change their focus around the turn of the century.³ A changed mission-providing care to all rather than just poor inpatients with chronic problems-required the latest medical technology.⁴ This in turn demanded increased construction of up-to-date facilities, as well as large operating expenses.

Recent years have seen further pressure on hospital budgets, as the health-care sector of the economy has become …

Reframing The Debate On Health Care Reform By Replacing Our Metaphors, George J. Annas

Faculty Scholarship

Metaphors matter, as our sterile debate on the fi-nancing of health insurance demonstrates so well. In that debate the traditional metaphor of American medicine, the military metaphor, was displaced by the market metaphor in public discourse. Metaphors, which entice us to understand and experience “one kind of thing in terms of another . . . play a central role in the construction of social and political reality.” The market metaphor proved virtually irresistible in the public arena and led Congress to defer to market forces to “reform” the financing of health insurance in the United States.

Women And Children First, George J. Annas

Faculty Scholarship

In the lore of the sea there are few events that have so exemplified heroism and self-sacrifice as the acts of the soldiers and sailors of the British ship Birkenhead when it sank in 1852. The soldiers of the 74th Highland Regiment stood at attention on deck (with the band playing) “while the women and children were saved and the captain very properly went down with his ship.” More than 450 lives were lost, and the phrase “women and children first” was introduced into the language as part of the “Birkenhead drill.” As Kipling put it in his poem …

Insurance Risk Classification After Mcgann: Managing Risk Efficiently In The Shadow Of The Ada, Maria O'Brien

Faculty Scholarship

A significant part of the health insurance debate which gripped the country during the first two years of President Clinton's administration focused on the critical shortage of employer-sponsored health insurance for disabled, br high risk, employees. Indeed, President Clinton's promise of universal access in connection with the promotion of his health care plan is apparently designed to ensure that the increasingly popular employer practice of excluding high risk employees becomes obsolete. In the meantime, while the merits of the Clinton plan and its competitors are debated, individuals like John McGann-working and insured--continue to discover that like their health, their insurance …

The Health Of The President And Presidential Candidates: The Public's Right To Know, George J. Annas

Faculty Scholarship

In July 1995, presidential candidate Robert Dole celebrated his 72nd birthday by releasing a detailed nine-page summary of his medical records. His personal physician told the press that despite the serious wounds Dole received during World War II, which left his right arm paralyzed and required the removal of one kidney, and despite his 1991 surgery for prostate cancer, his health was “excellent.” Dole was also photographed on his treadmill.

Medicine, Death, And The Criminal Law, George J. Annas

Faculty Scholarship

Errors in medicine are common and are at least partly responsible for the deaths of 180,000 patients a year. There is increasing concern about medical errors and the steps that should be taken to prevent them.Until recently, hospitals have addressed errors after the fact, through mortality and morbidity conferences, incident reports, and the like, rather than before the fact, through attention to systems defects and prevention. Likewise, medical-malpractice litigation can be filed only after an injury has occurred. Malpractice litigation is intended to create incentives to improve the quality of medical care by making physicians and hospitals accountable for their …

Patients' Rights After Health Care Reform: Who Decides What Is Medically Necessary?, Wendy K. Mariner

Faculty Scholarship

President Clinton's Health Security Act entitles individuals not to unlimited health care, but to a package of defined insurance benefits with specific exclusions and limitations. Like virtually all reform proposals, it would limit covered benefits to services that are medically necessary. If health reform is to control costs, not all medically necessary care can be covered. In the absence of a generally accepted definition of medical necessity, many services will not be guaranteed to all patients unless they are explicitly covered in the federal legislation or regulations. Without a federal definition of medical necessity or regulations listing covered services, health …

Patients' Rights To Care Under Clinton's Health Security Act: The Structure Of Reform, Wendy K. Mariner

Faculty Scholarship

Like most reform proposals, President Clinton's proposed Health Security Act offers universal access to care but does not significantly alter the nature of patients' legal rights to services. The act would create a system of delegated federal regulation in which the states would act like federal administrative agencies to carry out reform. To achieve uniform, universal coverage, the act would establish a form of mandatory health insurance, with federal law controlling the minimum services to which everyone would be entitled. Because there is no constitutionally protected right to health care and no independent constitutional standard for judging what insurance benefits …

Working And Poor: The Increasingly Popular Practice Of Excluding Disabled Employees From Health Care Coverage, Maria O'Brien

