A living will is a directive from a competent, seriously ill individual to medical personnel and family members regarding the treatment he wishes to receive when he becomes incompetent to make decisions for himself. It is important to remember that a living will is not necessary when an adult is competent and chooses to refuse treatment since it is clear that generally, an adult, whether critically ill or not, may refuse any treatment for any reason. A living will is applicable only when a previously competent patient is seriously ill and incompetent.

Recent concern about new medical technologies which can prolong the dying process without improving the quality of life has sparked interest in rhe living will. More than five million copies of sample living wills have been distributed throughout the country, often by churches and senior citizens groups. State governments have also responded to this interest; the first Natural Death Act was signed into law in California in 1976. Since then, thirteen states and the District of Columbia have passed similar legislation, sometimes referred to as right-to-die statutes (see table accompanying this column).

Medical staff clinical privileges are usually granted, denied, reduced, suspended, or revoked because of clinical competence and performance. Generally accepted standards for evaluation of clinical competence and performance are published by the Joint Commission on Accreditation of Hospitals. In addition, some states have established standards by statute and by administrative regulations. Hospital medical staffs and governing boards, therefore, have standards to use in evaluating clinical competence and performance. Courts generally uphold hospitals’ employment of these standards as the basis of their decisions about a physician's clinical privileges. However, denial, reduction, suspension, or revocation of clinical privileges based on a physician's disruptive behavior presents a more difficult problem for hospitals because there are no generally accepted standards against which physicians’ behavior can be measured.

Finding elderly patients lying on the floor beside their beds despite the presence of elevated bedrails seems paradoxical: how can a patient fall out of bed when the bedrails are up? Surprisingly, this paradox constitutes one of the leading incidents plaguing hospitals in the United States today. It exemplifies a much larger problem created, we believe, by the uncritical adoption of measures designed to enhance patient welfare, but which may in fact undermine it. This article documents our experience with bedrails, reviews the literature, and comments on the rationale for routine adoption of bedrails for the hospitalized elderly. It concludes by advocating that a randomized, controlled study be conducted to determine whether bedrails constitute protection or a hazard to the average elderly patient.

Product liability litigation may proceed under several theories when someone has suffered harm caused by a product furnished by a commercial supplier. Liability for injuries or death caused by defective products can be based on the negligence of the manufacturer, wholesaler, or retailer of a product; on breach of warranty; on misrepresentations made by the seller regarding the nature or quality of the product; and on a theory of strict liability. In all cases, however, the plaintiff must prove that the negligence of the supplier of the product or the defective or unreasonably dangerous product itself caused the injury. Very often the testimony of an expert witness on the issues of defect and causation may be required to establish a prima facie case.

The decision whether or not to treat a newborn infant with a major birth defect or other life-threatening condition presents a multitude of medical, ethical and legal problems for all individuals involved. This is particularly true when the child’s prognosis, even with therapy, is uncertain or when treatment may result in or prolong a life fraught with substantial suffering. The proper roles of the physician and other hospital personnel, and especially of the child‘s parents, have yet to be fully or adequately resolved. Nonetheless, recent public awareness of isolated cases has made it clear that the status quo is not acceptable. The Committee on the Legal and Ethical Aspects of Health Care for Children (Children’s Committee) believes that hospitals and state agencies must do more to protect seriously ill newborns and to provide greater support—medical, psychological, and financial—to those in need.

Can new medical technologies decrease the incidence of occupational disease? Do they work to the detriment of other worker interests? Do they shift the burden of maintaining a healthy workplace from employers to employees, by keeping sensitive individuals from jobs that they are otherwise qualified to perform? These are among the central issues presented by the emerging occupational use of biological monitoring and genetic screening, as highlighted at the conference on Biological Monitoring and Genetic Screening in the Industrial Workplace, held in Washington, D.C., on May 12-13, 1983. The meeting was sponsored by the American Society of Law & Medicine and the Boston University Schools of Law, Medicine, and Public Health.

Research in progress on these issues, at the Center for Law and Health Sciences at Boston University School of Law, was one of the motivating forces for the conference. With funding from the National Science Foundation and the National Endowment for the Humanities, the study, led by Professor Michael Baram, LL.B., of Boston University School of Law, is providing a comprehensive overview and analysis of the major philosophical, ethical, and legal issues involved.

Does a hospital bear a responsibility independent of that of the attending physician to ascertain that a patient has given an informed consent? Until recently, state appellate courts have provided a decidedly negative answer to this question. However, in Magana v. Elie, an Illinois appellate court recently adopted a different position, opening the door to a new area of hospital responsibility and, therefore, increased potential liability for hospitals. This column provides a brief review of the informed consent doctrine, discusses the traditional and the Magana approaches to the issue of hospitals‘ responsibility to obtain informed consent, and analyzes the implications, particularly for nurses, should the Magana approach be more widely followed.

On July 5, 1983. the Department of Health and Human Services (HHS) issued a revised version of its Proposed Rules for the so-called Infant Doe Regulations. The regulations are designed to prevent discriminatory denial of medical treatment to handicapped infants. An earlier version published last March had been struck down for procedural defects by Federal District Court Judge Gerhard Gesell. In the course of his opinion, Judge Gesell noted that the regulations touch upon one of the most difficult and sensitive medical and ethical problems facing society—the question of what, if any, life-sustaining medical treatment should be utilized to preserve the lives of severely mentally or physically defective newborn infants.

In his view not only were the original regulations procedurally flawed, but they also were substantively deficient. Arbitrary and capricious was Gesell's phrase to describe HHS's actions in establishing a toll-free 24-hour-a-day hotline on which anonymous tipsters could trigger an investigation of alleged nontreatment.

American hospitals are in turmoil, experiencing declines in community esteem, reductions in Medicare payments, pressure for cost control by employers and insurers, and internal conflict between managements and medical staffs. Each of these conflicts is simply another facet of an overall problem: American society's recently conceived notion that unlimited access to the best available health services constitutes a right. Americans have adopted this idea, however, without considering the economic consequences in an environment of rapidly advancing technology and an aging population. Costs have escalated rapidly, reaching ten and one-half percent of the gross national product; the health services system is in strong competition with other important societal segments for scarce resources. The money may not be running out, but a rather naive institution, the community hospital, has suddenly found itself in an environment for which it is ill-prepared.

Governmental licensure of health professionals has a long history, but significant federal intervention in hospital financing did not begin until after World War II with the advent of the Hill-Burton program, which provided funds for hospital expansion. Medicare introduced federal payment for hospital care provided to the elderly and used formulas for cost reimbursement in 1966.