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Medication administration by anesthesia providers in the perioperative environment is a uniquely risky endeavor because the prescribing clinician is the same person that dispenses, premixes, repack...

Background and objectives: The evaluation of public health law requires reliable accounts of underlying statutes and regulations. States often enact public health-related statutes with nonuniform provisions, and variation in the structure of state legal codes can foster inaccuracy in evaluating the impact of specific categories of law. The optimal format for empirical analysis is a machine-readable 50-state coded data set. This study provides a comprehensive assessment of these resources and related materials with a focus on statutory data sets. Research design: An exhaustive literature search was followed by a “pearling” or “snowball” approach to assure the most complete inventory of this very diverse and diffuse information. We also interviewed three leading investigators to identify barriers to wider use and availability of coded legal data sets. Results: We identified relatively few accessible coded statutory data sets, and others that are not available for use outside the group or individual that compiled them. The Robert Wood Johnson Foundation-funded Public Health Law Research Program has made funding available for the development and dissemination of additional data sets, as well as extensive guidance regarding their use in the evaluation of public health law. Investigators reported serious obstacles to these activities in the past. Conclusions: Compilation of coded statutory data sets requires a focused investment of resources that has only recently become available. Funders should require grantees to make their work accessible to other investigators so as to assure development of public health law research and evaluation.

This installment of Law and the Public’s Health considers the role of the judiciary in advancing public health goals. Typically, public health policy advocacy efforts aim to affect the regulation and legislation produced by the executive and legislative branches of federal, state, and local government bodies. But one branch of government—the judiciary—is less frequently considered as a venue, which is a missed opportunity for public health. The goal of this article is to demonstrate the need and identify the strategies for what we call “public health advocacy in the courts,” defined as actions by public health professionals that inform and affect how courts approach matters that affect the public’s health. We first review the court’s traditional roles in defining and deciding public health-related matters and consider judicial actions in the areas of constitutional and administrative law, civil litigation, and criminal law. Within criminal law, we highlight the recent expansion of problem-solving courts as a new opportunity for public health professionals to engage with the criminal justice community in advancing prevention strategies to address public health issues such as substance abuse and intimate partner violence (IPV). We then discuss specific strategies by which public health professionals can engage as advocates in the criminal and civil judicial processes. We conclude by presenting public health advocacy in the courts as a natural extension of existing public health advocacy, and offer strategies for overcoming the obstacles that public health professionals may encounter when they engage in these efforts. The courts, both state and federal, have a profound influence on public health policy and practice. This installment of Law and the Public’s Health examines the nature and power of the judiciary in the area of public health law and policy, discussing some of the landmark cases that together both define and test the limits of governmental powers and the rights of individuals and private interests.

This paper addresses the implications of cultural and religious beliefs and behaviours for the imposition of population-based health policies, and for law that delivers these policies. In particular, the paper addresses perceptions of health risk in recognition of the importance of risk assessment as a public health tool. In a public health emergency, to what extent should public health law impose public health interventions which might offend individual cultural or religious beliefs? The balance between public health and private right is examined to determine whether public health law can be framed to accommodate minority health beliefs and behaviours without detriment to the health of the population.

The preparedness of the U.S. public health system to respond to acts of terrorism has received a great deal of attention since September 11, 2001, and especially subsequent to the anthrax attacks later that year. The use of biologic agents as a weapon has served as a catalyst to better aligning public safety and health strategies through public health law reforms. Associated with this work is the renewal of the debate over the most appropriate means to both protect the public and asssure the rights of individuals when implementing readiness strategies. A key element of the debate focuses on what is a reasonable application of state-based police powers to ensure community public health standards. The doctrine of state “police power” was adopted in early colonial America from firmly established English common law principles mandating the limitation of private rights when needed for the preservation of the common good. It was one of the powers reserved by the states with the adoption of the federal Constitution and was limited only by the Constitution's Supremacy Clause—which mandates preeminence of federal law in matters delegated to the federal government—and the individual rights protected in the subsequent Amendments.1,2 The application of police power has traditionally implied a capacity to (1) promote the public health, morals, or safety, and the general well-being of the community; (2) enact and enforce laws for the promotion of the general welfare; (3) regulate private rights in the public interest; and (4) extend measures to all great public needs.3 The application of “police powers” is not synonymous with criminal enforcement procedures; rather, this authority establishes the means by which communities may enforce civil self-protection rules. More specifically, public health police power allows the states to pass and enforce isolation and quarantine, health, and inspection laws to interrupt or prevent the spread of disease. Historically, the exercise of public health police power was enforced with strong support of the courts and restraint of police power occurred only when there was open disregard for individual rights. The abilities of states to exercise their police powers has been constrained since the 1960s by the legal and social reexamination of the balance of power between the individual, the states, and the federal government, which affects contemporary efforts to reform public health law in the face of terrorism. Given the development of the criminally based threats to health marked by bioterrorism, the relatively recent emphasis on the personal rights side of the equation should be reassessed.4 A reexamination of the legal, ideological, and social limits of police power is appropriate since increased state capacity can be crucial for first responses to terrorist threats or actions. Effective first responses may be hampered in the absence of pragmatically designed realignments of the state-individual relationship and the redesign of state public health infrastructures.5 This article begins with an historical overview of the doctrine of state police power, addresses recent limitations imposed on the implementation of public health police powers, then uses the example of the imposition of quarantine orders to illustrate the state's capability to impose such orders in exercise of its police power. Finally, it suggests changes in state public health agency governance, focus, and regulation to rebalance public and private interests.

