Emphasis on cost containment by third-party payors has intensified economic competition within the health care system, creating powerful market forces which retail pharmacists had not envisioned a few years ago. Hospitals and alternative delivery systems now sell prescription drugs in direct competition with retail pharmacists. These entities are able to purchase their pharmaceuticals from manufacturers at prices far below those of the retailers. Retail pharmacist plaintiffs allege that such activities violate the Robinson-Patman Act which prohibits price discrimination. Retail pharmacists have achieved landmark victories in decisions establishing that nonprofit, state and local governmental hospitals reselling pharmaceuticals in competition with retail pharmacies are not exempt from the Act. This Article demonstrates that despite these victories, plaintiffs will have difficulty proving an actual violation of the Act by manufacturers and hospitals. Plaintiffs must establish competitive injury as well as refute the meeting competition defense. Retail pharmacists might discover that the Robinson-Patman Act is not the ally they had hoped for; instead, they should concentrate on innovative alternatives which will allow them to compete in an evolving health care system.

Infanticide, like most other species of homicide, is probably coeval with the human race itself. In modern Western civilization, what were formerly the most powerful incentives to infanticide have virtually disappeared. As with other social problems that affluence has seemed to solve, however, infanticide has reappeared in a new form that seems to have been made possible by affluence itself. This "new infanticide" occurs in a place whose very existence is the result of a tremendously wealthy society's devotion to its most vulnerable and least “useful” members. The modern neonatal intensive care unit, which treats, and often saves, extremely ill newborn children, who during most of history would surely have died, has proven to be a setting where many of the age-old incentives for infanticide have begun to operate again. The “new infanticide” consists of withholding food or needed medical treatment from selected infants who suffer from one or more serious, though treatable, medical problems. The national government has now enacted legislation designed to curtail the practice of infanticide by the medical profession. This paper traces the genesis of that legislation, explores the problem to which it is addressed, and evaluates its prospects for success.

This Article reviews recent case and statutory law concerning patients who refuse medical treatment. Among the special cases considered are: 1) the competent adult patient who refuses treatment on religious or privacy grounds; 2) the incompetent patient whose own wishes were never expressed, but whose family refuses treatment; 3) the incompetent patient who expressed the wish not to be treated before becoming incompetent; and 4) parents who refuse treatment on behalf of their child.

It is pointed out that recent court decisions have blurred the distinctions between “extradordinary” care and “ordinary” care and between withholding and withdrawing life-sustaining treatment. Reference is made to the recent trend toward allowing the family of an incompetent patient to assert the patient’s rights without court intervention either in the form of direct court order or through guardianship proceedings.

Finally, the implications of these legal developments for health care institutions are discussed. A protocol pertaining to incompetent patients is proposed. Health care institutions are encouraged to develop formal policies for dealing with patients who refuse treatment, and to work with their professional associations in lobbying for legislation which will clarify the law in this area.

Transfer trauma is alleged to be an increase in morbidity and mortality in institutionally relocated chronically ill elderly. Efforts by the legal profession to persuade courts that transfer trauma should be a legally recognized phenomenon invoking judicial protections against transfer (the “transfer trauma argument”) have been unproductive. In O'Bannon v. Town Court Nursing Center, Inc., the United States Supreme Court denied standing to elderly persons claiming a property interest in remaining in alleged substandard facilities. The Court rejected the argument that the possibility of transfer trauma constituted a deprivation of life or liberty that would have required due process protections of notice and hearing. Despite the Court's preclusion of transfer trauma litigation in a constitutional context and the general unwillingness of lower courts to recognize the phenomenon, attorneys continue to burden the judicial system with frivolous transfer trauma arguments. The unfruitful pursuit of a judicial remedy for the ethical and social problems that arise with relocation of the elderly continues, in part, because of a misguided belief that this distressing social phenomenon is best remedied by the courts. Judicial unwillingness to recognize the transfer trauma argument, however, does not preclude legislative consideration of the humanitarian issues concerning the institutional relocation of elderly persons. This Article examines gerontological research in order to understand the judicial rejection of the transfer trauma argument and argues in support of legislative and educational solutions for the ethical and social problems attending transfer.

