Fourth-party audit organizations (FPAOs) conduct utilization review and control programs, usually on behalf of employers that provide health benefits programs to employees. The existence of FPAOs and their increasing range of activity reflect the business community's great concern about the rising cost of health care. Over the past decade the business community has taken an increasingly active role in seeking to influence federal and state policies regarding health services, and in stimulating the development of new mechanisms of health delivery, with the goal of making its expenditures for health benefits more costeffective. Businesses rely on FPAOs to assist them in controlling the costs of health benefits programs for employees.

As desirable as cost containment in the health field is, however, the various means used to help reach that goal must be evaluated in terms of their practical effects and the relevant legal considerations. This article will (1) describe the functions performed by FPAOs; (2) provide an illustration of the impact of an FPAO in a patient care situation; (3) examine some of the practical problems created by the use of FPAOs; (4) indicate some of the legal questions presented by the activities of FPAOs; and (5) assess the role and likely impact of FPAOs in the future.

Most legislative proposals to solve the so-called malpractice crisis have been viewed by lawyers as attacks on lawyers and the legal system. Consequently, little thought has been given to whether we can find support for these proposals within the tort system. What I would like to suggest is that some of these proposals, including the increasingly popular cap on recovery for pain and suffering, are supported by the way the tort system has begun to look at injuries with several causes.

Initially, the legal system refused to recognize that the damages resulting from an injury could be apportioned among the various causes. Although we always recognized that every event has several causes, the law placed responsibility on “the proximate cause,” often the cause closest to the injury.

One of the first steps toward division of damages among causes was the replacement of contributory negligence with comparative negligence. Contributory negligence provided that if defendant and plaintiff were both negligent causes of the injury, plaintiff collected nothing.

Advances in medical technology have a habit of raising new, and usually unexpected, ethical and legal questions. Such questions arise when patients or physicians, for a variety of reasons, defer cardiopulmonary resuscitation (CPR) or other treatment with so-called no-code or do-not-resuscitate (DNR) orders. When all parties to the DNR order, including physicians, patient, and family, agree that it is appropriate in a given case, there is rarely controversy. However, when one party dissents from a no-code status, most commentators agree, grave moral, social, and legal questions are raised.

The most troublesome issues concerning DNR orders arise when physicians and family disagree about the appropriateness of such an order in the case of a mentally incompetent patient. These episodes not only raise complex legal issues but also go to the heart of, and challenge, modern medical ethics and the relationship of doctor to patient.

The use of a mechanical device is an ancient and crude form of contraception. Desert dwellers in ancient Africa placed stones in the uteruses of their camels to prevent conception during long treks across the Sahara. The metal intrauterine devices (IUDs) used in the late 1800s caused severe pelvic infections that, in the absence of antibiotics, often proved fatal. The first stainless steel and polyethelene IUDs were developed around 1960, and these attained a relatively reliable degree of safety. New compositions and materials decreased the risk of infection, and innovative devices could be inserted without dilating the cervix.

As mechanical means of contraception grew in popularity, pharmaceutical companies began to fight for a competitive edge, each touting the design or materials of its product as safer and niore efficient. By the mid-l970s, it is estimated, more than 15 million IUDs had been distributed throughout the world, many in developing nations.