Showing papers in "Journal of Law Medicine & Ethics in 1992"

Treatment decisions for terminally ill patients: physicians' legal defensiveness and knowledge of medical law.

Abstract: In this study, we investigated physicians' attitudes, knowledge, and reported practices regarding the effects of perceived legal constraints on the abatement of life-sustaining treatment from patients who are clearly dying. A factor in assessing these issues is the concept of defensive medicine -- that is the perception that doctors are being forced to order every possible laboratory test and second opinion, or to continue providing non-beneficial life-sustaining treatment, solely to protect themselves from future legal claims. This perception appears widespread among practicing physicians. However, we believe that defensive medicine represents only part of a complex constellation of factors that comprise physicians' reluctance to abate treatment. This phenomenon encompasses medical, legal, social, psychological, and spiritual factors interacting in ways that are not fully understood. We remain cognizant of the potential impact of all these factors. For purposes of this article, however, we have chosen to focus on legal and psychological aspects of physicians' reluctance to abate treatment and the corresponding ethical implications.

Germ-line gene therapy: a new stage of debate.

Abstract: Ethical debate on human germ-line gene therapy is in a new stage. After an era when only individual convictions could be examined, technology is on a threshold of real possibilities. Germ-line gene therapy can conceivably be carried out in either of two practical ways: 1) insertion of a gene into a pre-embryo, which is the subject of this paper, or 2) insertion of a gene into the germ cells of an individual. Transgenic animal research and pre-implantation embryo diagnosis have implications for human embryonic germ-line experiments to correct single gene disorders. When would such experiments be feasible and ethically acceptable? If further animal research supports it, we argue for a moral obligation to learn if human germ-line experiments are feasible and safe to attempt. The obligation is grounded in several social-ethical principles that lead society and researchers to set gods for studies that promisc to relieve and to prevent human suffering and premature death. These principles also shape the practices and restrictions of biomedical research.

The morality of physician-assisted suicide.

Abstract: In March, 19%). I 2 physicians published an article on the provision of care t o hopelessly ill patients. Unfortunately, inany of the siilxtantive points in that article received insufficient attention from readers hecause the authors’ call for appropriate, continually adjusted care for terminally ill patients was overshadowed by a portion of the document in which ten of the authors agreed chat “it is not immoral for a physician to assist in the rational suicide of a terminally ill person.”’ In June, 1970, Jack Kevorkian, a retired pathologist in Michigan, gained international media attention by enabling Janet Adkins, a woman in the early stage of Alzheimer’s disease, to terminate her life with the hclp of his “suicide machine.”’ The features of the case were so uriusual that physicians, ethicists, and attorneys i n health law who were interviewed by journalists were unanimous iii judging this particular act of physician-assisted suicide deplorable.) I n M‘irch, rggr, Timothy Quill, an internist in New York, published a detailed accotint of thc suicide of one of his patients identified only as “Diane,” a patient with acute niyeloinonocytic leukemia who requested and rcceived his assistance in killing herself with an overdose of barliturates.4 Given the features of this particular case, some of the professionals in medicine. ethics, and law interviewed by the incdia judged Dr. Quill’s action to have been inorally acceptable, even if against the law in New York.5 The issuc of physiciaii-assisted suicide (I’AS) is not limited to these wcll-puhlicized examples. The American Hospital Association estimates that many ot the 6,000 daily deaths in the United States are orchcstrated by patients, relatives, and physicians, although how many of these deaths are assisted suicides is unknown.‘, In a 1990 New York Tirnes-CRS poll, taken two weeks after tlie initial publicity of the Adkins case, 53 percent of the respondents said that physicians should be allowed to assist R severely i l l person in terminating his or her own life.7 Moreover, PAS is lieginning to he addressed as a separate ethical issue in the medical literature, without being lumped together with the related but different issuc of voluntary ei~thanasia.~ The legal status of PAS is also being tested in an unprecedented manner. The Hemlock Society, having failed three years ago to get “The Huniiine and Dignified Death Act” on the ballot in California, successfully worked with a coalition called Washington Citizens for Death with Dignity to get Initiative I i g on tlie ballot in Washington iii November, 1931. The wording of this initiative, iisiiig language that blurs the differences between PAS and voluntary euthanasia, simply asked voters: “Shall adult patients who are in i i medically terminal conditioii be permitted to request and reccive from ;I physician aid-in-dying?”” Given these cvents, the time has come for a serions discussion of the niorality and legality of physician-assisted suicide. I hope to contribute to that discussion 1)y tirst analyzing the concept of assisted suicide and descrihing the diversity of possible legal responses to acts of PAS. I will thcn provide an ethical aiialysis of I’AS b y discussing the cases of Janet Adkins and “Di;ine,” sorting out the competing ethical argiiments alwut this issue, ;ind making some recommendations for professional practice and public policy.

