Each year, millions of individuals in the United States are treated for a variety of serious medical conditions with prescription drugs whose therapeutic benefits are well known. The vast majority of these medications are used to treat medical and psychiatric illnesses. Generally, they are used as prescribed, and contribute to a better quality of life for persons suffering from debilitating or life-threatening disorders.

The fact that a small portion of these medications is diverted by those who seek their psychoactive effects raises the important policy issue: how to make drugs easily available for medical use while limiting access for purposes of abuse.

Such a responsibility poses challenges very different from those of the so-called “war” on illicit drugs, because this control must be achieved without impeding patients’ access to medical care. A rational public policy would attempt to achieve a balance between the need to minimize abuse and the need to provide relief.

What is informed consent in medicine? For more than a generation, this deceptively simple question has vexed the law, discomfited medicine, and generated much inspired, provocative, and even contentious commentary.

The question has also spawned several lawsuits. On one side stand patients who claim that, at the time of consent, they were ignorant of a particular risk; who state that, with more or different information, they would have chosen a different treatment; and who argue that, because of an adverse outcome, they now deserve remuneration. On the other side, doctors uneasily watch the lengthening list of suits. Some, troubled by the law's expectations, have reacted by variously describing informed consent as a myth, a fiction, an unattainable goal, or a snare to entrap physicians. They point to the legal commentary condemning informed consent law as ill-defined, diffuse, and fraught with inconsistency, hazy at its best and virtually indecipherable to physicians at its worst: and lacking a fair standard to determine when a patient has sufficient knowledge to give effective consent.

“It was the best of times. It was the worst of times.” Charles Dickens easily could have been describing our time and the dilemma in which victims of nonmalignant chronic pain find themselves.

I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life.

The morning of February 1983 severed my life into “before” and “after,” as clearly as if it has been cut by a sharp knife. The “before” included my career as an oncology nurse, a college nursing professor, and a writer; but that was abruptly ended by the catastrophic rupture of a deep cerebral aneurysm. Surgery saved my life, but something unforeseen occurred during the procedure; and so, in the “after,” I have had to live with a serious seizure disorder and memory loss.

We can think about the use of controlled substances in the treatment of anxiety disorders in two simple but diametrically opposed ways. First, we can say that anxiety disorders are trivial and require only acts of willpower, or, if anxiety disorders do require treatment, they are better treated without the use of benzodiazepines (BZs). When BZs are used to treat anxiety, they pose grave risks of addiction to the patients to whom these medicines are prescribed; they relieve patients’ symptoms, but are the equivalent of a pharmacological “roach motel,” a haven into which many unsuspecting patients enter, but from which few emerge without becoming addicted. Patients must then face terrible struggles to free themselves of dependence on BZs, and this compounds the problem for which they sought treatment. Furthermore, the large number of prescriptions for BZs are a threat to the public health because these drugs are widely abused by alcoholics and drug addicts.

On June 28, 1993, the United States Supreme Court ruled on the admissibility of expert scientific opinion and evidence in federal court cases. The importance of the case can be measured by the interest it stimulated. The scientific community turned out in particular force to register its views. At the heart of the controversy was a debate over the nature of scientific knowledge and its relation to law. More than any other Supreme Court case in recent memory, the amici seemed to view the Daubert case both as posing a potential challenge to basic scientific premises and as an opportunity to reclaim a lost prerogative to determine how science is applied in courts.

Why do some physicians continue to treat patients who are clearly dying or persistently unconscious, while others consider medical intervention to be futile past a certain point? No doubt, medical decisions vary in part because clinical information is often ambiguous in individual cases and because it may support more than one reasonable interpretation of a patient's chances for survival or improvement if a particular treatment is administered. Also, cases vary considerably to the extent that a patient's or a family member's preferences for treatment are communicated, understood, and implemented. But, beyond these contingencies, patients at the end of life may receive more, less, or different treatment because physicians themselves are social actors, individuals who bring to bear on their clinical decisions a variety of personal attitudes, values, concerns, and interests. Legal defensiveness, religious vitalism, authoritarianism, intolerance of ambiguity, and other traits may influence physicians’ behavior, but each may be concealed under the rubric of what is “medically indicated” or “medically appropriate.”

