Health Law and Policy Commons^™

Trust And Betrayal In The Medical Marketplace, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

The author argues in this Comment that disingenuity as first resort is an unwise approach to the conflict between our ex ante and our later, illness-endangered selves. Not only does rationing by tacit deceit raise a host of moral problems, it will not work, over the long haul, because markets reward deceit's unmasking. The honesty about clinical limit-setting that some bioethicists urge may not be fully within our reach. But more candor is possible than we now achieve, and the more conscious we are about decisions to impose limits, the more inclined we will be to accept them without experiencing …

A Vision Of Health And Human Rights For The 21st Century: A Continuing Discussion With Stephen P. Marks, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Professor Marks offers an eloquent vision of health and human rights in the 21st Century. As the Director of the Francois-Xavier Bagnoud Center for Health and Human Rights, Professor Marks ably carries the torch that Jonathan Mann lit in the field until his tragic death on September 2, 1998. Professor Marks stands along with the leading figures in health and human rights - e.g., Audrey Chapman, Sofia Gruskin, Michael Kirby, Daniel Tarantola, Brigit Toebes, Katarina Tomasevski, and Virginia Leary.

Surrogacy From The Perspectives Of Economic And Civil Liberties, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

The field of law and economics, of which Judge Posner is the leading theorist, has offered a rich and sophisticated framework for thinking about a wide variety of problems at the interface of law and society. The theory, based on economic principles for understanding behavioral incentives and disincentives, is widely taught in law schools and is influential in scholarship. I have not always agreed with the application of the theory to complex problems of individual and group behavior, yet I constantly have been impressed with the elegance of the writing and analysis.

Judge Posner thinks about surrogacy arrangements in terms …

Public Health, Ethics, And Human Rights: A Tribute To The Late Jonathan Mann, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

The late Jonathan Mann famously theorized that public health, ethics, and human rights are complementary fields motivated by the paramount value of human well-being. He felt that people could not be healthy if governments did not respect their rights and dignity as well as engage in health policies guided by sound ethical values. Nor could people have their rights and dignity if they were not healthy. Mann and his colleagues argued that public health and human rights are integrally connected: Human rights violations adversely affect the community's health, coercive public health policies violate human rights, and advancement of human rights …

Caretakers And Collaborators, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

A chilling subplot in the twentieth-century saga of state-sponsored mass murder, torture, and other atrocities was the widespread incidence of medical complicity. Nazi doctors’ human “experiments” and assistance in genocidal killing are the most oft-cited exemplar, but wartime Japanese physicians’ human vivisection and other grotesque practices rivaled the Nazi medical horrors. Measured by these standards, Soviet psychiatrists’ role in repressing dissent, Latin American and Turkish military doctors’ complicity in torture, and even the South African medical profession’s systematic involvement in apartheid may seem, to some, almost prosaic. Yet these and other reported cases of medical complicity in human rights abuse …

Handling Cases Of Willful Exposure Through Hiv Partner Counseling And Referral Services, Lawrence O. Gostin, James G. Hodge Jr.

Georgetown Law Faculty Publications and Other Works

Cases of willful exposure reveal the existing and future risks to the public health (especially women) which may be presented by individuals who willfully expose others to HIV through unsafe sexual or needle-sharing behaviors. In response to a documented case of willful exposure, a PCRS counselor or other public health official may, in his or her professional judgment, decide to act to avert a legitimate public health threat to known or unknown persons in the community. Yet handling such cases raises difficult issues in law, ethics, and public health practice. Public health authorities may be unable or ill-equipped to successfully …

Race And Discretion In American Medicine, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

The author’s focus in this article is on racial disparities in medical care provision--that is, on differences in the services that clinically similar patients receive when they present to the health care system. Racial disparities in health status, which is not greatly influenced (on a population-wide basis) by medical care, are beyond his scope here. Disparities in medical care access-potential patients' ability, financial and otherwise, to gain entry to the health care system in the first place, are also outside his focus. The author begins this article by putting the problem of racial disparities in medical care provision within the …

Discrimination Based On Hiv/Aids And Other Conditions: "Disability" As Defined Under Federal And State Law, Lawrence O. Gostin, David W. Webber

Georgetown Law Faculty Publications and Other Works

In this Article, we examine the disability definition "problem" from the standpoint of HIV infection, specifically HIV infection in its "asymptomatic" phase . . . We begin by summarizing the need for federal nondiscrimination standards offering protection for individuals with HIV. We then provide a brief discussion of the definition of disability under the resulting legislation, the Americans with Disabilities Act of 1990 (ADA). We summarize the early judicial and administrative views of the ADA as protecting individuals with HIV. We next turn to judicial interpretation of the ADA in cases in which that understanding has been disputed, including, most …

Dc Consortium Of Legal Service Providers: Legal Services 2000 Symposium, Peter B. Edelman

Georgetown Law Faculty Publications and Other Works

My main point is to urge you to the see what is possible in the way of what I might call a public health approach to lawyering for the poor. In a public health approach you find something that has polluted the river and you clean it up at its source instead of just treating its victims one by one. In legal and societal terms, when we are discussing why so many children are growing up poor and dying a slow death of disappointment, the challenge is to think about it in a public health way. Of course we cannot …

The Public Health Improvement Process In Alaska: Toward A Model Public Health Law, Lawrence O. Gostin, James G. Hodge Jr.

Georgetown Law Faculty Publications and Other Works

In this Article, we present the findings of our study on the improvement of public health law in Alaska. We examine and analyze the public health laws supporting the state's public health system. The fact that Alaska has attained statehood comparatively recently, and has a governing structure involving state, municipal, rural, and tribal entities presents unique opportunities for the State to improve its public health system and its supporting legal infrastructure

Liberalism And Abortion, Robin West

Georgetown Law Faculty Publications and Other Works

First in a groundbreaking book, Breaking the Abortion Deadlock: From Choice to Consent, published in 1996, then in various public fora, from academic conference panels to Christian radio call-in shows, and now in a major law review article entitled My Body, My Consent: Securing the Constitutional Right to Abortion Funding, Eileen McDonagh has sought to redefine drastically our understanding of the still deeply contested right to an abortion, and hence, of the nature of the constitutional protections which in her view this embattled right deserves. Her argument is complicated and subtle, but its basic thrust can be readily …

A Tribute To Jonathan Mann: Health And Human Rights In The Aids Pandemic, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

A tribute to Jonathan Mann, former head of the World Health Organization's global AIDS program and a key figure in the early fight against HIV/AIDS. The author discusses Mann's work in health and human rights, prevention of disease, and eliminating social injustice.

Rights And Efficiency In American Health Law, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

During the 1960s and 1970s, the individual rights revolution that swept through American society remade much of the nation's health law in its image. Sick people acquired the right to be told of the risks and benefits of proposed treatments and then to give thumbs-up or thumbs-down to their doctors' decisions. Successful suits for medical negligence went from rare to commonplace. Elderly and poor Americans achieved statutory rights of access to publicly funded healthcare, and courts burnished these rights with myriad procedural protections. The critically ill and their families won the right to refuse aggressive, life-sustaining treatments. Psychiatric patients acquired …

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, …

The Constitutional Right To Die: Ethical Considerations, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

In this commentary, the author first looks at some ethical reasoning supporting physician-assisted dying. Second, he examines some of the lines that have been drawn between withdrawing and withholding life-sustaining treatment on the one hand, and physician-assisted dying on the other. Finally, he relates both of these matters to constitutional reasoning, beginning with Cruzan and ending with the cases before the Supreme Court at the time of the article's publication.

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 …

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 …

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 …

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. …

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.

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 …

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.

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 …

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.