The transformation of health-care delivery from fee-for-service medicine to managed care represents a fundamental philosophical shift away from the prevailing medical ethos that the needs of the individual patient take precedence over competing social values, such as reducing health-care costs. In managed care, financial incentives to reduce health-care utilization may result in denying an individual’s claim for medical services.

Litigation challenging managed care’s resource allocation decisions often presents the need to resolve conflicting social policy goals, such as the tension between an individual patient’s access to health care and a managed care organization’s (MCO’s) need to restrain costs. Conflicts may arise when a patient’s desire for unconstrained health care clashes with a provider’s and an insurer’s cost containment strategies. In turn, cost containment strategies may raise questions about restrictions on physician autonomy and conflicts among stakeholders for control over resource allocation decisions.

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.

This article provides an overview of current knowledge about the relationship between mental illness, violence, homicides, and suicides, with a view towards crafting sensible public policy options for reducing gun violence towards self or others. With this knowledge as a backdrop, the limitations of the federal National Instant Background Check System (NICS) as both over-inclusive and under-inclusive in identifying people with mental illness who pose potential risks are discussed. Finally, the article describes emerging approaches for identifying and removing firearms from persons who pose potential risks of gun violence towards self or others, including Extreme Risk Protection Orders (“Red Flag Laws“) and other options.

The Second Amendment to the U.S. Constitution states: “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” Until recently, no federal appellate court had ever struck down any gun law as a violation of the Second Amendment. In fact, even laws outlawing most handgun possession, or restricting other types of firearms, had been upheld, in part, because the laws did not interfere with the functioning of state militias.

Then, in 2008, the U.S. Supreme Court — for the first time in nearly 70 years — decided a case squarely addressing the meaning of the Second Amendment. In District of Columbia v. Heller, the Supreme Court concluded that the Second Amendment protected an individual right to own handguns in the home, invalidating a Washington, D.C. law.

But Heller left many issues undecided, including the precise scope of the Second Amendment.

Extensive media coverage of the nation’s response to its obligation to furnish health care for service members wounded in current overseas conflicts in Iraq and Afghanistan has elevated public consciousness of the importance of the U.S. military and veteran’s health care systems to a level not seen since the end of the Vietnam War. The number of casualties of U.S. military engagements has varied in each specific conflict and is a direct result of both the type of battle and the military’s ability to handle battlefield injuries (see Table 1).

For at least the past three decades, injuries have been recognized as an important public health problem in the United States. In 2001, there were approximately 157,000 deaths due to injuries in the US. There were also almost 30 million non-fatal injury incidents.

Injuries have been defined as: “…any unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen”. Within public health, the field of injury prevention and control is dedicated to reducing the burden of injuries on the lives of people around the world.

Injury prevention seeks to reduce injuries by: 1) identifying risk factors, 2) designing interventions to address the risk factors, 3) implementing those interventions, 4) evaluating their effectiveness, and 5) replicating those that work. As with many other public health problems, interventions can target factors associated with the human or host, vehicle or vector, and the physical or social environment.

Recent years have seen an increase in the turn to rights discourse within the context of access to health and specifically health care. Developments took place at both the national and global levels, with a significant increase in right to health litigation around the world1 and developments at the international level, such as the appointment of a Special Rapporteur on the Right to Health and the adoption of a “General Comment” on the topic by the UN Committee on Economic, Social and Cultural Rights.

Recently, due to a number of converging factors, there have been significant shifts in public policy regarding the legitimacy of treating chronic pain with opioids. Traditional tenets handed down in medical, dental, nursing, and pharmacy education created a distinct reluctance on the part of practitioners to prescribe opioids on a continual basis. Much has been written about the reasons for these attitudes. One of the barriers that is very consistently reported by prescribers is the fear of regulatory and legal repercussions to ongoing prescription of this class of medications. It is in this arena that sentinel changes have occurred, the most recent of which is the promulgation of a document prepared by the Federation of State Medical Boards (FSMB), which suggests a set of guidelines meant to be endorsed or adopted by individual medical licensing boards on how to approach this particular aspect of practice. These guidelines, representing a broad consensus from a wide constituency, were developed in a relatively open forum and detail a balanced approach to the prescription of opioids for chronic pain.

Many writers suggest that managed care had a brief life and that we are now in a post-managed care era. Yet managed care has had a long history and continues to thrive. Writers also often assume that managed care is a fixed entity, or focus on its tools, rather than the context in which it operates and the functions it performs. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system.

This article argues that private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures; and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care internationally.

Many observers claim that business has become a powerful force in medicine and that the future of health care cannot escape that reality, even though some scholars lament it. The U.S. recently experienced the most devastating recession since the Great Depression. As health care costs rise, we face additional pressure to rein in health care spending. We also have important new legislation that could well mark a significant shift in how health care is provided and who has access to care, namely the Affordable Care Act (ACA). These changes underscore the need to bring new thinking to the conversation about health care and to move beyond conceptual and practical obstacles that inhibit our progress.

