Health Law and Policy Commons^™

The Epidemics Of Injecting Drug Use And Blood-Borne Disease: A Public Health Perspective, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

In this article, the author first examines the mechanism by which blood-borne disease is transmitted through sharing of injection equipment. Thereafter, he presents a public health strategy for reducing multi-person use of contaminated injection equipment. This strategy includes: repealing or modifying current laws and regulations making possession and distribution of sterile injection equipment a criminal offense; implementing syringe exchange programs to expand access to new syringes for users of injection drugs; and counseling, education, and treatment targeted to injecting drug users (IDUs), including those in the prison and health care system. The objective of a public health approach is not …

Dedicatory Essay: Honoring Ian Mccoll Kennedy, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Ian Kennedy is perhaps the best known and most important figure in health law and ethics in the United Kingdom, and probably one of the most significant in Europe and North America. How did his life and career evolve to the point where he would wield such influence? This essay examines the leadership, erudition, and passion Ian Kennedy has brought to the field of health law and ethics. It is perhaps not an overstatement to suggest that Professor Kennedy virtually invented the field in the United Kingdom. He did so through his scholarship, public advocacy, and influence in shaping institutions, …

Beyond Autonomy: Coercion And Morality In Clinical Relationships, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

This article considers the problem of line-drawing between autonomy-preserving and autonomy-negating influence in clinical relationships. The author’s purpose is not to propose particular boundaries, either with respect to reproductive decisions by HIV-infected women or for other clinical choices. Rather, he attempts to shed some light on what drives our disputes about whether one or another influence method is compatible with autonomous choice.

The author argues that such disagreements reflect underlying conflicts between normative commitments, and that resolving these conflicts is essential to settling controversies over whether particular influences unduly interfere with autonomous choice. Alternative understandings of the prerequisites for autonomous …

Health Policy Below The Waterline: Medical Care And The Charitable Exemption, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

For almost one hundred years, America's nonprofit hospitals have enjoyed nearly automatic exemption from federal income taxation. During this time, nonprofit hospitals transformed themselves from resting places of last resort for the sick poor into centers of high-technology intervention for all income groups. The financing of their services evolved in parallel, from primary dependence on the generosity of religious orders and charitable donors, to almost exclusive reliance on payments for services rendered. Meanwhile, the exemption's doctrinal underpinnings were repeatedly reinvented to accommodate change in the hospital industry's financial structure and social role. When Congress first enacted a charitable exemption to …

Tuberculosis And The Power Of The State: Toward The Development Of Rational Standards For The Review Of Compulsory Public Health Powers, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

This article uses tuberculosis as the paradigm for exploring rational standards for the exercise of compulsory public health powers. Extant doctrine in disability and constitutional law provides a lens for examining judicial review of state interventions. The author first sets out the central epidemiological and biological aspects of tuberculosis to demonstrate the strength of the governmental interest in curtailing the epidemic. Second, he examines the interventions of testing, screening, and confinement of persons with tuberculosis, where he focuses on two congregate settings--correctional and health care facilities--that present substantial health risks and are principal foci for the exercise of state intervention. …

Genetic Privacy, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Human genomic information is invested with enormous power in a scientifically motivated society. Genomic information has the capacity to produce a great deal of good for society. It can help identify and understand the etiology and pathophysiology of disease. In so doing, medicine and science can expand the ability to prevent and ameliorate human malady through genetic testing, treatment, and reproductive counseling.

