Toward a continuum of care for the elderly: a note of caution

The search for better ways to care for the chronically ill elderly has led to "alternatives to institutional care." A study fo geriatric day care and homemaker services finds that they were used as an add-on to existing care, few patients benefited, and costs were 60-71% higher than costs of a control group. Four more studies have confirmed the lack of substitution effects. Services could be targeted on those who need them even though it is very difficult to do so, and efficacy should be demonstrated before benefits are expended to new services.     

An unusual case of anaphylaxis. Mold in pancake mix

Anaphylactic reactions involve contact with an antigen that evokes an immune reaction that is harmful. This type of reaction is a rapidly developing immunologic reaction termed a type I hypersensitivity reaction. The antigen complexes with an IgE antibody that is bound to mast cells and basophils in a previously sensitized individual. Upon re-exposure, vasoactive and spasmogenic substances are released that act on vessels and smooth muscle. The reaction can be local or systemic and may be fatal. The authors report the death of a 19-year-old white male who had a history of "multiple allergies," including pets, molds, and penicillin. One morning, he and his friends made pancakes with a packaged mix that had been opened and in the cabinet for approximately 2 years. The friends stopped eating the pancakes because they said that they tasted like "rubbing alcohol." The decedent continued to eat the pancakes and suddenly became short of breath. He was taken to a nearby clinic, where he became unresponsive and died. At autopsy, laryngeal edema and hyperinflated lungs with mucous plugging were identified. Microscopically, edema and numerous degranulating mast cells were identified in the larynx. The smaller airways contained mucus, and findings of chronic asthma were noted. Serum tryptase was elevated at 14.0 ng/ml. The pancake mix was analyzed and found to contain a total mold count of 700/g of mix as follows: Penicillium, Fusarium, Mucor, and Aspergillus. Witness statements indicate that the decedent ate two pancakes; thus he consumed an approximate mold count of 21,000. The decedent had a history of allergies to molds and penicillin, and thus was allergic to the molds in the pancake mix. The authors present this unusual case of anaphylaxis and a review of the literature.     

Brief for 885 law professors in support of maintaining adherence to the Roe decision

This brief opposes the overturn of "Roe v. Wade" and resists weakening "Roe's central holding" that would allow states to overturn legal abortion. The brief was written for 885 law professors. "Roe" was not a "constitutional aberration," or "an exercise of raw, judicial power." Some members of the Supreme Court seem to think that the state has "an overriding interest" in protecting fetal life. Some Court members have questioned "Roe's" trimester framework. A person's decision to abort should be done privately. If women are not free to choose abortion, they will not have equality. There is an absence of "express rights of privacy and procreational freedom" in the Constitution. "Roe" was 1 instance of the Court's recognition of constitutional rights that are not named explicitly. Historical materials are drawn on to show the link between trends in society and the "judicial recognition of unenumerated rights." The most serious questions about "Roe" deal with its trimester framework. Justice Blackmun's majority opinion said that the 1st trimester of pregnancy was personal. "Roe" said that abortions created a medical risk at the beginning of the 2nd trimester. Therefore, the government was more interested in the health of the mother at that time. The state could then regulate abortion "in ways that are reasonable related to maternal health." The start of the 3rd trimester was when the fetus was viable. The right of a woman to end her pregnancy "offends powerful moral forces." Some of "Roe's" critics had their scientific facts wrong. Medical authorities think Justice O'Connor is mistaken when she says that "Roe" is "on a collision course with itself." The 23rd to 24th week of pregnancies where the fetal organs can "sustain life outside the womb." This has not changed since "Roe" was decided in 1973, nor is it likely to in the future. Some "amici" believe that the state can never have an interest in the fetus. The state can not have an interest in the fetus distinct from the woman who will give birth to it. During previability, restricting a woman's procreational rights would not be scientifically supportable. The state does have an interest in "upholding the value of human life." "Roe" is "within the mainstream" of constitutional jurisprudence and should be reaffirmed.     

