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PubMed1991

A call for action. The Pepper Commission's blueprint for health care reform.

After a year of deliberation and investigation, the Pepper Commission recommended action to ensure that all Americans would have health insurance protection in an efficient, effective health care system. Because it believes that action is urgent, the commission would build universal coverage by securing, improving, and extending the combination of job-based and public coverage we now have. Reform would entail the following elements: a combination of incentives and requirements that would guarantee all workers (with their nonworking dependents) insurance coverage through their jobs; replacement of Medicaid with a new federal program that would cover all those not covered through the workplace and workers whose employers find public coverage more affordable; guaranteed affordable coverage for employers--through reform of private insurance, tax credits for small employers, and the opportunity to purchase public coverage; a minimum benefit standard for private and public plans that would cover preventive and primary services as well as catastrophic care and would include cost sharing, subject to ability to pay; and a combination of public and private sector initiatives to promote quality and contain costs.

Cost Control↗
PubMed1994

Screening surgeons for HIV infection: assessment of a potential public health program.

OBJECTIVE: To develop a model to assess the impact of a program of testing surgeons for human immunodeficiency virus (HIV) on the risk of HIV acquisition by their patients. DESIGN: A Monte Carlo simulation model of physician-to-patient transmission of human immunodeficiency virus (HIV) infection using three different rates of physician-to-patient transmission per percutaneous exposure event (0.15%, 0.3%, 0.6%). Data from the model were developed from a review of the medical literature and from subjective probability estimates when data were not available. We used this model to estimate on a national basis the annual number of cases of HIV transmission from surgeons to patients with and without surgeon testing and practice limitations. RESULTS: The annual number of transmitted cases would range from 0.5 (+/- 0.3), assuming a surgeon HIV prevalence of 0.1% and a surgeon-to-patient transmission rate of 0.15%, to 36.9 (+/- 11.6), assuming a surgeon HIV prevalence of 2% and a surgeon-to-patient transmission rate of 0.6%. After one screening cycle, a mandatory screening program would be expected to reduce the annual transmissions to 0.05 (+/- 0.03) and 3.1 (+/- 1.1), respectively. CONCLUSION: Patients are at low risk of acquiring HIV infection from an infected physician during an invasive procedure. The potential costs of such a program extended beyond the costs of testing and counseling. In communities with high HIV prevalence, screening surgeons and limiting their practices may decrease patient access to care. A disability insurance program also would be required to protect surgeons and trainees performing invasive procedures. Screening surgeons for HIV infection would be a costly undertaking that would reduce but not completely eliminate this risk.

AIDS Serodiagnosis↗
PubMed1999

Catching patients: tuberculosis and detention in the 1990s.

The resurgence of tuberculosis (TB) in the early 1990s, including multidrug-resistant strains, led health officials to recommend the use of involuntary detention for persistently nonadherent patients. Using a series of recently published articles on the subject, this paper offers some opinions on how detention programs have balanced protection of the public's health with patients' civil liberties. Detained persons are more likely than other TB patients to come from socially disadvantaged groups. Health departments have generally used coercion appropriately, detaining patients as a last resort and providing them with due process. Yet health officials still retain great authority to bypass "least restrictive alternatives" in certain cases and to detain noninfectious patients for months or years. Misbehavior within institutions may inappropriately be used as a marker of future nonadherence with medications. As rates of TB and attention to the disease again decline, forcible confinement of sick patients should be reserved for those persons who truly threaten the public's health.

Communicable Disease Control↗
PubMed1990

The ethics of selectively marketing the health maintenance organization.

Health Maintenance Organization (HMO) administrators have been accused of engaging in 'selective marketing'. That is, through such strategies as tailoring the benefits package of the program or advertising in styles or in media that do not appeal to certain 'undesirable' audiences, the administrator can minimize the percentage of persons in the HMO who are heavy users of health care services. By means of analyzing what 'insurance' is (philosophically) and what it means for something to be a free market commodity, the author argues that, as long as American society chooses to regard health insurance as a commodity or service of the free market. the use of such strategies is within the moral rights of health administrators. The author concludes by noting some morally undesirable results of treating health insurance as a market commodity.

Capitalism↗
PubMed1986

Newborn screening for hemoglobinopathies: the benefit beyond the target.

