The wish of many to die with dignity in the face of medical technology, which holds out the hope of continued life but can dehumanize those whom it sustains, is played out countless times in hospitals and nursing homes every day. Each day, hundreds, if not thousands, of decisions must be made about administering or withholding life-sustaining treatment for critically ill patients. Occasionally it spills over into the courtroom and the press, creating the impression that there is a large volume of such litigation. In fact, the number of litigated cases is relatively small–approximately 50 reported cases since the Quinlan case in 1975, and possibly a few times that number in unreported cases.

Betty's case did not wind up in the courts, though it is the kind that could have, given the combination of her physicians not talking to Betty and her family, not listening to them, and not hearing them, and their apparent unwillingness to let Betty die peacefully without aggressive treatment.

Injury control has gained gradual acceptance as both a public policy concern and the focus of scholarly research during the last decade. Observers have noted the costs to American society of both intentional and unintentional injuries and have sought to identify preventive intervention strategies that can reduce their incidence and impact. Although many of these intervention efforts have just begun, researchers have been far more successful at identifying potential strategies for the prevention of unintentional than for intentional injury. Indeed, many observers have asked whether the majority of intentional injuries can be prevented at all. In this paper I examine the various problems associated with the prevention of intentional injuries such as homicide, assaultive violence, and suicide. Homicide among blacks is used to illustrate the variety of theoretical, ideological and practical concerns that must be confronted in efforts to successfully prevent intentionally induced injury.

Proponents of efforts to designate injury, both intentional and unintentional, as a health concern have suggested that one result of such a designation will be the development of more effective strategies for the prevention of injuries.

This well known position of the AMA Judicial Council implies that the distinction between intentionally causing death and letting a patient die is conceptually clear and ethically significant. Most opponents of active voluntary euthanasia accept the validity of this distinction; proponents inevitably do not. The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research is a notable exception.

Let us start with a conclusion that seems not to be in dispute: that in April of 1989 Samuel Linares had little or no interest in living. He had been competently diagnosed as being in a persistent vegetative state, by then eight months long. The cause was clearly prolonged asphyxiation, so that whatever uncertainty exists in cases of unknown etiology was not a factor. It could also be claimed that he had little interest in dying, in that he was probably incapable of suffering from prolonged treatment. But few advocate prolonged intensive care for preservation of mere vegetative functions. Nor is there serious argument that patients or surrogates who request discontinuation of treatment in such circumstances, when it serves no interest of the patient, are acting immorally. Even the vitalist federal Baby Doe regulations concede that life-sustaining treatment may be discontinued when the patient is permanently comatose.

The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research undertook a study of “Deciding to Forego Life-Sustaining Treatment” because this issue seemed to the commissioners “to involve some of the most important and troubling ethical and legal questions in modern medicine,” even though it was not part of the commission's original legislative mandate. In submitting the report to the President, Morris Abrams, the chairman of the commission, noted: “Although our study has done nothing to decrease our estimation of the importance of this subject to physicians, patients, and their families, we have concluded that the cases that involve true ethical difficulties are many fewer than commonly believed and that the perception of difficulties occurs primarily because of misunderstandings of the dictates of law and ethics.”

Injury and its prevention, like other areas of public health regulation, pose a number of interesting challenges to the theory of democratic self government. To understand these challenges, a good starting point is the Great Society era, when in a brief ten year period, major new agencies were created to promote safety in the workplace, the marketplace, and on our nation's highways—agencies like the Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), the Consumer Product Safety Commission (CPSC), and the National Highway Traffic Safety Administration (NHTSA).

The theory of injury that lay behind the new agencies was in sharp contrast to injury policy as pursued up to that time. The new public health and safety agencies were based on the idea that injury must be approached as an environment, not an individual, problem. The most articulate advocate of this view was William Haddon, Jr., the physician and injury researcher who became President Johnson's first head of NHTSA. Haddon argued for well over a decade for abandoning the view of injury as “accidents,” unpredictable and inevitable “acts of God.”

When the Linares case broke in Chicago, the media immediately began contacting ethicists and hospital lawyers in the area. Eventually, and somewhat wistfully as one paper reported, they were unable to find a single ethicist who did not think that the decision should have been made to withdraw treatment from Samuel far earlier in his treatment. Furthermore, ethicists argued that the family and physician should have made that decision. There was no need to consult with lawyers and especially not with courts.