Uncertainty in Clinical Research

"It is a fact of life that human beings find it difficult to maintain a consistent, self-conscious appreciation of the extent to which uncertainty accompanies them on their daily rounds and to integrate that uncertainty with whatever certainties inform their conduct. Physicians are not exempt from this human proclivity." Jay Katz¹     

STRATEGIES AND NEED FOR SYSTEMS CHANGE

Chief Judge Judith S. Kaye of New York delivered the following address to the Millennium Conference of the National Council of Juvenile and Family Court Judges in Washington, D.C., on November 15, 1999. In it, she describes the development of the philosophy of the family court in the past century. Judge Kaye describes the family court's transition from reliance on social science to the incorporation of procedural due process guarantees in the Gault decision. She suggests that a further transformation is required to meet the needs of children and families in the 21st century. Judge Kaye proposes that in the next millennium the family court abandon the "remote adjudicator" judge who evolved after Gault to a "problem-solving model of judging… a judge who looks at the issues that are driving the caseload, who looks at the results that are being achieved, and who uses a hands-on style to figure out how we might do better both in individual cases and on a systemic level."
The New York Times described Chief Justice Kaye as, "A dedicated and effective reformer of the state's sprawling court system. Each of her hard won changes has had a positive impact." Chief Judge Kaye recently received the National Center for State Courts' William H. Rhenquist Award for Judicial Excellence in November 1999. On the occasion of the award, Roger K. Warren, president of the National Center, observed about her,"There are many who are working hard to better process the many cases that come before the state courts, but there are few working an harder or more successfully to better serve the people who use the state courts."     

Dithranol: an unusual agent to produce artificial (false) bruise: a case report

Injuries are simulated by people for various reasons and may be labeled as "false/fictitious/forged." These may be self-inflicted or self-suffered. One such "injury" is an artificial/false bruise that may be produced by applying the juices of various irritant vegetable poisons. However, the present case is of an inmate of jail who used dithranol for producing 20 such artificial bruises on the back of his body. The purpose of such an act was to bring a charge of torture/beating against the jail officials.A good, thorough history taking and detailed and meticulous examination of the affected area, supplemented by relevant investigations and photography by a trained forensic expert, are a must to differentiate the "true" from the "false."     

Patient rights meet managed care: understanding the underlying conflicts

During the past several years, one of the favored areas for legislative (and editorial) debate in our Nation has been the proper level of legal protections that should be accorded to those individuals who have chosen to become members of managed care plans. As examined in the following article, this debate often rages with little notice being paid to the underlying conflicts between managed care and "patient's rights." Indeed, at times, the vociferousness of the debate obscures even those instances in which there is little fundamental conflict.     

绿色经济在中国的启蒙与复兴

绿色经济的概念为突破可持续发展机制面临的这个瓶颈在理念和方法上提供了一个新的机遇和选择,为可持续发展注入了新的活力。绿色经济体现了生态文明的理念,追求经济发展与环境保护的共赢与和谐。绿色经济的概念在当今经济全球化背景下尤其珍贵,有利于克服经济高度商品化带来的环境问题深化和危机,实现全球经济的可持续发展;绿色经济对中国等经济高速发展国家尤其重要。在中国经历了举步维艰的绿色经济目前正在获得新的发展契机。     

Hyponatremic seizures as a presenting symptom of child abuse

Poisoning is an uncommon manifestation of child abuse. The intentional administration of water to a child as a form of punishment has rarely been reported as the responsible substance among children who have been poisoned. We describe a case of a 5-year-old girl presenting with severe hyponatremia due to acute water intoxication. The patient was brought to the emergency room in status epilepticus. A history was obtained from the child's mother stating that the patient had been playing outside when she collapsed. She had had no known prior illnesses. Laboratory evaluation included a hemoglobin of 10.1 mg%, glucose of 60 mg%, serum sodium of 107 mEq/l, potassium of 3.2 mEq/l and chloride of 71 mEq/l. A CAT scan obtained approximately 1 h after admission revealed generalized cerebral edema. Careful examination of the skin revealed multiple linear ecchymosis of varying ages on the back and thighs and a hand print on the right flank. In addition, the child demonstrated severe failure to thrive with height, weight and bone age compatible with a 2.5-year-old girl. Appropriate therapy for severe hyponatremia was successfully instituted. For the next 12 h she was deeply somnolent, but the following morning was alert and conversant. She stated that she "would be good if she didn't have to drink any more water". The child's mother subsequently admitted that she frequently used water ingestion as a form of punishment. The child stabilized metabolically and demonstrated rapid in-hospital weight gain. She was placed in foster care at discharge and has had no further hyponatremia or seizures.(ABSTRACT TRUNCATED AT 250 WORDS)     

