In the two decades since the Karen Quinlan case first brought the issues that now go under the heading of the “right to die” to the attention of the courts and the public, a well-accepted legal consensus has developed about the law governing the forgoing of life-sustaining medical treatment. Law and clinical medical practice do not always run in tandem, however, and what law prescribes does not always occur in practice. One aspect of the legal consensus—that artificial nutrition and hydration is a medical treatment and thus may be withheld or withdrawn according to the same procedures and standards as other life-sustaining medical treatments—is probably less well accepted than the remainder. For reasons that I will explain, this is understandable. But what is puzzling is that this element of the consensus seems to be even less well accepted in nursing homes than in acute-care hospitals.

Medicaid has failed in its mission to care for the poor because doctors refuse to participate in the program. New ways are needed to entice physicians to treat Medicaid patients. TennCare, Tennessee’s Medicaid managed care demonstration project, shows that managed care plans can induce physicians to treat the poor by creating substantial collective purchasing power and by conditioning access to middle class patients on treatment of the poor, thus appealing to physicians’ financial self-interest. TennCare shows a new and promising approach, no matter how vociferously physicians complain about it.

TennCare, Tennessee’s Medicaid experiment, seeks to double Medicaid coverage in Tennessee—from approximately 750,000 people to 1.5 million. TennCare removes limits on Medicaid services, expands the medical services offered, and emphasizes low cost, cost-effective primary care. Perhaps most importantly, TennCare promises to mainstream health care for the poor by providing preventive and primary care in private physicians’ offices, moving the site of care away from expensive emergency rooms and hospitals. TennCare sounds like an ideal solution.

This study of the occupational health law of the European Union looks first at the jurisdiction of the Union and the history and scope of its legislation in this area.

The main body of the Article examines the level of protection that is afforded to the workforce under European Union law. The Article first considers the way in which assessment of risk is handled and then passes on to measures that are provided for both preventing and protecting against health risks. It notes the greater role given to protection. The Article also mentions the ancillary measures that are destined to make both prevention and protection effective. Finally, it looks at the Union's detailed provisions for worker involvement in occupational health matters and the more meager ones on employment rights and compensation.

The Article ends with a discussion of the problems faced by the Union in enforcing its rules and an assessment of the strengths and weaknesses of the European Union's occupational health law. It is suggested that, overall, it deserves a positive judgment.

Enormous and fundamental changes are currently taking place in health care delivery. These changes include the consolidation of health care providers—from hospitals, physicians, and insurance companies, to medical supply businesses, managed care networks, and other health care providers—and numerous health care and insurance reform efforts by government at all levels. These changes pose significant implications for the delivery of health care in the United States, and will impact the manner, cost, and accessibility of health care delivery. These changes will almost certainly affect the quality of health care services as well. The quality of health care in the United States has for many years been a central concern of government, industry, health care providers, payors, and consumers. Quality in health care is essential to overall national health, the guarantor of a productive and healthy populace, and an important indicator of United States social and technological preeminence.

Legal and ethical questions regarding existing organ transplant procurement policies and practices are numerous and unsettling. They arise because transplantable organs are scarce. The scarcity of such organs has been the hue and cry of several medical and legal scholars. For example, the scarcity creates competition among those who wait, necessitating equitable organ allocation procedures and guidelines. Medical obstacles surround the determination of when, how, and on whom such procedures can be performed successfully. Other obstacles range from finding a suitable donor for proper “matching” with the intended donee, to the time constraints involved in preserving excised organs until transplantation, to the donee's ability to fight off rejection of transplanted organs. There is also the obstacle of locating available organs. As medical technology continues to advance, the number of possible organ sources increases. Currently, these sources have included live human donors, cadavers, mechanical devices, animals, fetuses, anencephalic infants, and “brain-dead” donors.

The term medical futility has become a shorthand way to describe a situation in which a patient demands and a physician objects to the provision of certain medical treatment, on the ground that the treatment will provide no medical benefit to the patient. The dilemma of medically futile care has gained prominence as a subject for debate in medical and legal literature, has been discussed implicitly and explicitly in court opinions, and has weighed heavily in the debate surrounding health care reform and accompanying discussion of allocation of health care resources.

Recently, the issues surrounding the provision of nonbeneficial care became the subject of a federal court opinion. On February 10, 1994, the United States Court of Appeals for the Fourth Circuit handed down its decision in In re Baby K, a case that has since served as the central focus for debate over the provision of medical treatment deemed inappropriate or futile by a patient’s physician.

Currently the number of AIDS-related deaths in the United States has reached 311,000 and at least one million more Americans are infected with HIV. Of those one million or more infected, many spread the virus unknowingly as approximately forty percent of those infected have never been tested. More than eighty-five percent of the U.S. population has never been tested for HIV. No cure or vaccine for HIV currently exists.

The federal and state governments have set up a patchwork of free and confidential HIV testing at local clinics. States have enacted a variety of legislation concerning HIV testing and test results. Most states have enacted statutes that require informed consent for an HIV test to be conducted. All states require the reporting of AIDS cases, and many also require the reporting of HIV-positive status to state public health departments. Furthermore, many states mandate certain requirements for HIV counseling.