On the other hand, most lawyers contacted felt it was necessary to go to court to obtain permission to withdraw the respirator, since the legal status of such decisions in Illinois (as in most other states) was terribly unclear. Lack of “clarity” was a catchword in these interviews.

This dichotomy between the instinctive reactions of ethicists and lawyers is natural. It should be so. The ethicists consulted, philosophers, theologians, and physicians, are all skilled in clinical ethics.

Although in its 1986 Report on medical malpractice, the General Accounting Office found “No Agreement on the Problem or Solution,” it is readily apparent to any participant in or informed observer of health care delivery in the United States today that problems do exist regarding both the occurrence of medically-induced patient injuries and the management and resolution of medical liability claims. Public policymakers, on both the federal and state levels, have devoted a great amount of attention and energy in the past several years to attempts to devise solutions to these troubling patient injury and provider liability difficulties, difficulties that arguably impact negatively on the quality of medical care, its accessibility, its costs, the physician/patient relationship, and the progress of medical innovation. Private organizations have also undertaken initiatives in this area.

In December 1986 the New York State Commissioner of Health, David Axelrod, MD, designated an Injury Control Program within the Division of Epidemiology. This action was in recognition of the importance of injuries as a major public health problem in New York State. The public health importance of injuries is highlighted by the fact that injury particularly affects young and productive members of society as well as the poor and needy who make up the traditional clientele of public health departments. Injury is the leading cause of death in persons under age 35 in New York State and accounts for more years of potential life lost before age 65 than cancer, heart disease or AIDS (Figure 1). Injury is the fourth leading cause of death for all ages and a major cause of hospitalization and disability.

The New York State Health Department's authority to engage in injury control activities derives from four sources: the general powers and duties of the Health Commissioner as described in the New York Public Health Law; specific provisions of the law which direct the Department to engage in discrete injury-related activities, such as burn treatment and poison control; executive orders of the Governor, such as Executive Order #35 establishing the Governor’s Advisory Council on Highway Safety; and the authority of the Public Health Council to promulgate a State Sanitary Code which includes requirements for operation of swimming pools and bathing beaches, temporary residences (including children’s camps), regulations for emergency medical services, and so forth. The Injury Control Program’s major functions are based on the Department’s general authority.

The Linares case is one of the memorable moral dramas played out in a pediatric intensive care unit and in the press in a decade of momentous moral cases concerning the care of children. It was a vivid tragedy that posed intense conflict. Its characters were sharply drawn, and it culminated in a final, dramatic scene.

High drama tends toward heroes who are admired for their courage and distinguished performance, and villains who are embodiments of evil reviled for their wickedness. To make it simple for the audience, the good often wear white and the bad wear black. Not so in this story. Two nurses who took care of Samuel Linares, Karen Stratton and Laura Stark, wrote, ‘‘The media sensationalized Rudy Linares as a hero while Rush PICU staff members were portrayed as the villains. Who is right?”’

Nurses played a central role in the Linares case. Accounts of the drama in newspapers, television stories, and articles across the country contained opening paragraphs giving the basic facts: Rudy Linares, a 23-year-old laborer, held nurses at gunpoint just after midnight on April 26, 1989, while he disconnected his 16-month-old unconscious son, Samuel, from a respirator at Rush Presbyterian St. Luke's Hospital in Chicago and held him in his arms until he died.

In Britain the movement towards “Community Care” gathers apace. Segregation techniques in their traditional forms are steadily losing ground to newer community based alternatives. Both America and Britain have seen a massive reduction in the register of patients resident in mental hospitals; specifically in America from a peak of 560,000, and in Britain 165,000 in 1955, to some 273,000 and 70,000 respectively. And how has this been achieved? Through the rhetoric of “community care,” whose influence over policy in hospital admissions and discharges has been particularly remarkable, according to Peter Sedgwick, in that it does not in reality exist. America has been swift to adopt this new panacea “community care” where the emptying of asylums has turned out to have unforeseen problems. Creedmoor asylum for the borough of Queens in New York released 3,000 patients within a few months. Britain has been rather slow to follow—perhaps a little less ruthless—but the reduction of beds continues.

For decades, medicine has been dominated by a “spare-no-expense’’ philosophy that fostered an ethic of providing all care that is of any conceivable benefit, regardless of the cost. This extended financial honeymoon has now ended. Sweeping reimbursement reform is limiting payment for health care under both public programs and private insurance. As physicians respond to this emerging cost consciousness in health care by declining to perform procedures once considered necessary, will they be exposed to liability or will legal standards shift to accommodate the new constraints? This dilemma is one of the most important issues that will confront health care tort law throughout the remainder of the century.