As a result of New York State's Newborn Screening Program 4,565 neonates with trait hemoglobinopathies were identified and 3,200 families were notified of the results of testing their infants in New York City in 1982. Of the 1,531 families (2,190 parents) tested and counseled, 22 parents were diagnosed with sickle cell disease and 39 couples were found to be at-risk for having a child with sickle cell disease. Amniocentesis was performed in 14 of the 28 at-risk pregnant women and three of the four affected pregnancies were terminated. MCH-331001-01 to 04

Anemia, Sickle Cell↗
PubMed1990

HIV antibody testing among adults in the United States: data from 1988 NHIS.

Data collected from 21,168 adults using the 1988 AIDS supplement to the National Health Interview Survey were examined to determine awareness of and experience with HIV antibody testing in the United States. Three-fourths of adults knew of the blood test for HIV antibodies; awareness was lower among Blacks, Hispanics, older adults, and those less educated. Overall, 17 percent of adults had been tested; of these, 73 percent because of blood donation, 14 percent through other non-voluntary programs (such as military induction), and 16 percent sought testing voluntarily. While a smaller proportion of Black and Hispanic adults had been tested, they were more likely than their White non-Hispanic counterparts to have been tested voluntarily. Persons who reported belonging to groups with high-risk behaviors were also more likely to have been voluntarily tested. Most of those tested voluntarily received their test results, but only one-third also received prevention information. Three percent of adults plan to be tested voluntarily in the next year; about half will seek testing through their doctor or health maintenance organization.

AIDS Serodiagnosis↗
PubMed1989

HIV screening and counseling for intravenous drug abuse patients. Staff and patient attitudes.

At least one third of patients enrolled in a methadone maintenance treatment program are willing to comply voluntarily with screening for and counseling about human immunodeficiency virus (HIV). A questionnaire about knowledge, attitudes, and behavior concerning acquired immunodeficiency syndrome was answered anonymously by 79% (46) of the clinical staff and 67% (868) of the enrolled patients. On their own initiative, 21% of the patients had already received voluntary anonymous HIV screening and brief counseling, seldom discussing the result with the staff. Approximately 90% of the staff and a majority of the patients (72%) thought a voluntary HIV screening program should be offered to all patients. Almost all staff (98%), but only 50% of the patients, felt the HIV test results should be known to physicians, nurses, and counselors at the clinic. Few staff members (15%) believed that patients had changed their sex behavior; more (48%) felt that needle sharing was reduced. Patients believed methadone patients in general had changed their sex behavior (49.2%) and reduced needle sharing (62%) to prevent becoming infected. Patients reported statistically significant reductions both in number of sex partners and in personal needle sharing during the past year.

Adult↗
PubMed1988

Ethical issues in the prevention and treatment of HIV infection and AIDS.

The epidemic of infection with the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) poses a major ethical question: How can we control the epidemic and the harm that it causes without unjustly discriminating against particular social groups and without unnecessarily infringing on the freedom of individuals? This question pertains to three spheres of public policy in the United States: public health, the delivery of health care, and research. In the public health sphere, vigorous educational efforts will be required, as will modified approaches to intravenous drug use, prostitution, and homosexual and bisexual sexual activity. Carefully targeted, voluntary testing and screening programs should be coupled with counseling and with guarantees of confidentiality and nondiscrimination where these are appropriate. Both health care workers and the health care system have a moral obligation to provide care to people with HIV infection, but heroic self-sacrifice should not be required provided that infection control precautions are observed. Patients with neurological involvement and terminally ill patients will benefit from statutes allowing recognition of advance directives about preferred modes of care or nontreatment. There is a moral imperative to perform intensive research directed toward the understanding, treatment, and prevention of HIV infection and AIDS. The research process will raise challenging ethical questions.

Acquired Immunodeficiency Syndrome↗
PubMed1982

A survey to evaluate parental consent as public policy for neonatal screening.

Most states currently have laws which result in compulsory neonatal screening practices, despite a widespread consensus that participation in genetic services and programs should be voluntary. In 1976, Maryland adopted a regulation designed to respect parents' rights to refuse neonatal screening by imposing a parental consent requirement. The results of a study designed to evaluate the effects of this regulation are reviewed here. Many health care providers were unaware of the parental consent regulation. However, hospitals were generally in compliance with the technical stipulations of the regulations. There was little evidence that the regulation resulted in additional costs to the health care system, either in terms of hospital staff time or in terms of loss of efficiency in the number of infants screened. Mothers affected by the regulation were largely in favor of being informed about neonatal screening and learned a significant amount of new information from the disclosure process. They were almost evenly divided on whether they favored parental consent.