Faculty Scholarship

One might think, since passage of the Americans With Disabilities Act of 1990 (ADA),' that the employment story for disabled employees or would-be disabled employees was cheerful, or at least improving. This may be true in so far as obtaining and retaining employment is concerned;' however, the ADA, because it permits employers and third-party insurers to continue to utilize traditional risk management techniques, has resulted in reduced or (in some cases) non-existent employee benefits for the disabled. At the same time, more and more employers are opting to self-insure under the Employee Retirement Income Security Act of 1974 (ERISA),3 in …

Outcomes Assessment In Health Care Reform: Promise And Limitations, Wendy K. Mariner

Faculty Scholarship

If the fundamental goals of the health care reform effort are to ensure universal access to an acceptable quality of health care at an affordable cost, then the threshold question for reform is: What health care services should be provided in an efficient, equitable system?

Answering this question requires weighing a complex mix of medical and social policy factors, a process not attempted in this article. But the starting point for that process should be determining what health care services “work” and what they cost. Outcomes assessment holds considerable promise in finding answers to these subsidiary questions, because it is …

The Empire Of Death: How Culture And Economics Affect Informed Consent In The U.S., The U.K., And Japan, George J. Annas, Frances H. Miller

Faculty Scholarship

Historically, most Americans have treated health care as a private commodity whose price, and therefore availability, is primarily determined by market forces. In such a context, the law not unsurprisingly places a high premium on information disclosure by physicians. Personal autonomy-an individual's power to choose among medical options-enjoys its most zealous protection under U.S. jurisprudence.⁷ The dominant U.S. version of informed consent is grounded on principles of patient/consumer autonomy, and seems to enhance market choice. But a strong theme of collectivism now runs through some discussions of U.S. health policy.⁸ President Clinton was elected at least in part …

Scientific Evidence In The Courtroom: The Death Of The Frye Rule, George J. Annas

Faculty Scholarship

In one of the most anticlimactic cases in recent years, the Supreme Court ruled on the last day of its 1992-1993 term that federal judges should admit all relevant scientific testimony and evidence that is “reliable”. The result was so uncontroversial that both sides in the case said they were satisfied; because the result was also so vague, it will probably be years before its effect can be accurately ascertained. The facts of the case, Daubert v. Merrell Dow Pharmaceuticals, Inc., are somewhat more interesting than its prosaic legal conclusion.

Asking The Courts To Set The Standard Of Emergency Care - The Case Of Baby K, George J. Annas

Faculty Scholarship

Almost two decades ago, Dr. Franz J. Ingelfinger predicted that if physicians kept turning to the courts “to resolve essentially medical matters,” the medical profession's unfortunate “dependence on the lawyer in reaching essentially medical decisions will continue”1. One can argue about what decisions are “essentially medical,” but the trend that worried Dr. Ingelfinger has continued, and now physicians and a hospital have sought legal and judicial guidance about how -- and whether -- to treat an anencephalic infant known as Baby K.

Health Insurance Purchasing Alliances: Monopsony Threat Or Procompetitive Rx For Health Sector Ills?, Frances H. Miller

Faculty Scholarship

No abstract provided.

Informed Consent, Cancer, And Truth In Prognosis, George J. Annas

Faculty Scholarship

Barbara Tuchman records that during the Black Death epidemic in the early 14th century, “doctors were admired, lawyers universally hated and mistrusted”. The great plagues and wars of the Middle Ages produced a “cult of death,” including a vast popular literature that had death as its theme. As the 20th century closes, our emphasis is on the denial of death, and the honest discussion of death remains rare both in popular literature and in conversations between physicians and patients. This is one reason why Shana Alexander shocked a national conference of bioethicists last year by saying, “I trust my lawyer …

Death By Prescription, George J. Annas

Faculty Scholarship

Society and physicians in the United States remain unable to accept death and thus unable to deal with the physical, psychological, and spiritual approach of death. The hour of death itself “is commonly tranquil,” but “the serenity is usually bought at a fearful price -- and the price is the process by which we reach that point” -- a process that has been described as “a purgatory that may last for weeks.” Suicide has been seen as a rational way to avoid that purgatory, especially as a response to end-stage cancer and AIDS, and proposals to “legalize” physician-assisted suicide in …

When Should Preventive Treatment Be Paid For By Health Insurance?, George J. Annas

