Recent reforms in state nursing home regulations have created an-array of enforcement tools that relate the severity of the penalty to the severity of the violation. These intermediate sanctions, intended to be flexible and effective in enforcing state standards, include civil fines, receiverships, public disclosure, monitors. and suspension of admissions. As supplements to the more traditional remedy of license revocation, intermediate sanctions can enforce standards without closing facilities unnecessarily, thus avoiding trauma to the residents, aggravation of the shortage of nursing home beds, and lengthy administrative proceedings and litigation.

The study of nursing home regulation by the Institute of Medicine of the National Academy of Sciences offers a unique opportunity to evaluate the implementation of intermediate sanctions by the states over the past decade. Because of the high degree of similarity among the state statutes authorizing these sanctions, comparisons can be drawn.

Despite the current debate be tween proponents of regulation and of competition over the best way to control the inflation of medical care costs, both camps agree that health care for the uninsured poor is primarily a government obligation and cannot be left to market forces. Health care for the “medically indigent,” people unable to afford needed care due to poverty or inadequate insurance, has always been the responsibility of state or local governments. But it has often been rendered through the charity care of hospitals and other health care providers. As the willingness of private hospitals to render such care declines, policy-makers are beginning to study the uninsured and to develop new ways to finance and deliver health care to them. This interest is both timely, as the number of uninsured is increasing, and confounding, as health care costs and the pressure to reduce the federal deficit limit government's ability to expand public programs.

Ethicists, lawyers, economists, and clinicians have been invited to comment on the Report of the Massachusetts ‘Task Force on Organ Transplantation In this issue of Law, Medicine & Health Care. One can assume that the issues of access, equity, social justice, efficiency, and choice will be addressed. Accordingly, I shall return to the perspective of my earlier career as a federal bureaucrat to offer an overall appraisal and to comment on the political dimensions of resource allocation in dramatic, life-threatening diseases.

Nearly two decades ago, I served as the Director of Program Planning and Evaluation for the Surgeon General, at the time that cost-benefit analysis was introduced into the Great Society. The treatment of chronic kidney disease circa 1966 was then a problem akin to those of heart, heart-lung, and liver transplantation in 1984 or, perhaps, the next decade's problem of the artificial heart.

Less than two decades ago it was thought sufficient to say, “When a practitioner is in doubt on an ethical question, the best answer is usually No.” A more recent commentator has suggested, however, that “[s]uch platitudes have become increasingly inadequate to guide the attorney facing conflicts of interests in the private practice of law.“ Because of the general vagueness of the American Bar Association's Model Code of Professional Responsibility, and of state codes based on it, courts have begun to fashion a vast “common law” of conflicts of interest. A particularly controversial entry to this body of common law is the opinion of Justice Paul Liacos, sitting as single justice in the Massachusetts case of White v. Kaplan. This article examines the opinion and its theoretical suppon.

Less than two decades ago it was thought sufficient to say, “When a practitioner is in doubt on an ethical question, the best answer is usually No.” A more recent commentator has suggested, however, that “[s]uch platitudes have become increasingly inadequate to guide the attorney facing conflicts of interests in the private practice of law.“ Because of the general vagueness of the American Bar Association's Model Code of Professional Responsibility, and of state codes based on it, courts have begun to fashion a vast “common law” of conflicts of interest. A particularly controversial entry to this body of common law is the opinion of Justice Paul Liacos, sitting as single justice in the Massachusetts case of White v. Kaplan. This article examines the opinion and its theoretical suppon.

The medical and social fascination with organ transplantation, beginning with Dr. Barnard's pioneering work with heart transplantation in the 1960s, has most recently resulted in the highly publicized and experimental baboon heart transplantation and artificial heart replacements. Transplants of proven efficacy, such as of corneas, kidneys. bone marrow, heart-lungs, hearts and livers, are a reality of modern medicine and embrace the most fundamental ideals of medicine by alleviating suffering and saving lives. Nevertheless, many question the increasing allocation of such a large proportion of our scarce medical and financial resources for such a relatively small population of recipients. The debate over how much of our limited health care resources we are willing to commit to transplantation has encouraged development of the federal Task Force on Organ Procurement and Transplantation and of statewide committees, such as the Massachusetts Task Force on Organ Transplantation.

The Report of the Massachusetts Task Force on Organ Transplantation can be described as an incunabulum. This strange word, properly referring to a book produced in the first decades of printing with movable type, literally means “in the cradle.” The Task Force document appears in the infancy of a discussion that is certain to grow: the public policy debate over the allocation of scarce resources. The debate was born several years ago, but until now has either been argued in general terms or by way of administrative devices. The Task Force addresses a quite particular issue: how to or whether to make available to the citizens of the Commonwealth and their neighbors the medical technology of organ transplantation. It approaches the problem with a vivid awareness of the expense of this technology as well as the constraints on health care resources and financing.

The Report of the Massachusetts Task Force on Organ Transplantation can be described as an incunabulum. This strange word, properly referring to a book produced in the first decades of printing with movable type, literally means “in the cradle.” The Task Force document appears in the infancy of a discussion that is certain to grow: the public policy debate over the allocation of scarce resources. The debate was born several years ago, but until now has either been argued in general terms or by way of administrative devices. The Task Force addresses a quite particular issue: how to or whether to make available to the citizens of the Commonwealth and their neighbors the medical technology of organ transplantation. It approaches the problem with a vivid awareness of the expense of this technology as well as the constraints on health care resources and financing.