We are living through one of the greatest scientific revolutions in history: the “information revolution” in genetics. The revolution is leading to a deep understanding of biological processes and is uncovering the molecular basis of many human diseases and susceptibilities. It is also confronting society with a vast array of choices, and presenting each individual with the question of what knowledge to seek and how to act on that knowledge, My purpose is to discuss the scientific foundations of this revolution and to foreshadow its consequences.

The current scientific revolution has perhaps one appropriate historical precedent: the chemical revolution that followed Dmitri Mendeleev's key insight in 1869 that the elements could be organized in a simple periodic table.

Nowhere in this nation is the return of tuberculosis more visible or more pronounced than in New York City. Fueled by poverty, homelessness and AIDS, tuberculosis has again reached epidemic proportions. New York City is at the forefront of the battle against this advancing disease. For this reason, and because the dynamics at work in New York City are a microcosm of those same forces at work in the larger society, what transpires here often foreshadows the direction that other urban centers will take. It is in this context that our New York experience provides a valuable framework for learning and for action.

According to Giles Scofield, ethicists can provide expert testimony in descriptive ethics and metaethics, but not normative ethics. Lawrence Schneiderman appears to disagree with this view, and presumably believes that it is appropriate for an expert witness in ethics to provide ethics testimony in all three areas. I draw this conclusion from several claims made in his commentary which aim to show that we would be contending experts if both invited to testify on a case involving claims about futile medical treatment. This disagreement aside, taken together both commentaries suggest that my testimony in the case of Andrew Sawatzky is wanting.

In the response that follows I do not engage in a debate about the content of my testimony.

At one point in Edgar Allan Poe’s Narrative of Arthur Gordon Pym of Nantucket, Pym, who has stowed away in the hold of a whaling vessel, believes he has been abandoned and that the hold will be his tomb. He expressed sensations of “extreme horror and dismay,” and “the most gloomy imagining, in which the dreadful deaths of thirst, famine, suffocation, and premature interment, crowded in as the prominent disasters to be encountered.”

It is probably uncommon for hospitalized patients to feel as gloomy as Pym. Nevertheless, installed in a strange institution, separated from friends and family, forced to wear a degrading costume, confined to bed, and attended to by a variety of strangers who may or may not keep the patient informed of what they are doing, the average patient is intimidated and disoriented. Such an environment encourages dependence and discourages the assertion of individual rights.

As the physician-director of Boston’s Beth Israel Hospital has warned: “today’s hospital stands increasingly to become a jungle, whose pathways to the uninitiated are poorly marked and fraught with danger. . . .”

As Lee Dunn points out in his accompanying article, the Saikewicz case has been widely misunderstood and misinterpreted by health care providers both in Massachusetts and elsewhere. Two Massachusetts Appeals Court cases, Dinnerstein and Lone v. Canduru, have clarified some of the more controversial aspects of Suikewicz and should allay some of the fears which that case produced. The more important of the two decisions — Dinnerstein — involved the legality of “do not resuscitate” orders (DNR's) in the absence of a court order.

Mrs. Dinnerstein was diagnosed as suffering from Alzheimer's disease in July of 1975, although she probably had been afflicted with the disease since 1972. Alzheimer's disease is a progressive, unremitting disease of the brain which leads to disorientation, memory loss, loss of intellectual function, and, eventually, loss of all motor function. The usual course of the disease is five to seven years during which time the patient generally becomes a complete invalid and has to be institutionalized.

The governance structures of state public health systems vary as much as the states themselves, including the existence and role of state boards of health. Understanding these differences is essential to a complete understanding of the governmental public health enterprise. State boards of health are obvious vehicles for public health policy development in some states, where they work closely with or oversee state health agencies. In other states they do not exist or serve only in a non-binding advisory capacity.

In this article, we distinguish and identify state boards of health and state public health advisory boards, examine state boards of health in practice, and discuss their role in advocacy and policy development in the context of state politics. We used a set of mixed qualitative methods, including a literature review, online research of state statutes establishing state board of health authorities, and key informant interviews. Informants were five current and former state board of health members, four current and former state health officers, and nine state health agency senior policy staff, spanning 13 states.

