This essay argues that policies aimed at suppressing drug use exacerbate the nation's opioid problem. It neither endorses drug use nor advocates legalizing the consumption and sale of all substances in all circumstances. Instead, it contends that trying to suppress drug markets is the wrong goal, and in the midst of an addiction crisis it can be deadly. There is no single, correct drug policy; the right approach depends crucially on the substance at issue, the patterns of use and supply, and the jurisdiction's culture, institutions, and material resources. Decriminalization is no panacea for a nation's drug problems. Nevertheless, either de jure or de facto decriminalization of personal drug possession is a necessary condition for mitigating this crisis.

Recent years have brought increasing pressure from the public and the courts for truly informed patient consents to medical treatment and surgical procedures. Many courts have recognized that a patient's signature on a consent form is no assurance that the patient has received sufficient information, much less that he or she truly understood the information. A Pennsylvania court articulated this principle this way:

Here's what was sitting on my desk on my first day of work for Senator Jack Danforth last summer:

August 19

Liz-

Here is something you can start on when I am in Wyoming. Maybe you could begin pulling together some thoughts and material. Perhaps someone at YDS could give you some help. However, please don't attribute any conclusions to me as I have none.

What are the ethics of extending the length of life?

We cannot artificially end life (thou shalt not kill), but how about artificially extending life? Is that always good, sometimes good?

Is it good to extend the life of a senile 90 year old who wears diapers? How about “neonatal care”—for a baby who would otherwise die? What's the difference in these two cases, or should we have a difference?

In ethics, is keeping people alive the highest good? Should our priority be to keep people breathing?

Is it “playing God” to make distinctions on the basis of quality of life? Do we owe a lesser degree of care to the comatose patient than someone else?

There is no doubt that industry-sponsored biomedical research is under the microscope. Unfortunately, this new era of skepticism prematurely rushes in doubts of the ethos of science. Skepticism can lead to positive changes, but only when timely and supported by sound reasoning. Snapshot views and theories, especially those that result in costly new regulations and inefficient policies often do more harm than good. Many critics would have the reader doubt scientific integrity because they believe that the relationship between the pharmaceutical industry and biomedical research poses an unavoidable and dangerous conflict of interest. However, these conflicts are neither unavoidable nor dangerous per se.

Lainie Ross, in her article in this issue, criticizes on ethical grounds a number of factors in the University of Minnesota program that allows unrelated strangers to donate kidneys for transplant. I have to admit that when the transplant center at the University proposed allowing the practice of what came to be called nondirected donation, I was skeptical about a number of the same issues that trouble Dr. Ross. But as my colleagues and I examined and discussed the ethics of such a plan, along with the risks to prospective donors, their possible motivations, and the logistics of performing the surgeries under conditions of anonymity between donor and recipient, among other factors, we came to believe that such donations can be ethically acceptable. As a product of frequent meetings over the course of a year in advance of the first nondirected donation, we set out to craft a process that would first and foremost meet the test of an ethical approach to organ donation and transplant, the description of which was published in the New England Journal of Medicine in August 2000.

The Centers for Disease Control published its long awaited guidelines for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients on July 12, 1991. The guidelines recommend voluntary HIV and HBV testing of all health care workers performing exposure-prone invasive procedures. Special safeguards are applicable to any worker who is infected with HIV or the most virulent form of hepatitis B—i.e., hepatitis B e antigen positive (HBeAg). HIV or HBsAg-positive health care workers should not carry out exposure-prone invasive procedures unless an expert panel has approved and provided individualized guidance, and the patient is informed about the HCW's serological status.

Characteristics of exposureprone procedures include digital palpitation of a needle tip in a body cavity or the simultaneous presence of the worker's fingers and a sharp instrument in a poorly visualized or confined anatomic site.

Physicians nationwide, already worried by an increasing number of professional liability lawsuits and an expanding scope of liability, now face a new and potentially more troublesome development that had its genesis in what many thought was an extraordinary court decision. In Tarasoff v. Regents of the University of California, a psychiatrist was held, in a suit brought by the victim's parents, to be liable for negligence in the death of a woman who was murdered by a patient of that physician. The court held that even though the physician had complied with the traditional duty of protecting the patient's confidentiality, he nonetheless had a duty to warn the victim of the potential threat against her life. Tarasoff was eventually followed by a number of decisions that imposed liability on physicians under similar circumstances.

This article reviews and analyzes the original Tarasoff decision and subsequent judicial rulings on this subject. In addition, the authors briefly explore the historical backdrop of this decision and suggest practical steps that physicians can take to deal with the conflicting duties of protecting confidentiality and protecting potential victims from the danger posed by patients.

On June 25, 1990 the U.S. Supreme Court ruled for the first time in a right to refuse medical treatment case. The court's holding (by a majority of five of the nine justices) was essentially as follows: The right to liberty, which is explicitly mentioned in the Constitution, encompasses a person's decision to reject life-sustaining treatment; competent people are entitled to reject life-support and states are therefore prohibited from preventing people from making that choice. States may, however, regulate the exercise of the right, to ensure that the decision to stop treatment is indeed what the patient would have wanted. Asking for “clear and convincing evidence” of an incompetent patient's wishes (which means a demonstration that the person herself deliberately and thoughtfully made the decision in advance, or perhaps formally appointed someone else to make that decision for her) is a legitimate form of regulation by the state: It furthers the quest for what the person would have wanted and protects incompetent individuals from decisions made by others which might be influenced by the others’ interest instead of being based solely on what the individual would have wanted.