Special ethical issues in the management of PVS patients.

Abstract: The patient in a persistent vegetative state (hereafter, the PVS patient) has played a central role in recent American bioethical discussions and in recent litigation involving bioethical issues. From Quinlan’ to Cruzan and Wanglie, some of the most important cases involving ethical issues at the end of life have involved PVS patients. Major American medical groups such as the AMA and the American Academy of Neurology have adopted important policy statements on the care of such patients, statements that have been followed by at least one European group. I have always found this activity a bit of a mystery. There is, after all, a relatively clear consensus about decision-making at the end of life, a consensus embodied in such documents as a report from the President's Commission and a report from the Hastings Center.

Hospice care as an alternative to euthanasia.

Abstract: The same concerns that have led society to consider euthanasia as an option for relieving the suffering of the dying led to the development of the hospice movement. How effectively has hospice care met these needs, and is there still a need for euthanasia? Is the hospice approach to death an alternative to euthanasia, compatible with euthanasia, or euthanasia in another form? Do those health care workers who are drawn to providing hospice care favor or oppose euthanasia?

Futility: a concept in search of a definition.

Abstract: The simplistic concepts of futility and autonomy, then, cannot adequately inform society about the kinds of health care services that are appropriately provided to patients. Health care professionals, patients, and their surrogates are left with the arduous but necessary task of communicating effectively and of searching for an equitable resolution to the treatment conflict. With these introductory remarks to help frame the discussion, we invite you to read LMHC's mini-symposium on futility [articles by Steven H. Miles; Betty Dew; Kathryn A. Koch, Bruce W. Myers and Stephen Sandroni; Ann Alpers and Bernard Lo; Edward R. Grant; and Troyen A. Brennan], and to decide for yourself about this relatively new, extremely important, but also highly dangerous, concept of medical futility.

Required Reconsideration of “Do‐Not‐Resuscitate” Orders in the Operating Room and Certain Other Treatment Settings

Abstract: It is time to change the assumption that DNR orders apply in every treatment setting in the hospital. It is appropriate to mandate not only that these orders be reconsidered on the basis of time, but also on the basis of setting. When patients enter treatment settings in which discrete, time-limited therapies that can precipitate cardiac arrest are offered, they or their surrogates should reconsider the question of resuscitation with their current and primary physicians. While this will make patient transition from one hospital setting to another more complicated, it will allow patients to receive treatment directed toward their individual needs, immediate treatment objectives, and long-term treatment goals. It will also assure health care professionals that they will not be required to withhold treatment essential for meeting patients' treatment objectives in these settings.

Toward a theory of process.

Abstract: This article starts by finding a lack of procedural ethics in the usual debates over the functioning of ethics committees and the proper relationship of ethics committees and the courts, and traces this lack to the absence of a theory of process and process values. I then show why ethics commmittees are an excellent place to start in working on process. I therefore turn to the task of developing process values, and specifically a notion of patient-centered process. Here I recommend both process values commanded by our underlying substantive values, and further independent process values. I specifically suggest that surfacing problems of gender, racial, and economic bias make certain processes ethically mandatory. Having thus indicated what the needed process values might look like, I sketch their considerable theoretical potential. I return to the particular problem of ethics committees and the courts, and use my notion of patient-centered process to derive an answer to the question of how the two entities should interrelate. Finally, I step back to suggest where we might go from here in developing a theory of process.

Avoiding "Cloudcuckooland" in ethics committee case review: matching models to issues and concerns.