Genomic information can just as powerfully serve less beneficent ends. Information can be used to discover deeply personal attributes of an individual's life. That information can be used to invade a person's private sphere, to alter a person's …

Health Information Privacy, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Thoughtful scholarship in the area of informational privacy sometimes assumes that a significant level of privacy can coexist with the development of a modern health information infrastructure. Some commentators suggest that we can have it both ways: that adequate legal protection of informational privacy will eliminate the need to significantly limit the collection of health data. This article demonstrates that there is no such easy resolution of the conflict between the need for information and the need for privacy. Because significant levels of privacy cannot realistically be achieved within the health information infrastructure currently envisaged by policymakers, we confront a …

The Resurgent Tuberculosis Epidemic In The Era Of Aids: Reflections On Public Health, Law, And Society, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

The resurgence of tuberculosis and the rise in drug-resistant cases is neither inexplicable nor unexpected, but rather is the predictable outcome of a complex configuration of biological, social, and behavioral factors that have converged in America over the past decade. This article examines the biological, social, and behavioral causes of the epidemic, and suggests a comprehensive public health strategy for curtailing tuberculosis and other infectious diseases. When thoughtfully conceived, public health strategies can be implemented that are consistent with the limitations that both constitutional law and disability law place on the authority of the state. While traditional concepts of public …

Securing Health Or Just Health Care? The Effect Of The Health Care System On The Health Of America, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

The author first analyzes why the prevention of illness and promotion of health provide the leading justification for the government to act for the welfare of the population. His analysis focuses principally on the foundational importance of health for human happiness, the exercise of rights and privileges, and the formation of family and social relationships. He explains why health care, although critically important; is not the only, nor even the most important, determinant of health. Most morbidity and mortality in the United States is attributable to environmental conditions, pathogens, and human behavior, which are all more responsive to population-based interventions …

The Americans With Disabilities Act And The Corpus Of Anti-Discrimination Law: A Force For Change In The Future Of Public Health Regulation, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

In this paper the author reviews the constitutional history of the courts' attempts to check the powers of the public health department. He demonstrates how ineffective and inconsistent constitutional review has been, and suggests that adequate review criteria have not emerged. The author shows that, whether the courts are applying First, Fourth, or Fourteenth Amendment standards, ultimately they are highly deferential to public health officials. Then he carefully examines the key concepts in the Americans with Disabilities Act (ADA) as they apply to communicable disease. He reveals Congress' clear intention to include communicable disease, even asymptomatic infection, as a disability. …

Drawing A Line Between Killing And Letting Die: The Law, And Law Reform, On Medically Assisted Dying, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Traditional medical ethics and law draw a sharp distinction between allowing a patient to die and helping her die. Withholding or withdrawing life sustaining treatment, such as by abating technological nutrition, hydration or respiration, will cause death as surely as a lethal injection. The former, however, is a constitutional right for a competent or once-competent patient, while the latter poses a risk of serious criminal or civil liability for the physician, even if the patient requests it.

Health Care Reform In The United States, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

The author presents a brief description of the design features and objectives of the health care reform package, together with the reasons to support reform of the health care system in the United States.

Foreword: Health Care Reform In The United States—The Presidential Task Force, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

This essay serves as the foreword to Implementing U.S. Health Care Reform, a symposium held in 1993.

The exact specifications of the new health care system depend on the package that President Clinton will send to Capitol Hill and the changes that Congress will make in the reform package. Some of the basic structures and organizing principles of the new system that are being considered by the President are already the subject of intense public scrutiny.

The design being considered would involve new relations between the federal government and the states, between the public and private sectors, and between …

The "Gag Rule" Revisited: Physicians As Abortion Gatekeepers, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

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 seems …

Corporate Takeover Of Teaching Hospitals, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

This article explores the potential and the dangers of this novel form of collaboration between academic medicine and the for-profit world. The author focuses on those arrangements--purchases and leasing agreements--by which investor-owned corporations operate, for a profit, hospitals that serve as major medical teaching and research sites. He begins by reviewing how the evolving needs of academic medical centers and for-profit hospital chains have generated mutual interest in such arrangements. The author then considers some frequently expressed ethical, economic, and other public policy objections to the provision of hospital services by for-profit firms. Opponents of the acquisition and leasing of …

The Hiv Positive Health Care Clinician: Rights, Obligations, And The Academy, Sherman L. Cohn