People infected with HIV who persist in exposing others to infection through negligent, reckless, or criminal activity create a legal and ethical dilemma for public officials. Protection of the public health requires balancing the rights of infected people with the expectations of society. When reasonable efforts fail to obtain the voluntary cooperation of infected individuals, Colorado law permits health officers to restrict their behaviour. Since 1986, at least 20 people who were aware of their infection are known to have exposed others to HIV in Colorado Springs, Colorado. Restrictive measures have been initiated in 14 cases to date. Presented here is an overview of Colorado law, selected case studies, and a summary of its strengths and shortcomings.

In the Wake of Terror1 is a book to be read by any subscriber to the Journal who wishes to get a glimpse of what has happened to the United States since the events of September 2001. Despite being written in the immediate aftermath of those events (the book was 'put to bed' in the spring of 2002), and despite limiting its scope to medicine, this collection paints an alarming picture of how readily our human rights might be put aside in the name of the public good. With the events of 11 September 2001 and the subsequent dissemination of anthrax spores across the USA the world changed in significant ways. Our daily lives may not have altered much, but most of us see the world differently and perhaps we wonder how we might act if caught up in a similar catastrophe. And for many 'what would we do?' rapidly runs into the moral question 'what ought we to do, both individually and collectively?' Jonathan Moreno's latest book is an early attempt to ask if, and if so how, medicine and morality have changed in this time of crisis. It is a book performing both the essential functions of medical ethics2—helping us to right thinking about how values change in a changing world and, one hopes, helping us to right action. (His subtitle refers to morality, but I prefer the term ethics, synonymous but carrying less theological baggage.) First a necessarily brief description of the book itself whose editor heads the Center for Biomedical Ethics at the University of Virginia. Two things must be acknowledged at the outset: first, that the collection deals with the problems of terrorism principally from an American perspective, and second that its authors' remit excluded consideration of what Richard Horton2 has called the principles of harm reduction, i.e. prevention. The book's seventeen contributors cover in varying detail five general topics from both theoretical and practical standpoints. The first and longest section considers issues of public health: how medicine and society have dealt with medical crisis, especially wartime crisis, in the past (Jonathan Moreno; Paul Lombardo); what emergency powers ought and are to be accrued by governments (James Hodge and Lawrence Gostin); and what implications these have both for individual human rights (George Annas) and for public health as an ideology (Ronald Bayer and James Colgrove). The second section considers issues of resource allocation and particularly of allocation in the face of massive demand (James Childress; Kenneth Kipnis). The third considers how the roles of various health professionals necessarily change in response to major challenge (Lisa Eckenwiler) and how this will probably alter both the professional and the political environment in which they work (Griffin Trotter). Section four turns to the obligations of the pharmaceutical industry and shows how its traditional freedom from interference has already been reduced (Evan DeRenzo) and returns to consider how the organization of health care in the USA is likely to be affected (Ann Mills; Patricia Werhane). The final section considers the implications for research involving victims of terror, particularly the inadequacy of current regulations in protecting them (Alan Fleischman; Emily Wood), and the challenges for medicine and society posed by our capacity to make genetically modified biological agents and materials (Eric Meslin). There is much of great interest in this collection. Not all is brand new; James Childress, for example, has written elegantly about triage in the past. Some is concerned primarily with history, as is Paul Lombardo's fascinating demonstration of how easily accepted was the Second World War research into hepatitis conducted at the erstwhile Virginia Colony for the Epileptic and the Feebleminded. But the book is none the worse for that. Some chapters present factual groundwork. For example, Kenneth Kipnis' laying out of what a hospital can and cannot do when facing a disaster-level event such as the Tokyo subway poisoning, let alone a catastrophe-level one such as Hiroshima or Bhopal (or as might have occurred at the Twin Towers if greater numbers had survived their fall) is highly instructive. So is Griffin Trotter's demonstration of how a law passed by a well-meaning Congress wishing to guarantee emergency healthcare to the poor has resulted in A&E departments being legally forbidden from conducting just the kind of triage-and-transfer policy necessary in times of disaster. And some contributors, it must be said, tread a rather narrow path, such as Evan DeRenzo's recommendations for the pharmaceutical industry or those of Alan Fleischman and Emily Wood on human research. Much of the book, however, revolves around the question that should perhaps be of the greatest interest to JRSM readers—to what extent ought concern for the public good override individual liberties? Not a new question, but one highly relevant in the UK at a time of marked public distrust, when voices inside and out of Parliament are recommending a more authoritarian approach to a possible epidemic of severe acute respiratory syndrome (SARS), and when the newly formed Health Protection Agency has already heard concern that the existing balance between personal freedom and the measures needed to overcome threat is inappropriate in today's world.3 The US response has been the Model State Emergency Health Powers Act rushed forward in the immediate aftermath of September 2001.4 Because public health law in the USA is currently a matter for the individual states, and because laws vary greatly, the Model Act aims to provide a common framework for the fifty states to use in replacing existing legislation. The Act is premised upon the view that respect for the rights of individuals must yield in order to safeguard the health and needs of persons in the community, and aims to provide public health authorities, subject to limited restrictions, with whatever powers may be necessary to respond to catastrophic emergencies specifically including but not limited to bioterrorism. Among other things, the Act would require the collection and reporting of data relevant to any of the biological or chemical agents identified by the Centers for Disease Control and Prevention (CDC), remove any hindrance to the wide distribution of medical information among agencies and officials, and authorize the use of coercive powers over both persons and property. In this book the Act is vigorously defended by its principal proponents, Lawrence Gostin and James Hodge. The real question, however, is whether the sacrifice of human rights and the setting aside of the most fundamental principle of medical ethics, respect for patient autonomy, will in fact provide substantially greater security. The case against is argued persuasively in this collection by George Annas and by Ronald Bayer and James Colgrove (and peripherally by others). It may be summarized as follows. First, a nation's response to bioterrorism cannot be effective on a regional basis and in any case the national government already has the power to act by executive order. Second, the Act's proposals are contrary to constitutional law, especially as regards the rights of patients to refuse treatment and the obligations precluding doctors from treating patients against their will. Third, quarantine, the Act's central proposal, is widely regarded as being ineffective5 or even counterproductive6,7 in the settings envisaged. Fourth, coercion simply will not work. Rather we need to overcome widespread distrust by means of public participation and consent. Fifth, there is a distinct likelihood that the states' coercive powers would be extended beyond the area for which they are being proposed—think of the hysteria generated in the past by the appearance of AIDS or today by SARS. (The example of SARS is instructive. Its greatest impact has been in one of the most coercive and secretive of societies.) And sixth, it is not the forced commandeering of hospitals and staff that is needed, but rather a total rethinking of how, where and by whom disaster-level care is best provided. After a slow start, the months following the proposal of Gostin et al. saw widespread criticism from professional bodies, academics and civil rights advocates, and political opposition from both the liberal left and the libertarian right. So much so that in its final form the Act's authors include the remarkable disclaimer that their views do not represent those of their own institution, of the Centers for Disease Control which funds the institution, nor of a host of other named and unnamed governmental and non-governmental agencies and organizations. (The earlier published version claimed that the Act was being prepared for and in collaboration with just these agencies.4) Despite this, and no doubt partly because one billion dollars has been made available for emergency preparedness, the Act has been adopted, albeit mostly in part, by three-quarters of the states. In the light of this there is some slight justification in its principal authors concluding that 'the debate between protecting the public health and individual rights has [now] shifted to state and local government'. Could it happen here? Well, not in exactly the same way, of course. We are not likely to see so dedicated a right-winger as Home Secretary as is John Ashcroft as Attorney General, and political opinion here would likely be more diverse. But if public trust is the key to effective public health actions, and if openness, public participation and consent are essential components of public trust, we should not be too sanguine.