Abstract: ... The special concerns of families, patients, and caregivers are inevitably interwoven among the difficult ethical issues that ethics committees confront when they review individual cases. Certain of these ethical issues and special concerns can be addressed more effectively by the use of one particular case review model. This means that no one model for case review is suited to address every ethically difficult patient care situation. When one case review model is used exclusively by an ethics committee, some issues and concerns will not be resolved effectively. This difficulty cannot be ameliorated by switching to another exclusive model. To do so would be to trade an Athens for a "Cloudcuckooland." The case review model selected by ethics committees must vary from case to case. The model that is chosen should be geared to resolve the ethical issues central to that situation and the special concerns of patient, family, and caregivers. An examination of the three received models [the committee as a whole, teams, and individual members or consultants] will show that each is particularly suited to resolve certain kinds of ethical issues and special concerns. Because of this, ethics committees should develop a method for choosing the most appropriate model for reviewing specific cases.

Some ethical costs of rationing.

Abstract: The escalating cost of health care has forced people to confront the possibility of rationing-forgoing beneficial care for patients so that the resources might be used either for other current or prospective patients or for entirely different things in life than health care. Rationing of some sort makes eminent sense, not just economically; only those who are fanatics about health and medicine would urge that everything possible be spent on health care for even the slightest marginal benefit. Yet actual rationing of health care is usually thought to exact high, or at least disturbing, ethical costs. I will examine four of these costs here: (I) the sacrifice of physician loyalty to patients, (2) the substitution of misleading and discriminatory numerical measurements of medicine’s human benefit for more sensitive qualitative judgments, ( 3 ) the unfair bite that rationing is likely to take first out of poor people’s care before it affects wealthier patients, and (4) the general Substitution of public, group standards about life and health for the values and decisions of individuals. In m y discussion of the second and third costs, especially, I will refer to the state of Oregon’s concrete attempt at rationing. Throughout I will not just elaborate these moral costs hut assess them, estimating in particular the extent to which they can be minimized by certain forms of rationing and hy certain ways of conceiving of the values that rationing either represents or appears to threaten. Taken together, these four ethical costs portray rationing as preserving or enhancing the welfare of the larger society, at the cost of attending to the needs of each individual patient. Though to some extent these four ethical costs will affect any actual rationing of health care, I will argue that generally they are not as high as is commonly supposed. To the extent that this claim is correct, rationing’s conflict with full respect for individual patients can be significantly diminished. Another way of stating this general line of argument is to propose a reconception of what rationing represents. Rationing is commonly thought to reflect the “welfare of society”-the needs of people other than the patient whose care gets rationed out. If that indeed is the value that limiting medically beneficial care because of its expense essentially represents, it will (and probably should) be a long time indeed before American society comes to any kind of reasonably secure, ethical satisfaction with rationing. It will be accused, plausibly, of assaulting our most vulnerable citizens, the sick and disabled, so others can retain their desired level of amenities. As I have argued elsewhere,’ however, there is a different way of seeing the whole business. Rationing, properly formed, should represent people’s own hard judgment about the kind of society in which on balance, in the long term, and considering all the realities of cost and scarcity, they wish to live. Concomitantly, commitment to individual patients should involve much more than maximizing their welfare us pntients. Then respect for individual patients can be reconciled with rationing: if, beforehand, inclividual patients have consented, or clearly would have consented,‘ to substantive and procedural policies for rationing out care of relatively high expense per benefit, those policies’ ethical appeal will rest not merely on the morally controversial goal of increasing aggregate societal welfare but on respect for patients’ own values. I will apply this line of argument, with less success in some cases than in others, to each of the four ethical costs of rationing mentioned above.

Futility: not just a medical issue.

Abstract: Is it futile to sustain biologic life when the patient will permanently require intensive medical care? Dr. Koch and Dr. Miles agree that such treatment would be futile; however, their concept of futility rests on no explicit standards and reflects no communal judgment. The authors view the lack of widely accepted medical standards as an impediment to answering this question definitively. Dr. Koch laments that patients and their families have seized too much power and have begun deciding that mere biologic life is worth sustaining. And Dr. Miles sees benefit to perceiving a decision not to sustain such life as “primarily biomedical” and “realistic.” Here is where we disagree with these authors. We do not see the problem as a lack of standards that are medical. The question of prolonging a patient's life when the patient has no likelihood of regaining consciousness confronts moral, political, and economic issues.