Impacts,Measurements, and Art Policy: Starting the Change Process

The author discusses a survey of companies with art collections in German-speaking countries—Germany, Austria, and Switzerland. Drawing on the data collected in the survey, he highlights the differences between two groups of curators currently responsible for corporate art collections, the "new professionals" and the "management administrators." First, organizational changes in corporations that occurred during the "founding boom" of the 1990s had a significant effect on the roles of corporate art managers, introducing the art-educated "new professional" into the process, which before then had been controlled by the corporate-trained "management administrators." Second, the nature, content, and styles of current corporate art collections reflect specific "corporate cultures." Third, the "new professional" corporate art curators purchase contemporary art for their collections at art fairs, a reality that has significant impact on the art market. The author concludes with an analysis of the relationship between these new professional corporate collectors and the contemporary art market by highlighting significant changes in pre- and post-1990 corporate art collections.     

Roe v. Wade and the history of abortion regulation

In "Roe," the Supreme Court found that the privacy right in the 14th amendment's view of "personal liberty" encompasses a woman's right to choose an abortion. The Court found that "abortion is a fundamental right." These conclusions are mistaken. The Court's analysis of "the history of abortion regulation" had a lot of errors and did not consider the state of technology in which abortion evolved. Sir Edward Coke, a 16th and 17th century jurist, said that abortion was a "great misprison." Quickening, the point at which a woman feels life, was used to determine fetal viability. State courts, therefore, viewed "abortion after quickening as common law crime." By the end of 1868, 30 to the then 37 states had passed laws restricting abortion. The Supreme Court said that the 19th century laws were passed to guard the mother's health "against the dangers of unsafe operation." In the 15 months before "Roe," 5 state courts said that their abortion laws were constitutional. They said that this was "intended to protect the lives of unborn children." Therefore, the Court's belief that "the state courts focused on the State's interest in protecting "the health of the mother" was unexplainable. The Court said that in many states the woman couldn't "be prosecuted for self-abortion." 17 states did "incriminate the woman's participation in her own abortion," but the Court did not note this. The Court's premise about the greater hazards of late abortions is mistaken. The states were concerned, in the late 19th century, about whether the attempted abortion caused the death of a child. The "right to an abortion" can only be seen as "fundamental" if it is "implicit" in the "ordered liberty" concept or "deeply rooted" in US tradition and history. "Roe" struck down the abortion laws of all 50 states and should be overturned.     

An ethical analysis of the mandatory exclusion of immigrants who test HIV-positive

On 20 September 2000, Canadian newspapers reported that Health Canada recommended to Citizenship and Immigration Canada (CIC) that testing all prospective immigrants for HIV, and excluding those testing positive, constitutes "the lowest health risk course of action." Subsequently, the Minister of Citizenship and Immigration stated that CIC is indeed considering implementing mandatory HIV testing for all prospective immigrants to Canada, and excluding all those testing positive (with the exception of refugees and family-class sponsored immigrants) from immigrating to Canada on both public health and "excessive cost" grounds. This proposal was met with vehement opposition from a broad range of organizations and individuals. In particular, they pointed out that, as stated in the International Guidelines on HIV/AIDS and Human Rights (UNHCHR/UNAIDS, 1998: para 105), "[t]here is no public health rationale for restricting liberty of movement or choice of residence on the ground of HIV status." At the time of going to print, no final decision had been made about whether mandatory HIV testing for all immigrants would be implemented. There are sound ethical, legal, and public policy arguments against imposing mandatory testing and excluding those who test HIV-positive.     

