The use of a mechanical device is an ancient and crude form of contraception. Desert dwellers in ancient Africa placed stones in the uteruses of their camels to prevent conception during long treks across the Sahara. The metal intrauterine devices (IUDs) used in the late 1800s caused severe pelvic infections that, in the absence of antibiotics, often proved fatal. The first stainless steel and polyethelene IUDs were developed around 1960, and these attained a relatively reliable degree of safety. New compositions and materials decreased the risk of infection, and innovative devices could be inserted without dilating the cervix.

As mechanical means of contraception grew in popularity, pharmaceutical companies began to fight for a competitive edge, each touting the design or materials of its product as safer and niore efficient. By the mid-l970s, it is estimated, more than 15 million IUDs had been distributed throughout the world, many in developing nations.

The man on the Clapham omnibus, as common lawyers know, was a late nineteenth and early twentieth century image of the ordinary reasonable man who played an important part in fixing common law standards. As a lawyer with a continuing but general interest in medicine, biotechnology, ethics, and the law, I offer the following comments on the conference's topic of “Health Resource Allocation” from what may approximate the standpoint of an ordinary reasonable man.

How much “health” can a society afford? I do not think that it is possible to maintain that there is a right to health, expressed as an unqualified right to treatment—though I understand that the argument has been raised in the United States that there is a constitutional basis for a claim of entitlement to treatment for civilly committed mental health patients. So far as English law is concerned, the answer to this question is clear. In 1980 the English Court of Appeal dealt with a case in which four people in Staffordshire argued that the health services were insufficient in their area.

In Mount Isa Mines Limited v. Pusey, Windeyer, justice of the High Court of Australia, wrote of “[l]aw, marching with medicine but in the rear and limping a little.“ This remark, characterizing the stumbling approach of the law in providing damages for nervous shock occasioned by negligence, may be too kind when applied to the response of family law to the remarkable advances of knowledge and technology affecting human sexuality and conception.

Nowadays, there is a growing sense of urgency and impatience about the response of the law to medical developments. One writer trained both in law and medicine observed from his informed standpoint:

Since AIDS was first identified in 1981, its rate of spread among a primarily young and vibrant population has chilled the medical and lay communities. Today, the public response is sober and oriented toward the examination of specific policies that could lessen the impact of the disease. After six years' experience it is now feasible to propose a strategy for combatting AIDS. Consensus around the following policies should form the nucleus of the public health strategy to combat AIDS before the intervention of an effective vaccine or treatment.

Unprotected sexual intercourse and use of contaminated needles are intentional activities. Voluntary changes in behavior to avoid a high risk of transmission is currently the overriding public policy objective. The first line of defense in controlling AIDS, therefore, is to inform and educate individuals about high-risk behavior and about methods of altering behavior to protect against transmission of the infection.

Advances in medical technology have a habit of raising new, and usually unexpected, ethical and legal questions. Such questions arise when patients or physicians, for a variety of reasons, defer cardiopulmonary resuscitation (CPR) or other treatment with so-called no-code or do-not-resuscitate (DNR) orders. When all parties to the DNR order, including physicians, patient, and family, agree that it is appropriate in a given case, there is rarely controversy. However, when one party dissents from a no-code status, most commentators agree, grave moral, social, and legal questions are raised.

The most troublesome issues concerning DNR orders arise when physicians and family disagree about the appropriateness of such an order in the case of a mentally incompetent patient. These episodes not only raise complex legal issues but also go to the heart of, and challenge, modern medical ethics and the relationship of doctor to patient.

Despite philosopher George Santayana's famous injunction that those who do not remember the past are condemned to repeat it, history holds no simple truths. Nevertheless, there are a number of significant historical questions relating to the AIDS epidemic. What does the history of medicine and public health have to tell us about contemporary approaches to the very difficult dilemmas raised by AIDS? Is AIDS something totally new, or are there instances in the past that are usefully comparable? Are there some lessons in the way science and society has responded to epidemic disease in the past that could inform our understanding of and response to the current health crisis?

There are obviously no simple answers to such questions. History is not a fable with the moral spelled out at the end. Even if we could agree on a particular construction of past events, it would not necessarily lead to consensus on what is to be done. And yet, history provides us with one means of approaching the present. In this regard, the history of responses to particular diseases can inform and deepen our understanding of the AIDS crisis and the medical, social, and public health interventions available.

Every year thousands of patients suffer injury while attempting to make use of bathroom facilities. In addition to the suffering and protracted inpatient care that these incidents cause, hospitals have been faced with staggering costs in the form of increased insurance premiums arising directly out of an increased number of lawsuits. This problem has reached a proportion such that it clearly deserves careful and indepth industry study.

This article, while far from a comprehensive study, will attempt to draw certain conclusions and perhaps dispel certain myths based upon a study of 181 patient falls at a 200+-bed community hospital in the Northeastern United States.

In the not too distant past, hospitals could not generally be held legally responsible for failure to raise bedrails absent specific medical direction. Such was the case because few, if any, hospitals had guidelines or procedures for the placement of bedrails in the absence of a physician's order.