The Moral Standing of Animals in Medical Research

Abstract: Major segments of the news media, as well as many scientific journals, have produced innumerable articles and stories that polarize issues about proper protections for animals involved in research. The prevailing exposition of the issues is the following: On the one hand, animal lovers make emotional appeals to the public's attachment to animals and use clever tactics to increase the vulnerability of universities and institutions of research. On the other hand, arrogant scientists refuse to respond to public controversy, have an inherent conflict of interest in reviewing research involving animals, and are out to advance their careers and interests, callously using animals as means to that end. As a result, journalists warn NIH officials that they “can expect continuing criticism from two disparate and opposing groups—animal welfare activists, who consider NIH the fox guarding the chickens … and scientists and administrators from the research community, who regard tighter restrictions as unnecessarily burdensome.”

Ethics committees and due process.

Abstract: I have three points to make about due process and an IEC's responsibility to provide ethics consultation on request: 1) the problem of due process needs to be put into the context of ethics consultation, for which committees are responsible but which they are ill-equipped to deliver as a whole group, except in certain circumstances; 2) IECs that attempt to provide consultation without an early stage of bedside consultation, involving the key decision-makers and especially the patient, attending physician and nurse(s), are inviting due process problems as well as a general "failure to thrive"; and 3) due process issues are important to resolve at two levels: a) initial contacts with patient, family and other decision-makers at an early stage of consultation close to the bedside, and b) especially at a second level of conflict resolution, when part or all of the IEC may be involved, because no resolution of the ethical problem(s) has been found at the primary level of consultation and the level of conflict will probably be higher. I propose a two-stage or two-step model for due process issues, i.e., obligations exist at both levels to respect the patient's rights and his or her priority in the decision-making process. My recommendation will be that IECs and their consultants need to be especially meticulous in carrying out these obligations at a second level of conflict resolution, when all or part of the IEC will be involved.

Analysis of Power in Medical Decision-Making: An Argument for Physician Autonomy

Abstract: Two of the patient's rights in a Uniform Act for the Terminally Ill should be a) the right to be treated if there is reasonable doubt of the patient's wishes until it becomes clear that the treatment is not beneficial and that the patient is indeed terminally ill, and b) the right not to be subjected to treatment with no medical benefit. A physician with appropriate supporting independent opinions would be the logical individual to whom the responsibility of protecting those rights should be given. This is particularly true when the patient is incapable of his or her own medical decisions and has left no instructions regarding his or her personal goals in medical care in the event of severe illness. Two cases and an analysis of power in medical decision-making illustrate these points.

Justice, Politics and Community: Expanding Access and Rationing Health Services in Oregon

Abstract: In 1989 the Oregon Legislature voted not to wait any longer for national leaders to serve up a solution to the problem of the millions of Americans (450,000 in Oregon) who are uninsured for health care. Under the leadership of Senator John Kitzhaber, President of the Oregon Senate, the lawmakers put together a package of bills designed to bring every Oregonian the security of third party financing for needed health care. The Oregon Plan's key innovation is the idea that, from a societal perspective, some health services can be declared more important than others. From that central idea came the thought that the whole range of health services could be arrayed to reflect social priorities relevant to Medicaid budgeting and the design of new health insurance programs for “the uninsured.”

Physicians and futile care: using ethics committees to slow the momentum.

Abstract: Given the history of the medical profession's diffident attitude toward patients' rights and its reliance on well-meaning paternalism, the notion that doctors should determine futility and limit access to specific interventions must be carefully scrutinized. Indeed, the emergence of two other themes in health policy and ethics, in particular the living will/power of attorney initative on the one hand and the open discussion of rationing care in Oregon on the other, tends to undermine the key rationales for physician control over futile care. Careful review of all three trends suggests that we ought to brake the momentum in favor of physician determination of futility of care and that ethics committees can be the vehicle to address this goal.