Adult↗
PubMed1984

Ethical and social aspects of risk predictions.

This paper reviews past, present and future social and ethical considerations of screening carriers of autosomal disorders and other heterozygotes. A body of ethical and social guidance has evolved in the 1970's and 1980's for screening. The values of voluntaristic participation and informed consent are high. The goal of programs should be to provide couples, families, and individuals with knowledge respecting their reproductive choices. The dangers are coercive strategies, stigmatization, and careless communication of risk information. It is assumed that the number of autosomal carrier states that are screenable will undoubtedly increase as will states of heterozygosity that cause susceptibility to common diseases. Before the end of the century, something approaching a "biopsy of the human genome" will be a practical reality. To balance the potential for harmful psychological and social effects of so much new genetic knowledge, new efforts must be made to find treatments for progeny affected by recessive disorders. Maternal and paternal screening, prenatal diagnosis and treatment will be increasingly linked in the future. This paper will report on a case of fetal therapy for congenital adrenal hyperplasia as a paradigm for the future. The argument will be made that society ought to put a higher priority on prenatal care and prevention of disorders of prematurity than genetic disorders with a low frequency, lest genetic screening be distorted by unfounded concern about eugenics.

Adrenal Hyperplasia, Congenital↗
PubMed1992

Mandated choice. The preferred solution to the organ shortage?

BACKGROUND: A critical shortage of organs is perhaps the major barrier facing transplantation today. Adopting a system of presumed consent or mandated choice are among the solutions proposed. Under presumed consent, organs may be removed after death without explicit consent, unless the deceased had previously objected or the family objects at the time of death. Under mandated choice, all adults would be required to decide for themselves whether they wish to donate on their deaths and their decisions would be controlling. METHODS: To see if educated young people would support these proposals, I carried out two surveys at the University of Maryland, College Park, Md, of a total of 418 students who were at least 18 years of age. RESULTS: An overwhelming 90% would support mandated choice while a smaller percentage, just over 60%, would support presumed consent. The vast majority believe that the family should not be able to override the previously expressed wishes of their recently deceased loved one. Unfortunately, only a minority of respondents had discussed organ donation with their families and even fewer had signed donor cards. CONCLUSIONS: Even young, educated people frequently fail to consider organ donation prospectively and this is a major barrier to organ retrieval. While presumed consent and mandated choice are designed to deal with this serious problem, mandated choice seems preferable and would likely receive widespread support. Therefore, I suggest that a small scale trial of mandated choice be undertaken as soon as possible in the hope of finding an acceptable system that will quickly and efficiently increase the supply of desperately needed organs.

Adult↗
PubMed1992

Requirements or incentives by government for the use of long-acting contraceptives. Board of Trustees, American Medical Association.

Following the approval of the long-acting contraceptive levonorgestrel (the Norplant Contraceptive System) for use by women, government officials have required or proposed uses of levonorgestrel that are problematic. One court ordered a woman convicted of child abuse to use levonorgestrel as a condition of her probation; legislators have proposed that women on welfare be paid to use levonorgestrel. Court-ordered use of long-acting contraceptives because of child abuse raises serious questions about a person's fundamental rights to refuse medical treatment, to be free of cruel and unusual punishment, and to procreate. The state's compelling interest in protecting children from abuse may be served by less intrusive means than imposing contraception on parents who have committed child abuse. If government benefits were based on the use of long-acting contraceptives, individuals would have to assume a potentially serious health risk before receiving their benefits. Government benefits should not be made contingent on the acceptance of a health risk.

Adult↗
PubMed1989

Enforcing patient preferences. Linking payment for medical care to informed consent.

The legal and ethical doctrine of informed consent is well accepted in modern medicine. Nonetheless, medical interventions sometimes take place in the absence of informed consent, particularly in the case of life-sustaining medical procedures. These procedures ordinarily are reimbursed by third-party payers. This article proposes as a strategy to ensure greater attention to patient preferences in medical decision making that financial reimbursement for each medical service be linked to a requirement of valid patient (or surrogate) consent to the service involved. Utilization review bodies could monitor informed consent in the same way that other aspects of necessity, appropriateness, and quality are now monitored.

Consent Forms↗