“Pictures of Pain Pay Off,” proclaimed the title of a recent article in the legal literature. The thermographic picture, or thermogram, is raising the stakes in plaintiff back cases and gaining national attention in both the medical and legal communities. Doctors see it as a diagnostic tool; lawyers, as an objective means of documenting injuries.

Yet the diagnostic and demonstrative potentials of this modality are also arousing considerable controversy—of the kind that has attended the use in court of blood tests to determine paternity, intoxication tests, polygraphs tests, hypnosis, spectrographs, and neutron activation analysis. This article will examine the use and value of thermographic pictures as evidence of spinal conditions and nerve root compression.

Recent efforts to evaluate the effectiveness of the informed consent process between physician and patient have focused on the ability of patients to understand written “informed consent” documents. Several researchers, employing traditional readability formulas to measure the reading level of such documents, have noted that many of these forms are written at a level too difficult for most people to understand. Readability formulas, such as those of Flesch and Fry, and the SMOG formula, have become convenient measures of the effectiveness of informed consent documents in conveying information to patients to enable them to make decisions about recommended therapies.

Our experience, in a pilot study, with readability formulas to test an informed consent document used in childhood poliomyelitis immunizations led us to conclude that readability formulas are an inadequate measure of patients’ comprehension of written information about medical procedures.

Aesop‘s Fable, “The Dog and the Shadow,” begins with a dog walking over a bridge with a piece of meat in his mouth. Looking down into the stream, he sees his shadow. Thinking it is a bigger dog, with a piece of meat twice the size of his own, the greedy dog decides to get it. Snarling, he opens his mouth to attack. At that moment the meat falls from his mouth, into the stream. The dog realizes his mistake, and sadly says to himself, “Grasp at the shadow and lose the substance.“

Drs. Overcast and Evans have not yet realized their mistake, but this response may help them see that what they characterize as their “strong exception” to “procedural and substantive” points made by the Massachusetts Task Force on Organ Transplantation and the “major shortcomings” they purport to identify really involve insubstantial “shadows.” Their “appraisal” indicates no disagreement of substance with any of the Task Force's policy recommendations. and their tangential quibbles shrink when their content and context is understood.

The American health care system is currently engaged in one of the most profound transitions in recent history. Demands for cost containment propel this transition, catalyzed by third party payers—federal and state governments, Blue Cross/Blue Shield, private insurers, third party administrators, and employers. The era of usual and customary compensation for health care providers participating in third party programs may be rapidly ending. Pharmacy witnessed the demise of usual and customary compensation in the early 1960s and has been fighting to regain it since then.

In recent years, third party prescription programs (TPPPs) have been the subject of, or have been affected by, various lawsuits, rulings by the Federal Trade Commission (FTC), and state attorney general opinions. Most have not been favorable for pharmacists. In a previous article in Law, Medicine & Health Care, this author explored some of the litigation and legislation which pharmacists attempted as a means to solve the problems presented by TPPPs.

Health care cost considerations exert increasing influence today over clinical decision-making. One way to help contain costs while maintaining the quality of health care may be to increase among both physicians and patients an acknowledgment of, and tolerance for, a reasonahle degree of medical uncertainty. By medical uncertainty we mean here those clinical situations in which, based on available data, absolute scientific proof regarding some aspect of a patient's heallh status cannot be obtained.

To the extent that acceptance of medical uncertainty and a corresponding restraint among physicians can he encouraged without exposing the physicians to an undue risk of legal liability, all participants in the health care system would benefit from this tolerance. To help provide this encouragement. we will explore the legal implications of medical uncertainty, focusing on diagnostic testing, and argue that our legal system does now and will continue to recognize, tolerate, and perhaps even promote some medical uncertainty in the diagnostic realm.

Only one of the Ten Commandments offers a reward. We should honor our parents, we are told, so that our days may be long. When the federal or state governments appeal to traditional religious and family values, however, we should look to the costs and not the benefits. In Hawaii, House Resolution 54 would seek to reinstate a relative responsibility law that was repealed in 1965; the immediate concern is to correct a $30 million shortfall in Medicaid. In Massachusetts, a pending bill, House Bill 1753, would make each “responsible relative” of a Medicaid recipient residing in a nursing home accountable for up to 25 percent of the amount paid, although the total collected from all responsible relatives must not exceed 100 percent of Medicaid payments. According to the bill, responsible relatives are spouses, natural and adoptive children, or natural or adoptive parents of blind or disabled children under 18.

The definition and regulation of nursing practice are issues of growing national interest. A variety of factors, including rising health care costs and consumer awareness, have combined to catalyze changes in health care delivery, with an increasing emphasis on disease prevention and cost-effectiveness. These goals have necessarily focused attention on the respective roles of non-physicians—most prominently, nurses—as providers of lower cost, quality health care. In a climate of professional and economic competition, state legislatures, state nursing boards, courts, and professional nursing organizations are engaged in a process of changing, adapting, or interpreting existing nursing practice laws to meet the needs of the changing health care system.

This article reviews the history and evolution of nursing practice legislation, examines the present stage in its development, and highlights some important issues affecting contemporary nursing practice acts.

The task of determining who should or should not have access to a life-prolonging procedure would not be easy even if cost were no consideration. In an era in which rhe health industry has largely converted to the cost cutting religion, or at least the religion of budget limitation, a conversion for which health economics is partly responsible-the task becomes doubly difficult.