A Retrospective on Cruzan

Abstract: In 1990, the United States Supreme Court issued a decision in the Cruzan case, the first "right-to-die case" to reach that Court. Prior to the Court's decision, there was wide-spread speculation as to what it would decide and what the impact of the decision would be. Speculation about the impact of the decision intensified after it was announced, with many suggesting that it would prove to be a serious setback to the consensus about the legality of terminating life-sustaining medical treatment that had evolved in the state courts since the Karen Quinlan case ushered in the era of right-to-die litigation in 1976. This article examines a number of aspects of the legal consensus about forgoing life-sustaining treatment that emerged prior to Cruzan and discusses their viability in light both of what Cruzan did and did not decide and in light of subsequent judicial decisions in right-to-die cases. Two years after the Supreme Court's decision, it is apparent that the pre-Cruzan legal consensus is stronger than ever.

"Inducing a miscarriage": women-centered perspectives on RU 486/prostaglandin as an early abortion method.

Abstract: In countries where abortion is performed safely in medical settings, the vast majority of up to several generations of women have come to identify early abortion as a surgical experience—whether on an inpatient or outpatient basis, whether with local or general anesthetic or whether in a freestanding clinic or a hospital. In this context, the introduction of RU 486 with prostaglandin (RU 486/PG) as an alternative method of early abortion will once more alter women's experience of abortion. The first part of this paper explores the similarities and differences between an abortion with RU 486/PG and vacuum aspiration from a women-centered perspective. This comparison is limited by the fact that only women in France have so far had access to both methods, along with those who have participated in clinical trials, and that very few in-depth women's experiences and reactions to this method have been published.

Do pharmacists have a right to refuse to fill prescriptions for abortifacient drugs

Abstract: PIP: Some pharmacists opposed to abortion on moral ground are concerned by having to fill prescriptions for abortifacient drugs like mifepristone (RU-486). The issue of the right of pharmacists to refuse to fill such prescriptions depends on the model of the physician-pharmacist-patient relationship. The libertarian model of pharmacy practice holds that physicians, pharmacists, and patients are bound only by the contract that they freely negotiate with one another, thus the pharmacist has no moral obligation to fill a prescription for mifepristone unless he or she has expressly contracted to do so. The American Pharmaceutical Association's 1981 Code of Ethics does not specify what a pharmacist ought to do in particular circumstances. The right to refuse is strongly supported by the principles of nonmaleficence and respect for autonomy. These are principles of the libertarian model of the pharmacist-patient relationship but are also present in the guild or societal models stressing the duty to avoid harming others. Justification for pharmacists right of refusal appeals to their autonomy rights as members of the moral community rather than the profession of pharmacy. Since the professional right to autonomy is not absolute, moral consideration circumscribe it: it is difficult to argue that a pharmacist who believes that homosexuality is immoral has the right to refuse to fill a prescription for AZT. Even if a person who presents such a prescription is homosexual there is no causal relationship between filling a prescription for AZT and participating in a homosexual act. At the opposite end the libertarians reject the notion of even a basic right to health care. A woman in the above situation would not have a right to the abortifacient drug, so a pharmacist has no duty to dispense it. According to the technician model of professionalism, the pharmacist's personal values do not matter, so a pharmacist has a duty to provide the service.

Acceptability of mifepristone for early pregnancy interruption.

Abstract: It is the purpose of this article to review the current status of early pregnancy interruption with mifepristone (RU 486) combined with a prostaglandin analogue from the standpoint of its acceptability to women. Also discussed are the need for uniform terminology in acceptability studies, observations from clinical trials in California, France, and the United Kingdom, and comments on eventual utilization in developing countries.