The New York State Departm ent of Health established the Alzheimer's Disease and Other Dementias Registry in August 1986. A legal requirement was enacted through Public Health Law that stipulated physicians and facilities must begin reporting the diagnosis or confirmation of Alzheimerls disease beginning January 1, 1987. By September 1987, over4, 000 reports had been submitted to the registry. Analysis of the reporting experience up to September 1987 provided the basis for a revision of the case report form and procedures for reporting, that are intended to improve the validity of the data. The process of revising the confidential case report form involved both consideration of methodologic issues and reporter concerns.

This article analyzes four major assumptions that guide the Reagan Administration's health policies: 1) the Administration received an overwhelming popular mandate to reduce the federal role in the U.S. health sector; 2) the size and growth of federal social (including health) expenditures are contributing to the current economic recession; 3) the costs to business of federally imposed health and safety regulations have contributed to making the U.S. economy less competitive; and 4) market intervention is intrinsically more efficient than government intervention in regulating the costs and distribution of health resources. Based on these assumptions, the main characteristics of the Reagan Administration's health policies have been 1) a reduction of federal health expenditures and, very much in particular, expenditures to the poor, handicapped, and elderly; 2) a weakening of federal health and safety regulations to protect workers, consumers, and the environment; and 3) the further privatization and commodification of medical services. This article shows that there is no evidence to support the assumptions on which these policies are based. Quite to the contrary, all available evidence shows the opposite: 1) the majority of Americans want an expansion of federal health expenditures and a strengthening of federal health regulation; 2) U.S. government expenditures and regulations are much more limited than those of other countries whose economies are performing more satisfactorily; and 3) those countries with larger government interventions have more efficient health care systems than the American one, where the “free market” forces are primarily responsible for the allocation of resources. Thus, major Reagan Administration health policies are based on myth rather than reality.