“Wrongful birth” is a controversial malpractice action, which has arisen in the past two decades, secondary to an expanding knowledge of human genetics and the constitutionally protected access to abortion. Under the wrongful birth claim, parents of a child with a congenital illness or abnormality may bring suit against a physician who allegedly failed to provide appropriate prenatal counseling or information. Typically, the parents claim that they were inadequately warned of a potential problem in their child, and that this paucity of timely information prevented them from avoiding the pregnancy or from obtaining an abortion. While these cases have arisen in a variety of clinical circumstances, a characteristic example is the obstetrician who fails to offer amniocentesis to a woman of advanced maternal age who subsequently gives birth to a child with Down syndrome. Since the parents were prevented from learning of the abnormality and therefore exercising the option to terminate the pregnancy, they may claim damages for themselves for the wrongful birth of the infant.

A great deal has been learned in the past fifteen years from the study of pain mechanisms. More recently, the relief of pain has begun to receive much needed attention as well. Although most, if not all, acute and cancer pain can be relieved, recent evidence shows that inadequate treatment of pain is still common among the general population—even for pain due to cancer. Inadequate treatment of cancer pain is even more likely if the patient is a member of an ethnic minority, female, elderly, or a child. Evidence also suggests that substance abusers are at risk for poor pain treatment.

A number of barriers which involve problems of knowledge, attitudes, and laws and regulations affect health care professionals, patients, and the health care system; collectively, they contribute to the inadequate treatment of pain.

George Will, the well-known pundit, once observed: “A society's recreation is charged with moral significance. Sport—and a society that takes it seriously—would be debased if it did not strictly forbid things that blur the distinction between the triumph of character and the triumph of chemistry.” In opposition, Dan Duchaine, the highly publicized “steroid guru” and counter-culture columnist, declared: “There comes a time for many in competitive athletics where winning is more important than those initial goals of health, recreation, and relaxation.” The parallels of these two philosophies to life in general are patent simply by substituting “sports” and “winning” for “career” and “success,” respectively.

This paper will review the basis for banning anabolic steroids in athletics, and consider especially the recent medical findings that support this prohibition. This survey leads into a discussion of the available deterrents, and the secondary, but essential, role of random drug testing as a final safeguard.

Recent legislation, such as the Patient Self-Determination Act, establishes advance directives as an acceptable procedural means of incorporating patients’ preferences for life-sustaining treatments into their medical care. Advance directives can enhance medical decision making since they provide patients with an opportunity to communicate their preferences before suffering from an acute illness that may preclude their ability to do so.

Although patients expect discussions about life-sustaining therapies to be initiated by their physicians, very little is known about what prompts physicians to discuss advance directives with their patients. As in other areas of clinical decision making, there is evidence that patients’ sociodemographic factors influence whether discussions about advance directives occur between patients and their physicians. In one study of persons with the acquired immunodeficiency syndrome (AIDS), those who had not had discussions about advance directives with their physicians tended to be non-white, have no prior hospitalization, and were more likely to have been cared for in a health maintenance organization than in a teaching hospital.

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.

Because an equitable distribution of health care inevitably requires at least some government regulation, and because government regulations tend to impose rigidity on any system, it is widely believed in the United States (and elsewhere) that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day.

Advances in medicine depend not only on the generation of information but also on its dissemination. Clinically relevant data must be transmitted to the practitioners who will use it. Health care professionals in North America are aware of their ethical and legal obligations to inform patients adequately concerning interventions and treatments so that they may make informed choices about medical care. This obligation has been well described and defined by the courts and in the literature of medicine, ethics, and law. But do investigators and others who are responsible for disseminating information have any obligation to divulge adequately the results of clinical trials to practitioners so that the latter might offer the choice of appropriate care to their patients? Can incomplete disclosure of trial outcomes result in harm to patients? If this is the case, what possible avenues are available to avoid such harm?