In this paper we do not to claim to have solutions. Rather, our aim is to try to identify some obstacles to fostering a better conversation about the future of health care and to envisioning a better health care system.

The NIH has initiated a plan to mandate use of central IRBs for all multi-site research. This manuscript argues against the mandate, proposing that there is inadequate evidence to support the purported gains in efficiency and that the ethical integrity of research may suffer with any exclusion of the local review voice.

Millions of Americans are dependent on what is often called the “safety net.” These loosely-organized networks of health and social service providers serve the many Americans who are uninsured, dependent on public coverage, or for a variety of reasons unable to access other private systems of care. The Institute of Medicine (IOM) report, America’s Health Care Safety Net: Intact but Endangered, called attention to both the fragility and the resilience of this health care safety net. The IOM report underscored the critical importance of the safety net to the health and well-being of millions of individuals and called for efforts to strengthen it and improve the nation’s ability to monitor its viability. Given this central role, any health care reform efforts need to be fully informed by an understanding of what the safety net includes, how it is financed, and how it is responding to a series of challenges it now faces.

On April 16, 2007, Cho Seung-Hui used two semiautomatic handguns to kill 32 persons and then himself at Virginia Tech University in the largest campus shooting in U.S. history. Mr. Cho purchased his handguns from a pawnshop and a gun store in Virginia, where under state law a background check was conducted to determine whether he had any disqualifying criminal or mental health history. The paperwork for the background check was completed at the gun store, and the check itself was conducted through an “instant” system facilitated by a toll-free telephone number. The entire transaction took approximately 20 minutes. At no point was Mr. Cho asked why he wished to purchase the guns. And although he had been deemed a potential danger to himself by a state magistrate in 2005 – which should have disqualified his purchase of a gun under federal law – this information never reached those conducting the background check.

Recent developments in the health care industry have precipitated a new wave of interest in expanding the scope of practice for nursing. This is because the Patient Protection and Affordable Care Act (ACA), broadly designed to increase access to health insurance, will inevitably result in increased demand for primary care providers. And with compensation for primary care physicians already lagging far behind that of specialists, the role of nurse practitioners is once again receiving increased attention as a viable means by which to ease the pressure for access to health care.

But the economics of this trade-off are controversial. On one hand, it sets primary care physicians at odds with specialists; namely, if the ultimate goal is to “bend the cost curve downward,” should specialist compensation be reduced in order to increase spending on primary care?

In this era of globalization, as the health problems of poor countries and rich countries become increasingly intertwined, medical research is being conducted at the international level. For example, a research study may be sponsored by a developed country and conducted in a resource-poor country to address health problems faced by both nations. The globalization of medical research is, in effect, quickly outpacing the development of internationally accepted ethical guidelines for the conduct of research. For many medical researchers working in resource-poor countries, ethical decision-making is like sailing in the days before modern navigation; one is never quite sure where one is, or in what direction one is headed. Our aim in this article is to fix a few navigational points on an ethical compass to guide biomedical researchers from developed countries working in resource-poor countries.

Just as one of the principles underlying the Hippocratic Oath is “First, do no harm,” a principle underlying medical research ethics may be “First, do not exploit.”

Ideas of racial genetic determinism, though unsupported by scientific evidence and atavistic, are common and readily apparent in American medical education. These theories of biologic essentialism have documented negative effects in learners, including increased measures of racial prejudice.

Medical care in the United States traditionally has focused on the treatment of disease rather than on its prevention. Heart disease, cancer, hypertension, diabetes, and other chronic diseases are the primary drivers of American health care costs; compared to other high-income countries, U.S. health indices are lowest and costs are highest.

A “triple aim” — “improving the individual experience of care, improving the health of populations, and reducing the per capita costs of care for populations” — has gained traction, as the social determinants of health (non-genetic, non-clinical factors including health behaviors, social and economic factors, and the physical environment) are recognized as having significant effects on health outcomes.

Deception, cheating, and loopholes within the IRB approval process have received significant attention in the past several years. Surveys of clinical researchers indicate common deception ranging from omitting information to outright lying, and controversy surrounding the FDA's decision not to ban “IRB shopping” (the practice of submitting protocols to multiple IRBs until one is found that will approve the protocol) has raised legitimate concerns about the integrity of the IRB process. One author has described a multicenter trial as being withdrawn from consideration at one institution when rejection was imminent, in order to avoid informing other IRBs reviewing the protocol of the study's rejection (a requirement under the federal regulations for emergency research with an exception from informed consent). This practice and IRB shopping seem at odds with the spirit, if not the “letter,” of the regulations. While at first blush these practices seem to cast aspersions on the integrity of clinical researchers, the moral issues raised go deeper than the ethics of cheating.