Over the past three years there has been a flurry of legislation in Australia to provide answers for some of the legal questions and issues emanating from the new birth technologies. The chief of these is in vitro fertilization: the formation, in the laboratory, of a human zygote. The final result is, sometimes, a live birth. The test-tube baby process, as it is usually described in the media, has developed to include not only fertilization of a wife's ova with her husband's sperm but also the employment of donated gametes; cryopreservation of ova, sperm, and embryos; and, in terms of the possible, the employment of women to bear, deliver, and surrender a baby developed from a couple's laboratory embryo.

The publicity given to the new birth technologies, and the concern (and sometimes consternation) they have aroused, has been accompanied by renewed examinations of those older responses to infertility: AID (artificial insemination by donor) and surrogate mother arrangements effected either by the euphemistically and misleadingly labeled NID (natural insemination by donor) or by artificial insemination.

Fourth-party audit organizations (FPAOs) conduct utilization review and control programs, usually on behalf of employers that provide health benefits programs to employees. The existence of FPAOs and their increasing range of activity reflect the business community's great concern about the rising cost of health care. Over the past decade the business community has taken an increasingly active role in seeking to influence federal and state policies regarding health services, and in stimulating the development of new mechanisms of health delivery, with the goal of making its expenditures for health benefits more costeffective. Businesses rely on FPAOs to assist them in controlling the costs of health benefits programs for employees.

As desirable as cost containment in the health field is, however, the various means used to help reach that goal must be evaluated in terms of their practical effects and the relevant legal considerations. This article will (1) describe the functions performed by FPAOs; (2) provide an illustration of the impact of an FPAO in a patient care situation; (3) examine some of the practical problems created by the use of FPAOs; (4) indicate some of the legal questions presented by the activities of FPAOs; and (5) assess the role and likely impact of FPAOs in the future.

The rapid pace of medical innovation has raised the question: Can existing institutions, such as law reform commissions and other official bodies, and existing techniques, such as traditional legislation, deal effectively with the regulatory problems of today's world?

The New Biology has exhibited the capacity to arouse storms of public debate and to paralyze politicians or impel them towards unwise legislation. Examples of new and problematic technologies are the treatment of grossly defective newborn babies, live organ transplantation, cloning, the diagnosis of brain death, and, perhaps most important of all, manipulation of genes. But if there is one procedure that typifies the extreme reactions roused by the New Biology, it is in vitro fertilization (IVF), the technique whereby human eggs are fertilized outside the human body.

At the epicenter of the storm over IVF is the public debate concerning laboratory research and experiment on fertilized human eggs.

The AIDS (acquired immunodeficiency syndrome) crisis has aroused scientists to major research efforts and the public at times to near-hysteria. The media and their audience eagerly await the latest scientific reports, yet the public seems to respond selectively, embracing the most frightening interpretation of the data and discounting attempts to place those data in perspective. One might be tempted to conclude that questions of public health policy are best dealt with by expert judgment unsullied by lay opinion. Yet such an attitude supposes scientists to be governed by pure reason and to be beyond influence by narrow self-interest or by political or moralistic considerations, a self-serving assumption belied by an examination of the record. The erosion of public confidence in science has indeed bedeviled health authorities in their efforts to generate consensus on the policies they wish to implement, but the public response—including the response of scientists to AIDS—is a far more complex phenomenon.

The largest single group of hospitals in the country is composed of private nonprofit hospitals, which are exempt from taxation under the Internal Revenue Code. The second largest group of hospitals consists of for-profit hospital corporations. The third and fourth largest groups are, respectively, municipal hospitals and state and federal specialty hospitals, such as mental health facilities and public health hospitals.

Although the idea of hospitals engaging in business activities used to arouse scorn, the concept has now gained acceptance. This change began in the late 196Os, when the enactment of the Medicare and Medicaid programs forced hospitals to become more so phisticated in handling reimbursement issues, certification-of-need, unrelated business income, and productivity.

By 1981, the percentage of hospital charges reimbursed by the Medicare system had declined to 68.7 percent, from its 1974 level of 75.4 percent. In 1982, with the signing of the Tax Equity and Fiscal Responsibility Art (TEFRA), hospitals were essentially told that they must find their own solution to the problem of inadequate funding.

Virtually every state gives psychiatrists’ patients a broad statutory privilege to prevent the disclosure in legal proceedings of information about their diagnosis and treatment. Although the precise scope of the privilege varies from state to state, and a variety of exceptions are widely recognized, the contents of therapy sessions—and hence of psychiatrists’ written records of therapy sessions—are ordinarily protected by the privilege. Patients thus are gmerally entitled to prevent the courts and other government authorities from using their coercive evidencr-gathering powers to obtain psychiatric records or testimony about therapy. In conjunction with psychiatrists’ ethical and legal duties of confidentiality toward their patients outside legal proceedings, the privilege renders the privacy of the psychiatric relationship to a large degree sacrosanct.

The cloak of secrecy around the psychiatrist-patient relationship, however, must inevitably be lifted to some extent when third parties pay for psychiatric diagnosis and treatment. Any third-party payer, be it a private insurer or a government agency (such as Medicaid or Medicare), must be able to obtain enough information about psychiatric services to determine the propriety of claims for payment for those services.