RU 486/Prostaglandin: Considerations for Appropriate Use in Low‐Resource Settings

Abstract: Antiprogestins represent a new class of promising drugs in fertility regulation, especially in early termination of pregnancy. RU 4 8 6 (mifepristone), manufactured by RousselUclaf and marketed under the international trade name Mifegyne, is an antiprogestin tablet that is used sequentially with a prostaglandin for non-surgical termination of pregnancy. It has been chosen as a pregnancy termination method by over IOO,OOO women in France since its regulatory approval there in 1988. In addition, RU 486/prostaglandin was approved in July 1991 for use in the United Kingdom and an application for approval is being considered in Sweden. In Western Europe, it seems, RU 486/ prostaglandin is increasingly accepted by medical experts, regulatory officials and women as an alternative to vacuum aspiration or dilation and curettage (D&C) for early pregnancy termination. As the use of RU 486/prostaglandin becomes more established, health practitioners and women’s health advocates are beginning to consider the feasibility of using this method for pregnancy termination in low-resource settings.’ Clinical trials of sequential treatment with RU 486 and prostaglandins are already underway in Cuba, India, The People’s Republic of China, Singapore and Zambia. Low-resource settings-prevalent in developing countries but found in industrialized countries as wellwarrant special concern for whether or not RU 486/prostaglandin should be used. This article will discuss the possible reproductive health implications of RU 48 6/prostaglandin and explore the considerations for appropriate use of this drug combination for termination of pregnancy in low-resource settings. General description of RU 486

Whodunit? Causal Responsibility of Utilization Review for Physicians' Decisions, Patients' Outcomes:

Abstract: In the “olden days,” only a few years ago, physicians were free to order virtually any service they believed their patients needed, confident that virtually everything would be paid for Reimbursernent was retrospective, fee-for-service and generous, essentially a cost-plus system in which insurers only rarely challenged medical decisions That system is now gone Uncontrolled escalations in the cost of health care have prompted those who pay its costs—primarily governments, businesses, and insurers—to initiate a broad array of cost controls in hopes of at least restraining the rise of their expenditures, even if not actually reducing them Among the most prominent cost-containment mechanisms is utilization review (UR) Insurers have always engaged in retrospective review, denying payment for services that are not medically necessary, or not covered by the patient's policy, or not documented in the patient's records Recently, however, payers have added prospective review, in which physician and patient must secure advance payer approval for certain interventions if they wish to ensure reimbursement

Medical futility: legal and ethical aspects.

Abstract: I welcome the long-overdue recognition of medical futility represented by the contributions of Koch, et al., Miles, and Dew [in this issue of Law, Medicine and Health Care], although I would be more comfortable with using the more global (and optimistic) term of "beneficence." However labeled, the notion that medical treatment decisions are primarily that -- medical decisions -- is a far more appropriate starting point in both law and ethics than the customary departure point of patient autonomy. This is particularly true in cases in which the patient is not competent, and prior expressions of intent are remote, vague, or otherwise unreliable. Despite such flaws, prior statements have been invested with a talismanic quality, permitting avoidance of the genuine moral issues of duty and benefit that are presented by every severely ill and incompetent patient.

Mistakes and fraud in medical research.

Abstract: Violations of the ethical canons of research have been reported with increasing frequency in recent years. Nowhere have the reported incidents been so numerous or so troubling or attracted so much Congressionill attention as in biomedical research. Research ethics, once “something everyone agrees about,” has become the subject of disagreement now that issues of culpability and enforcement are demanding attention. How to distinguish mistakes from fraud has stopped being theoretically obvious and has become ;i practical problem.

Ethics committees, organ transplantation and public policy.

Abstract: CONCLUSION It is clear that ethics committees face many dilemmas in developing sound public policy on organ transplantation through their roles in serving their institutions and their communities. With conscientiousnes and good faith, different committees may adopt different approaches to the same issue, and arrive at different solutions when subscribing to the same approach. It is valuable that committee members should be aware of other committees' approaches and disclose the reasons for their own in a frank, non-defensive way. It should also be remembered that a measure of legitimacy can attach to ethics committees' decisions because of the integrity with which their decisions are reached, even when they differ from other committees' decisions. Like courts of law, their decisions carry weight because of how they are reached, not simply because of how they comport with the judgments of others. This is not to say that every or any legally permissible policy is ethically sound, but only that ethics committees can contribute to public satisfaction that institutions are under reliable control through the demonstrable integrity and competence of their processes of policy making.

