Damon or Pandora?

Americans have recently had thrust into their faces multiple media borne medical and social ethics dilemmas ranging from Dr. Kevorkian's euthanizing a patient on national television to payments by managed care providers for experimental medical treatments, to the nationally telecast situation which this paper will attempt to address. The case at hand concerns a minor in need of a repeat (third) kidney transplant who has been offered a kidney by her father. He also provided a kidney for her second kidney transplant some years ago. The teenage girl went into her current kidney failure/organ rejection state because, feeling well, she stopped taking her antirejection medications. Her father appears to understand the consequences of this offer and is willing nonetheless to donate his remaining kidney to his daughter. His ex-wife and daughter want the kidney and will take it knowing what it will do to him. Of additional interest is that he is incarcerated as a prisoner for a crime for which he will be eligible for parole in the not distant future. This means that although altruistically self-induced, the State will become financially responsible for his medical care and dialysis treatments. This paper will attempt to analyze the competing issues presented by this dilemma and address the underlying conflict between the parameters patient autonomy, parental beneficence and the deontologically based responsibilities of the state and of the health care team.

Legal and policy issues in long-term care.

Law and legislation are changing to reflect the growing needs of the long-term care constituency, Governmental protections include mandates for increased access for physically challenged people, changes in estate and trust laws, modification of Social Security benefits and categories of disability, increased research funding, and even changes in criteria to determine the point of death.

Any-willing provider laws: point and counter point.

Health care costs in the United States are placing businesses in a competitive disadvantage in the international market. Health Care is now the third highest cost category in US corporations after salaries and raw materials. Alternative Health Care delivery systems in the form of managed care have become popular mechanism to promote cost control. A critical element in most managed care programs is a limitation of freedom of choice of provider. As a result, physicians are being deliberately excluded from some managed care plans. Legislation called "Any Willing Provider Statutes" is being enacted in many areas to prohibit such actions. The authors outline the advantages and disadvantages of such legislation and discuss the economic implications for hospitals and the private practice of medicine. They also examine the impact "any willing provider" legislation will have on patient care and detail how this legislation involves who is going to control the practice of medicine in the years ahead. An examination of the American model should assist others involved with health care planning and regulating medical practice.

Managed competition.

People don't like change. That includes materiel managers, administrators, and clinical providers. Managed competition or managed care will work if, and only if, the American professions and the American public recognize the value of highly educated and qualified clinical and nonclinical providers and if the health care industry responds in kind.

Legal and economic challenges to personal autonomy: a view from the United States of America.

Steadily and surely, commonly accepted notions of individual rights and the place of the individual in society are subject to increasing scrutiny. This article critically analyses legal and economic parameters which directly affect both personal autonomy and the role of government, interpreted through its higher level state and federal judiciary, on the public.

International migration and medical credentialling.

The Single European Act of July 1987, coupled with various other regional and national laws, the purposes of which open borders to the free movement of peoples, goods and services, is soon to be put into operation. Although awaited with much eagerness and expectation, there is also a need for strategic planning in order adequately to address new and possibly ominous legal and medical practice problems. In the United States, a National Practitioner Data Bank, which went into full operation in September 1990 was created to monitor physicians, nurses and other health care providers involved in negligence actions which result in the payment of moneys by settlement or by verdict, and to prevent those whose licences have been suspended, revoked or restricted in any fashion in one state from practising in another based upon reciprocity licensure or board certification criteria. In order to protect patients from abuse by uncredentialled individuals or dangerous clinicians, and further to protect institutions from liability incurred by inadequate credentials checks or through ostensible liability, the creation of a practitioner data bank utilizing modern data gathering, storage and retrieval methods is proposed for the European Community. It should be created under the auspices of the United Nations--possibly through the World Health Organization which already accredits medical education and training programmes--and should be charged with creating uniform standards of professional practice; certifying professionals; and serving as a credentials' clearing house for the health care industry.

A Rehnquistean bed: the abortion issue revisited.

Individuals as members of societies are subject to externally imposed norms of behavior (laws). When societal control and regulation adversely impact upon individual autonomy, conflict is frequently the end product. Such issues surround the rights of privacy vis-a-vis the abortion issue. The Supreme Court addressed this issue in the 1988-1989 term. This article critically examines the court's decision and raises questions of individual and professional import.

PIP: Certain types of laws grant the state powers or rights over a person if that person is considered incapable of autonomy. In the past this has included mentally and physically disabled people as well as abandoned children. In Roe v. Wade the state granted itself the right to care for that unborn fetuses that were viable. Women were allowed to have abortions before viability or "quickening", usually the after the 1st trimester. Roe set up a balance between a woman's right to privacy and the state's interest in potential life and uses viability as the fulcrum. However the trimester approach using a test of viability is a self destructive argument. As medical technology progresses, viability moves closer to conception and increasingly restricts a woman's right to abort. The Webster decision has significantly narrowed the scope of Roe by allowing the Missouri law to stand that lets the state legislate viability instead of using the trimester approach of Roe. The fall-out from Webster is that the states no longer have any judicial guidelines for determining viability. This new situation leaves many fundamental question unanswered is the state obligated to fund the development of the fetus after viability? After birth? Will it ultimately become illegal to decide not to gestate if viability occurs at conception? Will the state mandate a mother's responsibility to the fetus after a complete extra-uterine gestation? Should the father pay to raise the child? If the state's rights continue to grow as Webster allows, the where does a woman's right to privacy begin and the states interest in potential life end?