The 1974 health care amendments to the National Labor Relations Act (NLRA or the Act) have given rise to several significant developments in the case law. This article focuses on the subjects of appropriate bargaining units, the inclusion — or exclusion — of house staff under the NLRA, and, briefly, the special strike notice requirements under section 8(g) of the Act. These areas have been the subject of substantial controversy and conflict among the federal courts.

In 1947, the Taft-Hartley Act excluded from the term “employer” as defined in the NLRA, “any corporation or association operating a hospital, if no part of the net earnings inures to the benefit of any private shareholder or individual.” In 1974, Congress removed the exclusion for voluntary, nonprofit hospitals and added the new term “health care institution.” In so doing, it found “no acceptable reason why 1,427,012 employees of … non-profit, nonpublic hospitals … should continue to be excluded from the coverage and protections of the Act.

Researchers trying to resolve the questions surrounding the AIDS epidemic may feel like Hercules trying to slay the Hydra: for every head that is cut off, two new ones grow in its place. Doctors have never treated their patients in a social vacuum, but the expectations and anxieties engendered by AIDS are bringing fundamental changes in clinical p-actice. Drugs are being raced from the laboratory bench to the bedside, health care providers are being forced to recognize new types of family constellations, and the general public is being shocked into awareness of the importance of prudent infection control policies. Clinical practitioners have had to deal with the ethical consequences of routine and arcane decisions as never before, knowing that yesterday's experiment or hospital rounds can become tomorrow's lead feature in the news media.

Diagnostic sonography, also known as ultrasound, has become an invaluable aid in the practice of obstetrics and gynecology. Rapid improvements in instrumentation have caused the sonologist and sonography to assume a primary role in the care of these patients. Patient and physician expectations have increased with the technological advances. This paper will outline the advances and capabilities of diagnostic sonography in obstetrics and gynecology, while reflecting upon the foreseeable legal implications.

The physics of ultrasound is rather complex. Briefly, ultrasound utilizes high-frequency, non-ionizing, mechanical waves, 2.25 to 10 megahertz, that require a molecular medium for propagation. The reflected energy is processed to produce an image. Because it employs non-ionizing waves, ultrasound is considered safe by most authorities when used at the intensities currently employed for diagnosis. No clinically significant adverse effects have been reported in humans to date.

In Stovall v. Confimed.com, the Kansas Supreme Court held that an out-of-state medical doctor who sold a prescription drug to a Kansas minor over the Internet did not commit an unconscionable act under the Kansas Consumer Protection Act (KCPA). The Shawnee Country District Court had enjoined the doctor from prescribing or dispensing prescription medicine within the state of Kansas, and the doctor appealed the injunction to the Kansas Supreme Court. The Supreme Court affirmed the district court's decision to grant injunctive relief, but found no unconscionable conduct under the KCPA.

The appellee, Washington physician Dr. Howard J. Levine, sold the sexual enhancement drug Viagra over the Internet through his online pharmacy. Neither the physician nor the online pharmacy was licensed to practice in Kansas. The purchasers were two Kansas residents, one of whom was a minor. Both purchased the drugs in a sting operation conducted by the Kansas Attorney General and received the drugs after completing an online application.

On January 22, 2002, California Governor Gray Davis released the state's long-anticipated, proposed regulations establishing hospital nurse-to-patient ratio requirements. The Safe Staffing Law (A.B. 394) mandating minimum ratios was enacted in October 1999 in response to legislators concerns that [q]uality of patient care is jeopardized because of staffing changes implemented in response to managed care. While the law was scheduled to take effect by January 1, 2002, conflict within the medical community regarding appropriate ratios slowed down the rulemaking process. Lawmakers now anticipate that the rule will be implemented by January 2003. Approximately 5,000 new nurses will need to be hired for California's hospitals to come into compliance with the proposed regulation.