Owen Barfield, the British solicitor and literary scholar, reminds us that many legal concepts have their origin as metaphors and legal fictions. We often fail to see the nature of legal metaphors, Barfield argues, because over time they ossify and we read them literally rather than figuratively. Look closely at changes in law over time, Barfield advises us, to see how effectively metaphor works in law and language. Many legal categories and procedures we now use had their origin in using a metaphor that revealed a new way of looking at a problem or that helped solve a legal problem. Legal metaphors also help us to identify critical limits and strains in adapting to new facts and circumstances.

George Annas has pointed out that our choice of metaphors for medicine can reframe our debates about health policy reform. And Analee and Thomas Beisecker remind us that patient-physician relations have been viewed through many metaphors. These include parent-child relations (paternalism); seller-purchaser transactions (consumerism); teacher-student learning (education); relations among partners or friends (partnership or friendship); or rational parties entering into negotiations or contracts (negotiation or rational contract).

For years, people living in rural areas have struggled unsuccessfully to attract and retain primary care physicians to supply basic medical care to their residents. Rural areas continue to suffer from chronic shortages of physicians and mid-level practitioners, as well as high rates of hospital closures and increased levels of uninsurance and underinsurance, reducing both the physical and financial health of these communities. Physical and economic barriers unique to rural areas block the adequate delivery of health care and contribute to this shortage of health care personnel.

Although Congress has made some progress in identifying where health care shortages occur, it has not adequately identified the source of the shortages, and thus, it has not been able to find adequate solutions to rural health care ills. Past legislative action has involved identifying shortage areas and then providing financial incentives to attract physicians and increase the financial health of hospitals by subsidizing the difference between rural America's ability to pay and what physicians are willing to accept.

A study of conflicts of interest in Canadian health care law supposes that Canadian law contains features that distinguish it from law in any other jurisdiction. There was a time when law applied in the Canadian Common Law jurisdictions lacked these features. The law and legal process of the Common Law jurisdictions derived directly from England, whereas the Civil Law of Quebec was fashioned on the French Code Napoléon. Indeed, as recently as 1959, a distinguished Canadian academic commentator observed that “a perusal of Canadian law reports … conveys the impression that most of the opinions reported there are those of English judges applying English law in Canada, rather than those of Canadian judges developing Canadian law to meet Canadian needs with guidance of English precedent.” However, modern developments in Canadian society in general, and in its health care system in particular, now justify the claim that Canadian law is sufficiently distinctive to warrant its inclusion in comparative studies of legal regulation of health care professionals’ conflicts of interest.

A sexual assault trial requires a court to balance evidentiary privileges enacted by a state legislature against a criminal defendant's constitutional trial rights. State legislatures enact various privileges which either limit or prohibit the discovery of confidential communications in criminal trials. Such statutes reflect a firmly based legislative effort to protect citizens’ private and personal confidences from unwarranted public scrutiny. When a defendant charged with sexual assault seeks to compel discovery of the victim's privileged medical, psychiatric, or counseling records, a conflict inevitably arises. States and victims assert that courts must respect statutory assurances of confidentiality; defendants assert that their constitutional right to a fair trial and their right to confront the witnesses and evidence against them mandates disclosure. Resolution of this pressing conflict requires a careful balancing of both the state's and defendant's interests on a case by case basis.

Despite overwhelming epidemiological evidence that cigarette smoking causes cancer, and that addictive nicotine in tobacco keeps smokers smoking, our legal system has yet to allow a recovery against the tobacco industry for the massive harms it knowingly causes. Plaintiff smokers have sought recovery, only to be thwarted by affirmative defenses of assumption of the risk and contributory negligence, preemption of their claims by federal cigarette labeling laws, the difficulty of proving that cigarette smoking causes cancer, and the enormous resources of the $45 billion per year tobacco industry.

After forty years of unsuccessful lawsuits against the tobacco industry, a new plaintiff has come forward. In 1994, Florida and Massachusetts passed legislation enabling the states to bring suit against the tobacco industry to recover Medicaid costs of treating smoking-related illnesses.

Pleas for reform of the legal system are common. One area of the legal system which has drawn considerable scholarly attention is the jury system. Courts often employ juries as fact-finders in civil cases according to the Seventh Amendment of the Constitution: “In Suits at common law, where the value in controversy shall exceed twenty dollars, the right of trial by jury shall be preserved … .” The general theory behind the use of juries is that they are the most capable fact-finders and the bestsuited tribunal for arriving at the most accurate and just outcomes. This idea, however, has been under attack, particularly by those who claim that cases involving certain difficult issues or types of evidence are an inappropriate province for lay jurors who typically have no special background or experience from which to make informed, fair decisions.

The legal system uses expert witnesses to assist triers of fact in understanding issues which are beyond their common knowledge or difficult to comprehend.

Dan Boyles, Jr. secretly videotaped Susan Kerr while they engaged in sexual intercourse. Boyles’s friend, Karl Broesche, suggested the videotaping. Boyles agreed. Broesche and two other friends hid a video camera in the bedroom and videotaped themselves crudely joking and commenting on the situation. They left the camera running and snuck out of the house. The camera recorded the ensuing encounter between Dan and Susan.

Boyles took possession of the tape and showed it to friends on three occasions. Approximately ten people actually saw the tape. Susan Kerr learned of the tape’s existence several months later, confronted Boyles, and eventually took possession of the tape. In the meantime, Kerr’s reputation at her school, Southwest Texas State University, took a turn for the worse. She was called “porno queen” by many of her acquaintances, and was constantly confronted with questions about why she did it and whether she would do it again.