The cover story of the June 12, 1978, issue of TIME magazine characterized the US. Department of Health, Education and Welfare as The Beneficent Monster. The physicians and lawyers of this nation often find themselves acting as sometime keepers and trainers of The Monster in many of its activities. While numbers of monstrous proportions may not intimidate the current generations who have witnessed the coining of the words googol (the number 1 followed by 100 zeros) or googolplex (10 raised to the 100th power), most of us are impressed when we discover that millions are affected and billions of dollars spent annually by the Social Security Administration.

That we will come into contact with The Monster is quite likely: As individuals we may become members of the beneficiary population; as practicing professionals, we may be involved in pursuing for another what may appear to be a tortuous process to guide that person to benefit status under the Social Security Administration Disability Programs.

Much has been written and discussed this past year about the responsibility and obligation of hospitals to actively support and comply with Section 504 of the Rehabilitation Act of 1973. which was designed to ensure that federally assisted programs and activities would be operated without discrimination on the basis of handicap. The Department of Health, Education and Welfare (HEW) last year published comprehensive regulations implementing this controversial section of the law. Since almost all hospitals and health care institutions receive some form of Medicare, Medicaid or Hill-Burton Funds, this regulation is of special significance to the administrators of facilities who must now make both their physical plant and programs accessible to individuals suffering from a broad range of disabilities.

In as much as a significant portion of the regulations relate to the development of plans to identify physical obstacles limiting accessibility and time schedules for making required modifications to buildings, many hospital officials equate Section 504 solely with the needs of individuals confined to wheelchairs or utilizing other such devices to assist in mobility

The hospital medical record is a multi-purpose document. It is the repository for all relevant (and sometimes not so relevant) medical information concerning the care and treatment of a patient during his or her stay in the hospital or visits to the Out-Patient Department or Emergency Ward. In addition, it serves as a form of communication among all past, present and future providers to help them provide medical care to the patient. With the gradual disappearance of solo practice as a major mode of health care delivery, and with the emergence of group practices, Health Maintenance Organizations, neighborhood health centers and hospital based primary care programs, this communicative function assumes even more importance. As a legal document, its existence is mandated by statute in many states, and it is frequently used as evidence in malpractice suits and other court proceedings. The medical record also serves as a research resource from which statistics and findings can be compiled to aid in a variety of studies and medical audits. Finally, it is an educational document which often is employed as a teaching tool in training students in the health field.

As general counsel to one of the largest hospitals in the United States, I want to discuss a topic which affects 15 to 20 patients in our hospital every day, those on whom physicians have written what we call “DNR” orders (Do Not Resuscitate). Any large tertiary care hospital has to deal regularly with this problem with respect to patients who are terminally ill and how to treat such patients in a wide variety of circumstances. What are the physician's and the hospital's obligations to provide Care?

On November 28,1977, the Massachusetts Supreme Judicial Court handed down its opinion in a case that has caused tremendous repercussions in hospitals throughout the country regarding the withholding or withdrawal of life-support to terminally ill patients. At the time this opinion was handed down, the decisions of physicians and hospitals on what to do with respect to withdrawing such care were based primarily on one of four models.

Proposed federal legislation concerning recombinant DNA research attempts to restrict the ability of local governments to regulate the research. In March of 1978, the House Commerce Committee approved a bill that would “bar states and localities from setting their own standards over gene transplant technology.” Two weeks later, the House of Representatives Science, Research, and Technology Subcommittee approved a bill which would permit a state to regulate such researchonly when it is “necessary” to protect local health. The “necessary” standard usually requires strict proof that a regulated substance or activity will cause significant harm to public health. Under this standard a locality might have to wait for significant harm to occur before it could adopt regulations that are stricter than federal requirements.

This anomaly presents the basic question of this article: Who should decide whether recombinant DNA research is a health hazard — the local or the federal government? This article will utilize a legal approach to answer the question, analyzing and weighing the issues presented by pertinent cases.

This article presents an overview of the role of the medical expert witness in litigation involving issues of medical liability or malpractice in order to introduce the potential physician expert witness to some of the major problems and situations that may arise.

The expert medical witness is needed among other reasons, to define the standard of medical care required in the Physician/patient relationship which is frequently the crucial element in a professional liability case. The plaintiff. in order to prevail in his law suit, must show, among other components, (1) what the required standard of care was in his case, (2) that the defendant failed to meet that standard, and (3)th at this failure was the cause of the injury alleged.

The standard of care required of a physician is commonly defined as adherance to “the skill and learning commonly possessed by a member of the profession in good standing.”

As Lee Dunn points out in his accompanying article, the Saikewicz case has been widely misunderstood and misinterpreted by health care providers both in Massachusetts and elsewhere. Two Massachusetts Appeals Court cases, Dinnerstein and Lone v. Canduru, have clarified some of the more controversial aspects of Suikewicz and should allay some of the fears which that case produced. The more important of the two decisions — Dinnerstein — involved the legality of “do not resuscitate” orders (DNR's) in the absence of a court order.

Mrs. Dinnerstein was diagnosed as suffering from Alzheimer's disease in July of 1975, although she probably had been afflicted with the disease since 1972. Alzheimer's disease is a progressive, unremitting disease of the brain which leads to disorientation, memory loss, loss of intellectual function, and, eventually, loss of all motor function. The usual course of the disease is five to seven years during which time the patient generally becomes a complete invalid and has to be institutionalized.

In what may prove to be the most controversial medicolegal decision of the year, the Massachusetts Supreme Judicial Court has ruled that, in certain cases, courts are the proper forum in which life-sustaining medical decisions should be made. The controversy goes deep. It involves questions of who should make life-prolonging decisions, in what forum, and on what criteria. Until the last few years, these questions arose almost exclusively in the context of Jehovah's Witnesses cases — cases in which life-saving blood transfusions were being refused for religious reasons. But with society's increasing consciousness about the way people die in hospitals, medical decisions are increasingly coming under public scrutiny.

Death, of course, is a natural process and a uniquely personal experience. If pressed to categorize it, most would probably term the major controversies surrounding it ethical, rather than medical or legal. Nevertheless, there is a trend to ask the courts whether or not life-sustaining treatment should or should not be withheld from patients who are unable to make this decision themselves.