Georgetown Law Faculty Publications and Other Works

The questions raised by a case of an HIV positive student-clinician in an acupuncture school provide an analytical framework for considering the many conflicts raised by HIV positive health care providers in general. A number of conflicting social values are discussed in the context of federal and Maryland state law. HIV positive people are protected by certain antidiscrimination laws, provided they do not pose a significant risk of transmission. This protection must be balanced against the rights of patients to informed consent, the relative risk of a relatively noninvasive procedure such as acupuncture, and the academic freedom of the school …

An Alternative Public Health Vision For A National Drug Strategy: "Treatment Works", Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

This article returns to a war waged virtually throughout this century--a war between the theories of punishment and rehabilitation in curtailing the drug epidemic. Today, the terms of the war are recast as supply-side policies based upon law enforcement; destroying crops in source countries; interdiction and increased sentencing; and demand reduction based upon prevention, education, and treatment. The war on drugs has reached a feverish pitch. New policies and statutes have tightened the grip of supply-side policies, with images of battle and hate mongering which go beyond the vilified drug lords and governments which harbor them, to the middle men, …

Genetic Discrimination: The Use Of Genetically Based Diagnostic And Prognostic Tests By Employers And Insurers, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

This paper analyzes the law, ethics and public policy concerning "genetic discrimination," defined as the denial of rights, privileges or opportunities on the basis of information obtained from genetically based diagnostic and prognostic tests. The Human Genome Initiative will enhance the ability to gather and organize information that may predict a person's future potential and disabilities. Enormous human benefits may ensue from understanding the etiology and pathophysiology of genetic disorders, including disease prevention through genetic counseling, and treatment of the disorders through genetic manipulation. This information will help clinicians understand and eventually treat many of the more than 4,000 diseases …

Advance Directives Under State Law And Judicial Decisions (Medical Decision-Making And The ‛Right To Die’ After Cruzan), Judith C. Areen

Georgetown Law Faculty Publications and Other Works

In the decision of the United States Supreme Court in Cruzan v. Director, Missouri Department of Health on June 25, 1990, a majority of the Court announced that it will leave to the states the question of what legal requirements may be imposed on decisions to discontinue treatment for incompetent patients.

Almost every state now recognizes some form of written advance directive, be it living wills or appointments of proxy decision-makers. The problem with directives is thus increasingly not legal as much as it is practical: very few people prepare advance directives.

The Interconnected Epidemics Of Drug Dependency And Aids, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Drug dependence and human immunodeficiency virus (HIV) are America's two most pressing epidemics, interconnected by a cycle of urban poverty, physical dependence and a culture of sharing needles and syringes. Extant political strategies to curb these interconnected epidemics involve two traditional approaches. The first--law enforcement and interdiction--is designed to limit the supply of illicit drugs to the marketplace. This strategy is advanced by broad criminal sanctions against importing, selling, distributing, medically prescribing, or possessing illicit drugs or drug paraphernalia. The second strategy to combat the drug and HIV epidemics involves reducing the demand for illicit drugs. Education, counseling, and treatment …

Ethical Principles For The Conduct Of Human Subject Research: Population-Based Research And Ethics, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

This paper provides a halting first step in organizing a set of ethical guidelines for the conduct of population-based research, surveillance and practice. These principles are not distinct from, but an expansion of, traditional ethics. Research ethics, which matured significantly from the Nuremberg Code through to the Helsinki IV and the Council for International Organizations of Medical Sciences (CIOMS) guidelines, nourished the individual human spirit. Ethical principles should have a similarly profound impact in the development of science and the protection of human populations in the 1990s and beyond.

A Decade Of A Maturing Epidemic: An Assessment And Directions For Future Public Policy, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

The author's goal in this article, is not merely to propose public health strategies for the future, but also to examine why government has been so slow, so equivocal, in its public health response to the acquired immune deficiency syndrome (AIDS) epidemic. He argues that there has been a fundamental ambivalence in perceptions of the epidemic. For some, AIDS is perceived as a disease, with sympathy for sufferers. Once AIDS is viewed as a disease, like other catastrophic diseases, it follows that public policy will be based upon science and epidemiology--health education, research and treatment.