At one level, the Massachusetts Task Force on Organ Transplantation has dealt with this task simply by recommending that the final decision be postponed, and that a limited program of organ transplantation he introduced in an “Initial Social Assessment” phase.

Every lawyer and law teacher is familiar with the basic developments in computer-assisted legal research that have changed at least the method of legal research. Computer-assisted research has gone far beyond LEXIS and Westlaw (computerized collections of state and federal legislation and decisions, as well as other legal material) in areas that are of critical importance to effective research for the teacher of health law. The nature of health law research has special, although perhaps not unique, characteristics that are particularly benefited by computer assistance.

Research in health law, especially policy-oriented research, rarely relies entirely on case law. Rather, its reach extends to interdisciplinary or cross-disciplinary research, comparative research, and the popular, as well as the scholarly, view. While health law teachers develop the ability to keep abreast of the rapid changes in case law and federal statutes and regulations, it is more difficult to keep pace with legislative developments on a state-bystate basis.

Criticisms of the impersonal ways in which some physicians relate to their patients, as well as calls for the infusion of more compassion, empathy, and humanity into the delivery of medical care, have abounded in recent months, as physician-watching gains popularity as a major American sport. Various culprits have been ‘indicted” for current shortcomings in the humanistic quality of many physician/patient relationships: the traditional paternalistic orientation of the medical profession, the explosion in the scientific knowledge that physicians are expected to master, the growing importance and effectiveness of medical technology in diagnosing and curing disease, economic pressures, and the ever-present, anxiety-stimulating shadow of medical malpractice. Whatever its specific etiology, the too-prevalent concern for “curing” at the expense of “caring” among modern medical practitioners has been widely lamented in both professional and lay forums.

When asked which patients receive kidney transplants in England, a social worker attached to a prestigious British teaching hospital recently told me, “Probably the undeserving.” By that she meant that trouble-making patients who lacked the self-discipline to cooperate with dialysis regimes, or who complained the loudest, were often “gotten rid of” by eliminating the need for dialyzing altogether.

Such candor was unexpected, but it points up the fact that even under Great Britain's National Health Service, where egalitarian concerns have always been paramount, criteria other than pure medical need can determine access to organ transplants. Ironically. “negative” social factors provided the key to transplant availability in the cases that the social worker described, although unconventional social factors are probably more often used in the United States to deny the benefits of transplantation to patients who do not fit the middleclass ideal.

In the mid-1970s the alarming state of nursing home care in the United State was dramatically exposed by the Subcommittee on Long-Term Care of the special Committee on Aging of the United States Senate, which released a series of papers collectively entitled Nursing Home Care in the United States: Failure in Public. Simultaneously a plethora of media investigations, exposés in the popular literature, scholarly articles, and state commission reports condemned conditions in nursing homes and called for reform. These investigations and reports uniformly demanded more rigorous government regulation of nursing homes. In response, in the late 1970s and early 1980s, virtually all of the states adopted some form of nursing home reform legislation. The federal government also adopted regulations mandating oversight of long-term care facilities participating in the Medicare and Medicaid programs.

Diagnostic sonography, also known as ultrasound, has become an invaluable aid in the practice of obstetrics and gynecology. Rapid improvements in instrumentation have caused the sonologist and sonography to assume a primary role in the care of these patients. Patient and physician expectations have increased with the technological advances. This paper will outline the advances and capabilities of diagnostic sonography in obstetrics and gynecology, while reflecting upon the foreseeable legal implications.

The physics of ultrasound is rather complex. Briefly, ultrasound utilizes high-frequency, non-ionizing, mechanical waves, 2.25 to 10 megahertz, that require a molecular medium for propagation. The reflected energy is processed to produce an image. Because it employs non-ionizing waves, ultrasound is considered safe by most authorities when used at the intensities currently employed for diagnosis. No clinically significant adverse effects have been reported in humans to date.

The recent Report of the Massachusetts Task Force on Organ Transplantation represents a watershed in public policy formulation in the health care field. The Report reflects the views of a diverse group drawn from fields which include public health, religion, surgery, law, private industry and consumer affairs. As such, it is, happily, unlike nearly every other advisory study of health care technology that has been commissioned by federal or state bodies during the past twenty-five years.

All too often, assessments of medical technology commissioned by government or publicly funded scientific agencies, such as the National Institutes of Health, the Office of Technology Assessment, or the Public Health Service, have been confined to the views of “experts” in the area of technology being assessed.

Recent reforms in state nursing home regulations have created an-array of enforcement tools that relate the severity of the penalty to the severity of the violation. These intermediate sanctions, intended to be flexible and effective in enforcing state standards, include civil fines, receiverships, public disclosure, monitors. and suspension of admissions. As supplements to the more traditional remedy of license revocation, intermediate sanctions can enforce standards without closing facilities unnecessarily, thus avoiding trauma to the residents, aggravation of the shortage of nursing home beds, and lengthy administrative proceedings and litigation.

The study of nursing home regulation by the Institute of Medicine of the National Academy of Sciences offers a unique opportunity to evaluate the implementation of intermediate sanctions by the states over the past decade. Because of the high degree of similarity among the state statutes authorizing these sanctions, comparisons can be drawn.