In his foreword to a forthcoming issue of the American Journal of Law & Medicine dedicated to Harry A. Blackmun, Supreme Court Justice William J. Brennan calls it “superbly right that the American Society of Law & Medicine honors Mr. Justice Harry A. Blackmun with this edition of its Journal.” Last October the Society presented its first Presidents' Award for Outstanding Contributions to Law and Medicine to Justice Blackmun. Justice Blackman attended our Annual General Meeting and a banquet at Boston University School of Law, where he was presented with the award. We found Justice Blackmun to be a gentle, modest man despite the unique illumination and perception that he has contributed to health law in America. “That makes it only the more fitting,” as Justice Brennan says, “that the American Society of Law & Medicine should award this richly deserved honor, in Learned Hand's words, to ‘Acclaim one who—all unaware of his deserts—has so richly earned our gratitude.’”

for Robert W. Switzer

Well after Brown v. the Board of Education, Jackson, Mississippi, maintained racially segregated public swimming pools, claiming that only through segregation could violence and social chaos be avoided there. The federal courts saw through this stratagem, noting that it was a variant of the heckler's veto thinly masking racial animus. But did Jackson integrate its pools? No. The city council voted instead to close them all. This time out, the courts were not so wise.

In 1971, the Supreme Court upheld the constitutionality of the pool closings. The Court was snookered by the surface similarity of the policy's treatment of blacks and whites—neither could, after all, use the swimming pools. The practice appeared to treat similar cases similarly. And indeed the pool-closing statute did not refer in any way to blacks.

Debates about how much it costs to treat persons with AIDS and how the burden of these costs is and ought to be distributed raise fundamental questions about social policy in the United States. The most important questions concern entitlement: Who has what obligations to provide what services to whom, under what conditions and at whose expense?

As a result of our political history, we were unprepared for the challenge of AIDS to social policy in the 1980s. We had, over a half-century, linked entitlement to medical care to age, disability, employment, and, for people with end-stage renal disease, to diagnosis. Our policies proved inadequate to pay for medical care for persons who died at considerably younger ages than normal, who were disabled for a brief period that was still long enough to end their employability, and whose condition progressed with unusual rapidity from diagnosis to death. By early 1988, it was clear that we would, as a society, assume the substantial costs of caring for persons with AIDS. Who would pay, and how equitably we would provide care, remained in debate.

At the end of 1987, the insurance industry could breathe a sigh of relief. By a combination of good luck, astute planning, and nerve, life and health insurers had managed to impose HIV-testing requirements on insurance applicants while making few concessions to the gay community or insurance regulators. To a greater degree than almost anyone had thought possible, the insurers had deflected most of the expected health costs from the AIDS epidemic onto the nation’s taxpayers, and had taken steps to deny life or health insurance to anyone they considered to be at risk of AIDS.

The use of blood tests to determine if an individual is infected with the human immunodeficiency virus (HIV) that causes AIDS has been a matter of considerable controversy. Yet to date only a handful of states have restricted the use of HIV testing by companies offering life or health insurance.

Most of us, I think, supposed that the debate over euthanasia (doing something to end a life that could otherwise continue) had been pretty well settled. For a long time a minority favored it and a majority opposed it—at least in principle, although not always in practice. Recent court decisions, however, have thrown the whole question open again, while public opinion polls reflect a marked increase in tolerance, if not positive approval. What follows is a lay discussion of the issue—not legally or medically professional but still, it is hoped, acceptable intellectually.

My own role in the ethical defense of euthanasia goes back a long way. I began to expound it in the early 1930s. The British organized a euthanasia society in 1935. The Euthanasia Society of America came three years later. It started out with a petition by 1,776 physicians addressed to the New York State Assembly, which promptly rejected it.

Most of us, I think, supposed that the debate over euthanasia (doing something to end a life that could otherwise continue) had been pretty well settled. For a long time a minority favored it and a majority opposed it—at least in principle, although not always in practice. Recent court decisions, however, have thrown the whole question open again, while public opinion polls reflect a marked increase in tolerance, if not positive approval. What follows is a lay discussion of the issue—not legally or medically professional but still, it is hoped, acceptable intellectually.

My own role in the ethical defense of euthanasia goes back a long way. I began to expound it in the early 1930s. The British organized a euthanasia society in 1935. The Euthanasia Society of America came three years later. It started out with a petition by 1,776 physicians addressed to the New York State Assembly, which promptly rejected it.

Doctors or hospitals facing the issue of withholding or withdrawing treatment from patients voice a number of concerns, some factually based and some less so. One important concern is the possibility that such behavior will lead to an indictment for murder. How realistic is this fear? This article will review the U.S. cases involving withholding or withdrawing treatment, as they pertain to the issue of criminal liability.

The criminal law, in general, has not been used as a tool to regulate medical practice. While criminal actions against medical professionals are not unknown, few such actions arise dircctly from the practice of medicine. A physician charged with Medicaid fraud, sexually molesting patients, or prescribing drugs for non-therapeutic purposes has not been charged with a crime that involves scrutinizing the standard of care he or she uses in practicing medicine. For example, by definition, there is no medical standard for the non-therapeutic use of prescription drugs.

George Annas’ review finds most of what is in the Hastings Center’s Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying “solid.” He takes no issue with the major substantive points. The fundamental premise of the book—that patients’ interests must be protected and their decision-making authority defended—is a view Professor Annas has long championed as well.

Despite this basic agreement, Annas’ criticisms would be significant ones if the Guidelines were what he presents them to be. But they clearly are not. As the Guidelines themselves state: These are ethics guidelines; they are not legal guidelines. They are an attempt to offer practical and reasonably concise suggestions for how to make decisions; they are no substitute for the literature on the pros and cons of different approaches to the termination of treatment. They are meant to provoke a necessary process of debate within a health care institution; they are not the final moral truth.