The ethics of involving persons with cognitive impairments and/or mental illness in research continues to gain academic and public attention. Concerns about the ability of such persons to provide ethically and legally valid consent and about the appropriateness of their research involvement in certain categories of studies have resulted in publication of guidelines, position papers, standards, and court decisions. These analyses address not only when and from whom informed consent may be obtained but also under what conditions it is ethically permissible to involve persons in research who are too decisionally impaired to provide their own consent.

It is an advance in research ethics that there is heightened appreciation of the need for greater protections for, and possibly research participation limitations on, persons unable to give their own consent. In our zeal to protect potentially vulnerable subjects, however, we must craft new protections carefully. Prudence is required in shaping and implementing any new protections.

The February 1997 announcement of the birth of Dolly, the sheep cloned from a mammary cell of an adult ewe, has drawn attention to the growing ability to select, alter, or otherwise manipulate the genome of offspring. Prior to Dolly, ethical discussion of genes in reproduction had focused on negative selection: carrier screening, prenatal diagnosis, and abortion or embryo discard. After Dolly, ethical debate will have to consider the direct or positive use of genetic selection or alteration technology.

The principal use of genetic selection techniques in human reproduction (reprogenetics) likely will be to treat or prevent disease in offspring. In the future, however, such techniques might also be used to enhance or even diminish expected characteristics of progeny. Techniques to accomplish these goals are likely to include: selection of the nuclear genome, as occurs in somatic cell cloning; chromosomal transplants; or direct insertion or deletion of specific genes.

Global Cumulative Treatment Analysis (GCTA) is a novel clinical research model combining expert knowledge, and treatment coordination based upon global information-gain, to treat every patient optimally while efficiently searching the vast space that is the realm of cancer research.

For more than twenty years, Opinion 6.01 of the American Medical Association's (AMA) Code of Medical Ethics has specified that “a physician's fee for medical services should be based on the value of the service provided by the physician to the patient.” In 1994, the AMA amended Opinion 6.01, adding a new statement that “a physician's fee should not be made contingent on the successful outcome of medical treatment.”

We believe that the amendment is wholly indefensible. Therefore, in this essay, we argue that the AMA should lift this prohibition and encourage the use of result-based compensation for medical services in appropriate circumstances.

The 1994 amendment dramatically changed the significance and scope of Opinion 6.01. Result-based compensation arrangements clearly satisfy the original version of Opinion 6.01 because they base compensation on the “value of the services provided … to the patient.” Yet, it is equally clear that result-based compensation arrangements violate the amended version of Opinion 6.01 because they necessarily make compensation “contingent on the successful outcome of medical treatment.”

The ethical debate on embryo research, particularly on whether to destroy human embryos for stem cell research, is sometimes said to involve a confrontation between religion and science. The claim is misleading at best. Ironically, religious claims have not infrequently been invoked by those who support human embryonic stem cell research, who have said that such research will enable us to “answer the prayers of America’s families” or present us with “the biblical power to cure.” And even religious organizations (as well as scientists and ethicists who share some of their concerns on this issue) have often made the case against the ethical acceptability of this research relying on science, and on general ethical considerations that transcend religious divisions. The Catholic Church, in particular, maintains that the ethical norm against directly taking the life of any innocent human being can be understood and embraced by people of good will, with or without religious faith, and that the application of this norm to the present controversy depends on an understanding of some basic facts about early human development.

The capacity to treat pain has never been greater; but, as you will read in the articles that follow, the problem of undertreated and neglected pain in the United States persists. Deep-seated perceptions and practices undergird this strong and well-documented pattern of neglect. Among the reasons frequently noted for the inadequacy of treatment for pain, however, is that the legal system actually penalizes effective interventions to relieve pain while it leaves neglect of pain unthreatened. It is the mission of the American Society of Law, Medicine & Ethics (ASLME) to explore areas, such as this one, where developments in medicine directly encounter the law and, in turn, create ethical issues for clinicians, regulators, patients, and lawyers.

This special issue of the Journal of Law, Medicine & Ethics is part of a multi-year project in which ASLME, with the wonderful support of the Mayday Fund, has worked to address legal and regulatory barriers to effective pain relief.

The firearms data infrastructure in the United States is severely limited in scope and fragmented in nature. Improved data systems are needed in order to address gun violence and promote productive conversation about gun policy. In the absence of federal leadership in firearms data systems improvement, motivated states may take proactive steps to stitch gaps in data systems. We propose that states evaluate the gaps in their systems, expand data collection, and improve data presentation and availability.

This article argues that the Supreme Court should not require a religious exemption from vaccine mandates. For children, who cannot yet make autonomous religious decision, religious exemptions would allow parents to make a choice that puts the child at risk and makes the shared environment of the school unsafe — risking other people’s children. For adults, there are still good reasons not to require a religious exemption, since vaccines mandates are adopted for public health reasons, not to target religion, are an area where free riding is a real risk, no religion actually prohibits vaccinating under a mandate, and policing religious exemptions is very difficult.

With more than 95% of school-aged youth enrolled in schools for 6 hours per day for up to 13 years, schools offer a broad reach to obesity prevention initiatives. Schools reach students of all races and ethnic backgrounds, income levels, and U.S. regions. Therefore, integrating health promotion activities into schools may equalize health disparities by providing access to a healthy environment for most of the nation’s youth, regardless of background. In addition, health behaviors, including physical activity (PA) and nutrition, are related to academic achievement.

The purpose of this article is to re-visit how rationing is defined for a health-care context, Two reasons justify returning to this topic. First, the variability as to how rationing has been defined in the legal, medical, and philosophical literature justifies a careful examination to identify its critical features. Second, I believe that if the definitions typically employed in the literature, several of which are discussed below, are compared to those that would be offered by the American public, ethically weighty dissimilarities would be apparent. Disparate characterizations are worrisome because serious “disconnections” between policymakers’ understandings, rhetoric, and priorities and those of the general public are more likely.