The potential conflict between malpractice law and cost containment has received considerable scholarly attention over the past dozen years, particularly following the 1983 reform of the Medicare program and the 1986 California appellate decision in Wickline v. State of California concerning that state's Medicaid program.

Despite considerable declines in the early 1980’s, drunk driving remains a major public health problem in the US. In 1986, 46,050 people were killed on the nation's highways. Traffic crashes are the leading cause of death in the age group 1-34 years. Alcohol is unquestionably a major contributor to these crashes. In 1986, 23,987 traffic deaths, 52 percent of the total, involved a driver or pedestrian who had been drinking, and 16,728, 36 percent of the total, involved someone with a blood alcohol level above 10 percent. Many of the victims of drunk driving crashes were not drinking at the time of the event; more than one third of alcohol related vehicular deaths were persons other than drinking drivers: passengers, other drivers or pedestrians.

Legislation may influence drinking and driving behavior, and the consequences thereof, in a variety of ways: limiting access to alcohol; restricting access to vehicles; making vehicles and roadways safer; separating drinking and driving. Taxation, dram shop laws, minimum drinking ages, server liability, land use laws pertaining to the location of alcohol outlets, and prohibitions on advertising alcoholic beverages affect the driver's access to alcohol.

The Infertility (Medical Procedures) Act passed by the Parliament of Victoria, Australia in 1984 was the first legislation anywhere in the world to deal specifically with the regulation of in vitro fertilization and embryo experimentation. As with any pioneering legislation, it has had its problems. Prominent among them was the question of precisely when an embryo comes into existence. This question, which may seem mere semantics, gave rise to a heated controversy with real practical consequences for researchers and infertile couples. The issue was only resolved by the Victorian parliament passing an amendment which specified, more precisely than any legislature had done before, the moment at which egg and sperm become an embryo. This enactment could be seen as a legal declaration of when a life begins—although it remains an open question what legal or ethical significance such a starting point possesses.

Since the Quinlan decision in 1976, courts and legislatures have made substantial progress in defining rules to govern nontreatment of dying and debilitated patients. For example, the right of the competent patient to refuse necessary care is now widely established, and the legality of withdrawing respirators and even nutrition and hydration from permanently unconscious patients is increasingly recognized.

More difficult questions arise, however, when the patient is neither competent nor permanently unconscious, but instead is in a conscious, severely demented and debilitated state, with experiences that appear quite limited. Thousands of patients in this condition are cared for in private homes, hospitals, and nursing homes, the victims of stroke, senility, Alzheimer's disease, and other illnesses. Even though they usually require only low-tech, minimally supportive care, such patients can impose great stress on their families and high financial costs on the health care system.

Motor vehicle injury in the United States constitutes the leading cause of death during more than half of the normal lifespan: from a few months after birth until 40 years of age. The number of deaths from motor vehicles in the U.S. annually during the 1980s has ranged from 5 1,000 to 43,000, approximately equal to the total deaths of U.S. combatants in the entire Vietnam War. In addition, millions of people each year are the victims of nonfatal motor vehicle injury and thousands become permanently disabled and dependent for the remainder of their lives as a result of brain, spinal cord and other damage incurred in motor vehicle crashes.

During the first half of this century, the manufacturers of motor vehicles successfully evaded responsibility for the damage done by their products. Although the increased risk of motor vehicle travel compared to horse-drawn vehicle and train travel was recognized by 1905, vehicle manufacturers and “safety experts” (often allied in symbiotic associations) managed to define the problem as mainly one of errant drivers.

The issuance of do-not-resuscitate orders was one of the first dilemmas scrutinized by lawyers, health care professionals and philosophers in the field of bioethics. In 1983, the President's Commission articulated the basic principles that should guide decisions about CPR: respect for the choices of patients capable of deciding for themselves, recognition of family members as appropriate surrogates for decisionally incapable patients and the importance of an open dialogue with the physician as a predicate to informed consent.

Six years have passed since the President's Commission issued its landmark report. More than a decade of discussion and written commentary has clarified the ethical and social questions presented by resuscitation decisions. In many states, judicial decisions and legislation have addressed some of the legal uncertainties associated with do-not-resuscitate (DNR) orders. Nonetheless, the gulf between recognized ethical principles and clinical practice remains broad and resistant to change. Nowhere is this gap more evident than in decisions about cardiopulmonary resuscitation (CPR) for competent patients.