Patenting human beings: do sub-human creatures deserve constitutional protection?

The availability of patents for genetically altered animals raises questions about the patentability of human beings. Genetic research will produce beings who fall halfway between what we currently think of as "animal" and "human." It is unclear on which side of the legal line these creatures will fall. In April 1988, Congress revised the Patent Act with a statement that human beings are not to be considered patentable subject matter. Congress, however, failed to supply a definition of the term "human being." A definition will clarify the legal status of sub-human creatures. The author addresses this problem and proposes a definition of "human being" as an amendment to the Patent Act.     

Ten Years That Shook the World

Goethe once said, "It passed as though it had never been: those who shook up Russia are exactly the same." I confess that sometimes I think he may be right. Perhaps it is true: the "Gorbachev era" never existed, nor the hopes that flared so brightly ten years ago—the fervor; the rush of excitement; the happy, festive energy that swept up if not everyone, at least the most mobile and responsive segment of that society. That would explain why the results of the last decade seem to bear little resemblance to the thoughts, the expectations, and the plans we had then.     

Why hasn't integrated health care developed widely in the United States and not at all in England?

There have been influential advocates for financing and organizing health care in the United States and England based on the model of integrated health care delivery systems (IHCDSs). Despite good evidence that a few IHCDSs provide high-quality health care economically, such organizations are rare and localized in a few market areas in the United States and are absent in the English National Health Service (NHS). The explanation of why this is so includes various contributory factors: the way the development of the medical profession in each country pursued specialization; the division in British medicine between general practitioners and specialists; and the characteristics that we identify of established successful IHCDSs, which created formidable barriers to entry for a new IHCDS. This explains why currently the most promising organizational developments in U.S. health care are hybrids resulting from vertical integration. In England government policies of an "internal market," as adopted in the 1990s and currently, were and are based on a purchaser-provider split with the objectives that providers would compete and be funded by a system in which "money follows the patient." These policies recognize the division in British medicine, which also means that it is difficult to implement a reorganized English NHS based on high-performing IHCDSs.     

Unmanaged care: towards moral fairness in health care coverage

Health insurers are generally guided by the principle of "actuarial fairness," according to which they distinguish among various risks on the basis of cost-related factors. Thus, insurers often limit or deny coverage for vision care, hearing aids, mental health care, and even AIDS treatment based on actuarial justifications. Furthermore, approximately forty-two million Americans have no health insurance at all, because most of these individuals cannot afford the cost of insurance. This Article argues that Americans have come to demand more than actuarial fairness from health insurers and are increasingly concerned by what I call "moral fairness." This is evidenced by the hundreds of laws that have been passed to constrain insurers' discretion with respect to particular coverage decisions. Legislative mandates are frequent, but seemingly haphazard, following no systematic methodology. This Article suggests an analytical framework that can be utilized to determine which interventions are appropriate and evaluates a variety of means by which moral fairness could be promoted in the arena of health care coverage.     

Vladimir Shapoval: "The CEC Is Destined to Be the Scapegoat"

"The law is harsh, but it is the law"—the well-known ancient Roman saying is entirely suitable as a brief synopsis of the Lb.ua interview with the chairman of the Central Election Commission (CEC), Vladimir Shapoval.

"Any electoral legislation, I emphasize, any, will always be 95 percent the product of political expediency. Always. This way gives them an advantage—so be it." This is how he calmly parried my emotional "How can the advantage of the strong be codified in the law (!), and the weak essentially have no chance? What can you do, how can it be?" "All this ‘whining and crying,’ say, the law is this and that in substance, I do not accept it. The laws were adopted—so we will follow them. You cannot get away from it," he added.

It might seem to someone who does not know Vladimir Nikolaevich that the chief vote-counting official is being clever, "covering up" the "distortions" of the authorities "at the local level." He is in fact speaking frankly. The chairman of the Central Election Commission formed on the eve of the 2007 preterm parliamentary elections by a "coalition"—a retired Constitutional Court of Ukraine (CCU) justice, and a doctor of legal sciences who is an active member of the High Council of Justice (HCJ), he can permit himself that. Shapoval contrives to call things by their names: "How the law is written is another matter. And its parts are written abominably," he states bluntly.