Nursing home discharges of employees based on patient abuse raise a difficult issue when the motivating factor for the disciplinary action is union activism. A tension is created between the rights of employees to engage in protected concerted activity and the rights of patients to quality care. In 1974, Congress passed the Health Care Institutions Amendments, which granted to non-profit health care workers collective organizing and bargaining rights substantially similar to those which workers in other industries had enjoyed for decades under the National Labor Relations Act. Congress intended to give health care workers only that degree of parity, however, which is compatible with the provision of high quality patient care. The agency charged with enforcing the Act, the National Labor Relations Board (NLRB), has failed to distinguish employee misconduct in industrial settings from patient abuse in health care institutions when fashioning remedies for discriminatorily discharged union activists. The NLRB typically has ordered the reinstatement, with back pay, of the patient abuser as the patient’s primary care-giver. This Article suggests that a front pay remedy is more appropriate to these cases because it protects the patient’s right to be free from abuse without sacrificing employee unionization rights.

Medical malpractice claims are filed nearly ten times more frequently in America than they are in Great Britain. British patients generally adopt a less adversarial stance toward medical malpractice than do American patients. This Article examines the British malpractice system, as compared with the American system, and explores the differences between the two, in terms of costs and fees, liability rules, statutory provisions, and judicial attitudes toward malpractice litigation. The Article also discusses British social and institutional factors, such as the “taint” of litigation and the National Health Service, and evaluates how these factors affect British malpractice litigation. The Article presents the alternative forums available to British patients in seeking satisfaction for their medical service complaints. The Article concludes with an evaluation of how these factors achieve the three societal objectives of malpractice litigation: reparation, emotional vindication and deterrence.

Until recently, physicians have been the primary health care providers in the United States. In response to the rising health care costs and public demand of the past decade, allied health care providers have challenged this orthodox structure of health care delivery. Among these allied health care providers are nurse practitioners, who have attempted to expand traditional roles of the registered nurse.

This article focuses on the legal issues raised by several major obstacles to the expansion of nurse practitioner services: licensing restrictions, third party reimbursement policies, and denial of access to medical facilities and physician back-up services. The successful judicial challenges to discriminatory practices against other allied health care providers will be explored as a solution to the nurse practitioners’ dilemma.

Selective non-treatment decisions involving severely handicapped neonates have recently come under renewed judicial and legislative scrutiny. In this Article, the Author examines the legal, ethical and social considerations attendant to the non-treatment decision. In Part II of this Article the Author discusses the predominant ethical viewpoints relating to this issue and proposes a new moral standard based on personal interests. Part III presents a survey of the jurisprudence relating to selective non-treatment decisions. Parts IV and V of this Article provide a critical examination of the recently enacted Child Abuse Amendments of 1984, a federal legislative initiative designed to regulate treatment decisions relating to handicapped infants. The Author suggests that the ethical standards and treatment criteria proposed in this Article may prove useful to courts seeking to balance the handicapped neonate's constitutional right to privacy with the requirements of the new federal law.

The preferred provider organization (PPO) is a recent innovation in the health care industry, designed to reduce costs through selective contracting and utilization controls. This Note examines malpractice liability theories potentially applicable to PPOs. The Note compares PPOs to other health care institutions, including hospitals and HMOs, and concludes that PPOs are at minimal risk of incurring liability for physician negligence.

In 1984, the New Jersey Supreme Court became the first high court to impose liability successfully upon social hosts for the torts of their intoxicated adult guests. The wisdom or folly of that decision, and its social ramifications, have become subjects of widespread discussion. This Case Comment argues that social host liability, in its present form, is an unwise extension of common law principles. Through an examination of the elements of the cause of action proposed, the standards of proof employed, and the public policies weighed by the court, this Comment concludes that social host liability is ill-adapted to furthering the court’s stated goal of reducing drunken driving.