Faculty Scholarship

In the national debate about who should have health insurance, surprisingly little attention has been focused on what medical services health insurance itself should cover. Historically, discussions of this topic have centered on concepts such as basic health care or medically necessary care. When the power of medical diagnosis and treatment was limited, these terms had boundaries as well. As physicians' diagnostic prowess has increased, however, especially in the area of genetics, such terms have become open-ended. To avoid predictable conflicts over benefit coverage, much more precise definitions will be required, so that patients and health care providers can understand …

Malpractice Liability And Physician Autonomy, Frances H. Miller, Anthony Harrison

Faculty Scholarship

Opinion. Discusses legal modifications concerning liability for medical negligence evolving in similar ways in the United States and Great Britain. Parallel and divergent trans-Atlantic trends; Ailing and increasingly costly health care systems; Traditional relationships among doctors, hospitals and other health sector players.

Physician-Assisted Suicide — Michigan's Temporary Solution, George J. Annas

Faculty Scholarship

Lewis Thomas has noted that doctors “are as frightened and bewildered by the act of death as everyone else”. “Death is shocking, dismaying, even terrifying,” Thomas has written. “A dying patient is a kind of freak . . . an offense against nature itself”. It is thus not surprising that many physicians have difficulty talking candidly with dying patients and caring for them, a reaction that often results in undermedication for pain and expensive and ineffective overtreatment.

American patients know this, and although death is a culture-wide enemy, many Americans fear the process of dying in an impersonal modern hospital …

The Supreme Court's Narrow View On Civil Rights, Jack M. Beermann

Faculty Scholarship

The right to choose abortion, although recently significantly curtailed from its original scope,' is a federally protected liberty interest of women, and is at least protected against the imposition of "undue burdens" by state and local government.² Some of the most serious threats to women's ability to choose abortion have come not from government regulation, but from private, national, organized efforts to prevent abortions. In addition to seeking change through the political system, some of these organizations, most notably Operation Rescue, have focused on the providers of abortion, and have attempted to prevent abortions by forcibly closing abortion clinics …

Detention Of Hiv-Positive Haitians At Guantanamo, George J. Annas

Faculty Scholarship

Speaking for the United States, Secretary of State Warren Christopher told the June 1993 World Conference on Human Rights in Vienna that human rights are universal and that “we cannot let cultural relativism become the last refuge of repression”. The universality of human rights was first recognized internationally in the 1948 United Nations Declaration of Human Rights. But the fact that these rights are recognized and even seen as universal does not ensure that they will be respected, even by their strongest supporters. The lack of an international tribunal with jurisdiction to hear complaints about human-rights violations and provide remedies …

Control Of Tuberculosis -- The Law And The Public's Health, George J. Annas

Faculty Scholarship

In their history of tuberculosis, The White Plague, Rene and Jean Dubos note that the first national movement to control tuberculosis in the United States came from the Medico-Legal Society of the City of New York, a group of lawyers, scientists, and physicians devoted to solving social problems. At a meeting in 1900 to organize an American Congress on Tuberculosis, the group drafted legislation designed to prevent the spread of the disease. Even though almost every state eventually passed tuberculosis-control laws, it was not the passage of legislation, or even the development of effective treatment, that led to the decline …

Problems With Employer-Provided Health Insurance — The Employee Retirement Income Security Act And Health Care Reform, Wendy K. Mariner

Faculty Scholarship

Health care reform is in the wind. As the nation prepares for a new presidential term, a more equitable and cost-effective health care system is beginning to sound inevitable.1 But the shape of that system remains a matter of debate. Employer-provided health insurance is the cornerstone of several national proposals for reform.2 3 4 5 6 The Bush administration's preference for tax credits rested on the assumption that most employers would continue to provide health insurance to their employees. President-elect Bill Clinton's proposal relies on insurance reform to enable small businesses to buy affordable private health insurance. Lawmakers …

The Supreme Court, Abortion, And The Jurisprudence Of Class, Wendy K. Mariner

Faculty Scholarship

The US Supreme Court's decision in Planned Parenthood of Southeastern Pennsylvania v Casey both protects a woman's liberty to choose to terminate her pregnancy and permits the state to make it more difficult for her to exercise her choice. In their opinion on the case, Justices O'Connor, Kennedy, and Souter eloquently defend constitutional protection of the right to make intimate decisions like continuing or ending a pregnancy. At the same time, they permit the state to try to persuade pregnant women not to have abortions and to make abortion harder to obtain and more costly, as long as the state's …