National parliaments and the European Union: part of the problem or part of the solution to the democratic deficit in the European constitutional settlement?

European integration is as much an opportunity as a threat to national parliaments. The view that national parliaments have been the main losers in the process is not substantiated by empirical evidence. National parliaments have adapted their structures and procedures to keep pace with the increasing scope of integration. This process has included strengthening the constitutional powers of parliaments in some of the member states. The recognition in the Nice and Laeken declarations that national parliaments have an important role in enhancing the democratic legitimacy of the Union and the key provisions of the draft protocols on the role of national parliaments and subsidiarity adopted by the Convention on the Future of Europe will ensure that national parliaments have the opportunity and the means, if they so choose, to be closely involved in Union affairs. Constitutional change at the Union level is likely to trigger normative and procedural change in the member states.     

The reasonable physician standard: the new malpractice standard of care?

We are in the midst of a tremendous, but essentially unacknowledged, shift in the standard applicable in medical malpractice cases across the United States. The author provides a preliminary survey of this fluid area of the law, and provides rationales for the changes. At the same time, it is not yet clear whether the net impact of these changes will be for the better or for the worse--particularly in light of the simultaneous increase in societal emphasis of cost-conscious care.     

Doctors in the executive suite: should the U.S. and U.K. be putting M.D. licensure at risk for shortfalls in institutional quality of care?

As our healthcare system becomes further managed, delivery organizations are reincreasingly relying upon physician executives to administer the delivery of care by other individual providers. In both the United States and the United Kingdom, this has led to instances in which physician disciplinary procedures have been invoked with respect to physicians who are perceived to be responsible for institutional defiiciencies. The author examines and analyzes the contrasting approaches taken in the two countries, and recommends an activist approach for disciplinary agencies faced with these circumstances.     

Obstacles to dependent health care access in Oregon: health insurance or health care?

In the 1980s, Oregon was one of a handful of "states that could not wait" for national health care reform. Oregon's chosen approach to reform was predicated on two widely accepted assumptions. First, universal access to health care is best achieved by universal access to health insurance. Second, universal access to health care could best be achieved, at least politically, by incrementally building upon the existing health care delivery and insurance system. This article questions both of these assumptions in light of Oregon's decade-long experience in trying to expand access to health care among its dependent population.     

What is the goal of access to health care?

This article first examines the justifications for the goal of access to health care and the variations between health systems in their endorsement of individuals' rights to health care irrespective of income, ethnicity, age and other characteristics. It then examines the meanings of the goal of "access" to health care and considers four key dimensions--service availability ("having" access), service utilisation ("gaining" access), the relevance and effectiveness of services and equity of access. These dimensions provide a common framework that can be applied across countries and health systems and employed to assess the extent to which access to health care is actually achieved.     

The fundamental law that shapes the United States health care system: is universal health care realistic within the established paradigm?

In this article, the author draws from his own experience as a doctor in describing the issues the uninsured patient population faces. Pointing out that neither the U.S. Constitution nor case law provides a positive right to health care, the author describes the parameters of federal health care funding and ultimately concludes that universal health care cannot be fully achieved in the U.S.     

Unwarranted variations in the quality of health care: can the law help medicine provide a remedy/remedies?

This Article reviews the essential findings of studies of variations in quality of care according to three categories of care: effective care, preference-sensitive care, and supply-sensitive care. It argues that malpractice liability and informed consent laws should be based on standards of practice that are appropriate to each category of care. In the case of effective care, the legal standard should be that virtually all of those in need should receive the treatment, whether or not it is currently customary to provide it. In the case of preference-sensitive care, the law should recognize the failure of the doctrine of informed consent to assure that patient preferences are respected in choice of treatment; we suggest that the law adopt a standard of informed patient choice in which patients are invited, not merely to consent to a recommended treatment, but to choose the treatment that best advances their preferences. In the case of supply-sensitive care, we suggest that physicians who seek to adopt more conservative patterns of practice be protected under the "respectable minority" or "two schools of thought" doctrine.     

The conflict between the ethics of th individual and the ethics governing public health: practical sustainability of health care in jeopardy?

The "health rights movement" has reconstructed the clinical relationship between health care workers and patients by simultaneously demanding more from traditional medical care and challenging the perceived power differential between doctors and patients by rejecting the paternalistic medical model in favour of an individual patients' rights model. However, the growth in individual expectations of a right to health care creates a potential conflict with the ethics that prioritise public health and guide the rationing of its limited financial and human capital resources. This, in turn, creates a practical dilemma which requires public health institutions to become service orientated while sacrificing their integral role in training and educating the medical workforce and potentially compromising the practical sustainable delivery of public health in Australia. However, the law can play a role in resolving this conflict through legislation, regulations, codes, administrative law and common law in an effort to ensure the quality and future sustainability of public health in Australia.     

The internet and the state: Instrument of social control or subversive tecnology?

Conclusion Technological progress always contains within it the ironic dialectic of liberation and domination. The computer-based information highway is no exception. As a consequence, our own view is that the computer revolution contains the potential for both over-control and subversion of control. Science and technology are not neutral. They are social constructs that exist only within a context of choices of development and application. Therefore, it is not the technology that constrains, or oppresses, or liberates. Rather, the emancipatory potential of this new technology lies in the degree to which those who use it can disseminate it and maintain it as a relatively low-cost communication tool. To date, many of those involved in expanding the Internet frontier have generally been suspicious of and resistant to government intrusion into the Net. While it is often easier to simply dismiss such suspicion as the ranting of conspiracy theorists, history has taught us that such a na?ve faith in the benevolence of the government is unwise. Our intention here has not been to provide a definitive conclusion about the past, present, or future state of technological progress; instead we hope that our discussion will spark further critical analysis of technology and related topics.     

Effects of purchaser competition in the Dutch health system: is the glass half full or half empty?

In 2006, the Dutch health insurance system was radically reformed to strengthen competition among health insurers as purchasers of health services. This article considers whether purchaser competition has improved efficiency in health-care provision. Although supply and price regulation still dominates the allocation of health services, purchaser competition has already significantly affected the provision of hospital care, pharmaceuticals and primary care, as well as efforts to gather and disseminate information about quality of care. From this perspective, the glass is half full. However, based on the crude performance indicators available, the reforms have not yet demonstrated significant effects on the performance of the Dutch health system. From this perspective the glass is half empty. The article concludes that the effectiveness of purchaser competition depends crucially on the success of ongoing efforts to improve performance indicators, product classification and the risk equalisation scheme.