In Kartell v. Blue Shield of Massachusetts, Inc., the First Circuit held that Blue Shield's reimbursement practice known as the “ban on balance billing” did not constitute an unlawful restraint of trade in violation of the antitrust laws. Underlying the First Circuit's decision was deference to what it viewed as efforts by Blue Shield and by the Commonwealth to promote cost containment.

This Comment argues that, to the contrary, under an appropriate analysis of antitrust law, the practices employed by Blue Shield did constitute unreasonable restraints of trade on the physicians' service industry in Massachusetts, given Blue Shield's market dominance in the Commonwealth. The Comment also argues that such inhibition of the competitive functioning of this industry is unwise, and that costs should instead be contained by effectuating the antitrust laws and encouraging the development of competitive forces within this industry.

With the onset of the energy crisis in the 1970’s, thousands of homeowners insulated their homes with Urea Formaldehyde Foam Insulation (UFFI). The discovery that UFFI releases formaldehyde, a carcinogen and irritant, prompted various state and federal responses to this problem. This Note reviews those responses and concludes that a ban on the sale of UFFI, coupled with a removal and repurchase program, is the most effective solution from the standpoint of consumer health.

Capital punishment by lethal injection, which was expected to be the most safe and effective of available methods, can produce unusually cruel and inhuman death. In Heckler v. Chaney, inmates sentenced to death by lethal injection, as well as members of both the medical and legal communities, challenged the Food and Drug Administration’s (FDA) refusal to regulate certain drugs used for capital punishment by lethal injection. By declining to review the FDA’s nonenforcement decision, the Supreme Court also declined an opportunity to reevaluate its standard for determining cruel and unusual punishment, which upholds any method of execution that is no more unusually cruel than existing methods. This Comment examines the propriety of judicial and administrative regulation of capital punishment by lethal injection.

A hospital, while performing its major function of providing health care, is also viewed as a business. It needs capital from a wide variety of sources, many of which are government regulated. Over the past few years, federal expenditures for Medicare have increased dramatically, as has regulation of hospital revenue sources. Congress enacted the Medicare Prospective Payment System (PPS) to curb hospital cost inflation.

This Note examines historical trends in health care financing and analyzes the Medicare reimbursement system, with emphasis on PPS and its impact on hospital revenues. The Note suggests that hospitals, due to the effects of PPS, will be forced to reduce their levels of financial leverage and will have to look for corporate financial alternatives. PPS may signal a new era in hospital finance. Survival mandates an increased focus on efficient corporate, financial and managerial policies.

The freestanding emergency center, which combines the functions of a doctor's office and a hospital emergency room, has emerged as a new provider of health care. These centers have generated considerable controversy over their role in the health care market. Proponents argue that freestanding emergency centers reduce costs by providing care in a more efficient manner and cause other health care providers such as hospital emergency rooms to reduce costs and improve service. Opponents argue that the centers create an additional layer of health care which duplicates existing services and increases total health care costs. This Note examines the controversial issues of licensure, regulation and reimbursement. The Note concludes that freestanding emergency centers can help to reduce health care costs and discusses the steps that should be taken to aid centers in achieving this goal.

“Fetal vulnerability programs,” which are employer attempts to protect employees' unborn fetuses from harm caused by the mothers' exposure to hazardous material in the workplace, have been challenged as a form of employment discrimination. This Note analyzes the recent judicial application of the Pregnancy Discrimination Act (PDA) and the disparate impact theory to fetal vulnerability cases. The Note also examines the business necessity defense's accommodation of legitimate employer interests. The Note concludes that a more potent business necessity defense, a stricter standard for evaluating alternative protective measures, and a judicial interpretation of the PDA which is more consistent with congressional intent are necessary for fair and reasonable resolution of these cases.