In long Midwestern winters, two things are certain: snow and basketball. But two things that you cannot count on are snow day school closures and a home-team collegiate basketball championship. In Kansas last winter, we had both. Winter precipitation was much above average, resulting in a rare invocation of the University's inclement weather policy to cancel classes in early February. And the Kansas Jayhawks basketball team brought home the National Collegiate Athletic Association championship trophy for the first time in two decades. The Chancellor commemorated the achievement with a campuswide celebration, including all-day class cancellation. This is all well and good. I am all for respecting Mother Nature's forces and celebrating remarkable athletic accomplishments.

But the combination of events does leave law professors nearing the end of the semester in a bit of a quandary. How to make up the cancelled classes to ensure compliance with American Bar Association accreditation instructional hours requirements? How to cover the missed course content? How to find mutually agreeable make-up class times and locations with a group of busy, upper-level law students?

Obesity is the definitive epidemic of the modern era in the United States. Its well-documented public health impacts, especially related to children and adolescents, are horrific. Nearly one-third of American minors are overweight; over 50% of them are obese. Already, these kids suffer from multiple adverse physical and mental health conditions. Sadly, absent serious communal and individual interventions, their lives may be cut short compared to their own parents’ life expectancy. While recent surveillance suggests childhood obesity may be trending down slightly in some populations, public health experts remain concerned about the threat obesity poses to the health of America's youth.

The concurrent travesty underlying childhood obesity is the relative societal failure to slow and reverse its spread.

The relationship between law and a population’s health is complex and poorly understood. To the extent that scholarship exists on the subject, it has usually focused on epidemics that are concentrated in relatively vulnerable, marginalized communities. Often, individual behaviors are assumed to play a major role in the epidemiology of these diseases. Perhaps, as a result, these illnesses become stigmatized and the object of coercive laws, which in turn become the subject of litigation, legal debate, and ultimately scholarly analysis. Thus, to the extent that U.S. legal scholars have thought about public health in the last 30 years (and they seldom have), they have generally done so in the context of tuberculosis (TB), intravenous drug abuse, and a handful of similar conditions. Likewise, Jonathan Mann’s own appreciation of the importance of human rights to public health emerged in the wake of his work with HIV, which is perhaps the prototypical stigmatized disease.

In The Abuse of Casuistry Jonsen and Toulmin describe one view of moral reasoning as follows:

Whether or not all moral reasoning resembles “strands to a rope,” bioethics testimony certainly does. Bioethics testimony is eclectic, a composite of many loosely woven strands. Rarely, if ever, is bioethics testimony “a chain of unbreakable deductions.” Rarely is it “pure” ethics, much less pure normative ethics.

Physicians have long served as expert witnesses in litigation, and their medical knowledge can contribute to the appropriate resolution of a case. However, ethical issues may arise when physicians appear on behalf of the tobacco industry. Two ways that doctors participate in lawsuits are through depositions (statements given under oath before trial to attorneys, who often use them to prepare the case or develop a strategy) and by testifying in court during trial. The Tobacco Deposition and Trial Testimony Archive (DATTA) is an electronic database of depositions, trial testimony, opening and closing statements, and other material from tobacco lawsuits collected by the Center for Tobacco Use Prevention and Research. At the time the research for this article was conducted, the database included depositions and trial testimony of expert witnesses from 232 smoking and health cases.

What I propose in this article is application of existing dispute resolution practices that take place outside the courtroom to the negotiating that takes place between health providers and families when they try to reach agreement about the limits of medical care that arguably is futile. Specifically, I focus on a bargaining paradigm that is associated with divorce proceedings, and suggest how this paradigm is at work in the conflict about futile treatment. At issue are not the well-publicized aspects of high profile cases, but the rather unpublicized bargaining that goes no further than the clinical setting.

Physicians and families who disagree about the futility of medical treatments frequently engage in give-and-take exchanges about whether to start disputed treatments, about what period of time might comprise a reasonable trial period if a treatment is to be administered, and about when and how to transfer a patient to another facility if the dispute cannot be resolved.