In view of this, my discussion with Shapoval—formally tied to the start of a local elections campaign—went far beyond the bounds of a discussion of the legislation on this topic, and even the specifics of the campaign. The more so as I had already discussed this in detail with CEC Deputy Chairman Andrei Magera. Vladimir Nikolaevich, without concealing his indignation, related just what the HCJ is really afraid of (and it turned out it was not at all, or more precisely not only, what they are portraying it to be). Relying on nine years of experience as a CCU justice, he elucidated the risks of the invalidation of the 2004 constitutional reform by the current Constitutional Court—"only those who have face can lose it." Sketching out the situation in the body politic, he summed up, "If the Party of Regions (PoR) does not win the local elections, many questions will arise."     

Frontal collision in the reclining-sitting position. Medical and legal aspects

An account is given of a head-on collision involving a sleeping female who was a front-seat passenger in a sitting-reclining position and who was not wearing a safety belt. Biomechanical, clinical and radiological findings are reported (longitudinal fracture at the L3, vertebral compressions, intervertebral disc lesions, vertebral arch lacerations and incomplete paraparesis from L2 distally. In the course of several lawsuits leading up to the Federal Supreme Court, two judgments were pronounced that outline the legal obligations of the driver towards sleeping front-seat passengers. In this case, there was a conviction on account of "neglect." A district (LG) and an appellate court (OLG) acknowledged the liability of the driver for injury to person and property damages. The fact that he had not awakened the women passenger to draw her attention to the necessity of fastening the safety belt in a sitting position and in this way giving her the opportunity to make her own responsible decision was considered as "at least contributory" towards the damages sustained in the accident. The settlements regarding the private insurance liability are also derived from these rulings.     

Special report on reimbursement. Final Medicare fraud and abuse safe harbors are published

There has been great concern in the health care industry that business arrangements that do not comply with the Safe Harbors will automatically be deemed illegal. HHS has confirmed that this is not so; the commentary to the Regulations expressly states that "The failure of a particular business arrangement to comply with these provisions does not determine whether or not the arrangement violates the statute because...this regulation does not make conduct illegal. Any conduct that could be construed to be illegal after the promulgation of this rule would have been illegal at any time since the current law was enacted in 1977....This regulation is intended to provide a formula for avoiding risk in the future." 56 Fed. Reg. at 35955. In the final analysis, the majority of transactions will fall outside the Safe Harbors and thus will continue to be judged by the standards established by the Medicare antifraud statute enacted 14 years ago. Under these standards, as HHS states, "the degree of the risk [in any particular transaction] depends on an evaluation of the many factors which are part of the decision-making process regarding case selection for investigation and prosecution." Id. at 35954. Providers that are mindful of these criteria should therefore still be able to accomplish, with relative safety, transactions that do not qualify for Safe Harbor protection.     

The Ethical Health Lawyer: An Empirical Assessment of Moral Decision Making

Writing in 1999, legal ethics scholar Brad Wendel noted that "[v]ery little empirical work has been done on the moral decision making of lawyers." Indeed, since the mid-1990s, few empirical studies have attempted to explore how attorneys deliberate about ethical dilemmas they encounter in their practice. Moreover, while past research has explored some of the ethical issues confronting lawyers practicing in certain specific areas of practice, no published data exists probing the moral mind of health care lawyers. As signaled by the creation of a regular column "devoted to ethical issues arising in the practice of health law" in the Journal of Law, Medicine & Ethics , the time to address the empirical gap in the professional ethics literature is now. Accordingly, this article presents data collected from 120 health care lawyers. Presenting this population with a number of hypothetical scenarios relating to how they would respond when confronting an ethical dilemma without an obvious solution or when facing a situation in which their personal values were in tension with their professional obligations, this article represents a first step toward better understanding how lawyers who practice in health care settings understand and resolve the moral discomfort they encounter in their professional lives.