The "Gag Rule" Revisited: Physicians as Abortion Gatekeepers

Abstract: In this article, I explore this failure [of the therapeutic exception as a compromise device in federal abortion counseling regulations] with an eye toward its broader lessons about the social uses of medical discretion and the difficulty of achieving an abortion compromise in America. I begin by examining the legal underpinning beneath the widespread belief that the "gag rule" imposed a near-absolute ban on discussion of the abortion option. This conventional wisdom, I conclude, collapses on careful inspection. It fails utterly to account for the strong support to be found in the Title X regulations and their larger legal context for a therapeutic exception unconstrained by administrative or judicial definition. Next, I observe that this legal unboundedness would have empowered Title X clinic physicians (and perhaps others who do counseling) to exercise broad discretion over abortion access, under the rubric of medical indication.... By so doing, however, physicians would have become abortion gatekeepers. This would have raised difficult ethical and clinical questions about the extent to which medical judgment should be allowed to incorporate (and shield) socially-disputed moral choices. I briefly consider some of these questions, along with the countervailing appeal of preserving a measure of intimate freedom under medical cover. I then conclude by positing some connections between the moral infirmities of medical gatekeeping and the political failure of the therapeutic exception. I suggest, in essence, that this failure was ensured by a strong resonance between the exception's moral infirmities and the fears of the medical leaders, pro-choice activists, and abortion opponents who framed the public debate over the "gag rule." The potential breadth of the therapeutic exception went unrecognized and unexplored because professional and popular understanding of the abortion counseling regulations was molded by the activists who framed the debate...

RU 486: what physicians know, think and (might) do--a survey of California obstetrician/gynecologists.

Abstract: The results of this informal survey indicate that a solid majority of California obstetricians and gynecologists are very interested in RU 486 and are following its story closely; that this majority is confident in the research already conducted on the drug, and feel that RU 486 should be made available at this time for both clinical practice and additional research; that many physicians already performing abortions would utilize RU 486 in their practices; and that a significant number of physicians not currently performing abortions would do so using RU 486, thus potentially increasing access to early abortion services in this country. However, strong support for RU 486 among American physicians has not yet had an appreciable impact on hastening the eventual availability of RU 486 in the United States.

Do those who cannot speak really have a voice

Abstract: Joseph Finelli, after a heart transplant, is being artificially maintained by medications and a gastrostomy tube (G-tube). He is not brain dead nor in a persistent vegetative state. In my role as court-appointed Guardian ad Litem (GAL-court investigator), it appears to me that Mr. Finelli is being treated against his stated goals and values. After applying the substituted judgment factors, I recommend the withdrawal of the medication which sustains his life. His family adamantly opposes my position.

Studying the acceptability and feasibility of medical abortion.

Abstract: Various approaches of measuring acceptability used in contraception research can be used to measure acceptability of abortions induced by RU-486. The primary acceptance method determines whether women will or will not choose RU-486 in the absence of other abortion methods, if offered it, and how many women will indeed undergo a medical abortion. The comparative acceptance method determines how many women will choose RU-486 if other methods are available. Another acceptability approach is interviewing women to learn if they suffered any side effects or have any complaints. Researchers can also see if women think that they would choose RU-486 again should the need arise. This method would work best with women who have undergone both surgical and medical abortions. It is important to examine acceptability because medical service delivery systems in developing countries cannot always perform safe and effective surgical abortions and individual choice is important in matters concerning stressful and intimate issues, such as abortion. Research is beginning to show that women in both developed and developing countries tend to be motivated by the same issues when choosing RU-486 over surgical abortion. For example, women in Cuba, India, and Europe chose RU-486 because it avoids surgery and hospital admission and is easy and convenient. More than 90% of the women in studies in India and Cuba considered their RU-486 experience to be at least satisfactory. 83% who had earlier undergone a surgical abortion preferred RU-486 induced abortion. 90% of repeat abortion seekers would choose RU-486 again. Feasibility studies examine whether medical institutions can handle medical abortion technology. Feasibility depends on cost, clinic facilities (e.g., availability of sonograms), clinic management, professional training, and the presence of back-up systems (e.g., high quality surgical services with transfusion capability). Researchers also need to determine whether medical abortion burdens medical systems and patients.