For others, AIDS is caused …

The Politics Of Aids: Compulsory State Powers, Public Health, And Civil Liberties, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

This article argues that compulsory public powers are justified only if they meet the following criteria: there is a significant risk of transmission of the acquired immune deficiency syndrome (AIDS) virus; the public health response is efficacious in preventing a primary mode of transmission of the virus; the economic, practical, or human rights burdens are not disproportionate to the public health benefits; and the public health power is the least restrictive alternative that would prevent viral transmission.

The author carefully examines the levels of risk posed by behavior which can potentially transmit human immunodeficiency virus (HIV), and demonstrates that compulsory …

Bioethics And Law: The Second Stage – Balancing Intelligent Consent And Individual Autonomy, Judith C. Areen

Georgetown Law Faculty Publications and Other Works

The principle that government rests on the consent of the governed eventually spread beyond the political arena to alter such private behavior as the relationship between physician and patient. This Article examines the successive transformations of the principle of consent as it has developed in the field of law and bioethics from bare consent to informed consent, and then, more strikingly, to beyond informed consent. This most recent form of the principle may prove to be every bit as revolutionary as the idea of popular sovereignty in 17th century England.

Hospitals, Health Care Professionals, And Aids: The "Right To Know" The Health Status Of Professionals And Patients, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

This article addresses why patients and health care professionals (HCPs) with human immunodeficiency virus (HIV) should have autonomy and privacy rights to choose whether to consent to an HIV test and to disclose their serologic status. It also demonstrates that the risk of HIV transmission in health care settings is exceedingly low, that it is probably lower than other well-accepted risks taken by patients and professionals, and that there are other less intrusive ways to further reduce the risk. The article concludes that knowledge of a patient's serologic status is unlikely to reduce risk, since no effective action could be …

A Need For Caring, Judith C. Areen

Georgetown Law Faculty Publications and Other Works

Review of AIDS AND THE LAW: A GUIDE FOR THE PUBLIC. Edited by Harlon L. Dalton, Scott Burris, and the Yale AIDS Law Project. New Haven: Yale University Press. 1987. Pp. vii, 382.

Review Of Reproductive Genetics And The Law, Judith C. Areen

Georgetown Law Faculty Publications and Other Works

No abstract provided.

A Scarcity Of Organs, Judith C. Areen

Georgetown Law Faculty Publications and Other Works

The scarcity of organs will be eliminated only if significantly more people agree to donate their own organs and those of close family members. For this, a more fundamental rethinking of the present system of organ retrieval may be required. Such a revision would begin by placing the debate between supporters of a system based on voluntary giving and those who favor either a market system or one based on expropriation (presumed consent) in the larger context of debate about the kind of society we favor.

The Future Of Public Health Law, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Developments in medicine and constitutional law dictate modification of public health legislation in the United States. Traditionally overlooked by legislators, present public health laws provide inadequate decision-making criteria and inappropriate procedures for dealing with issues. Revised legislation should provide health care officials and agencies with the tools to balance individual rights against public health necessities. This article makes four recommendations for legislative reform: (1) remove artificial legislative distinction between venereal and other communicable diseases; (2) provide criteria defining "public health necessity" to limit discretionary exercise of police power by health officials; (3) provide strong confidentiality protections in the collection and …

Foreword: Public Health & The Law—A Symposium Dedicated To Professor William J. Curran, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

This essay serves as the foreword to Public Health & the Law, a symposium dedicated to Professor William J. Curran held in 1987.

During his career, Professor Curran chaired the Harvard School of Public Health Committee on Human Research; he directed the Program in Law and Public Health; and he was co-director of the Harvard Interfaculty Program in Medical Ethics from 1973 to 1980. He was also an advisor to the World Health Organization and spent two sabbatical periods in Europe with WHO organizations. He advised and lectured in countries throughout the world.

At Harvard Law School and at …