[The physician as expert witness. Aspects of an ambivalent role exemplified by expert testimony for legal health insurance]

This article provides a broad survey of the difficulties confronting the physician in his role as a specialist in the Health Insurance Medical Service, assessing claims relating to the state medical insurance system. These problems can be divided into the three following categories. Firstly, problems on a personal level relating to the interaction of the different people involved, albeit within the given institutional framework. Secondly, problems involving matters of principle in reconciling diagnosis, the patient's subjective assessment of his condition and legal criteria. Thirdly, problems arising from the pressure created by socio-cultural developments which influence both the patient and the specialist physician in his assessment.

Annotated guidelines on gifts to physicians from industry. American Medical Association Council on Ethical and Judicial Affairs

We have responded on an individual basis to many requests for interpretations of grey areas in the opinion on gifts from industry since its release in December 1990, and many physicians and companies asked for a detailed list of these interpretations. While the council agrees with the concerns several individuals have expressed about additional rules, it authorized this revised list of questions and answers which replaces the earlier draft. It also established three main principles for future implementation: 1. The key principles of the guidelines should be carefully observed by physicians, and the AMA will remain active in attempting to secure compliance by its members. The overriding rule is that individual physicians should not accept substantial gifts from industry, even if the gift has an educational or patient benefit. It is important that the profession set clear and enforceable standards in this regard. 2. Professional associations should make their own interpretations of the appropriateness of gifts to them from industry. Under appropriate conditions, associations of physicians may, of course, receive gifts from industry. 3. Neither the council nor its staff will attempt to regulate minor issues or minute details of compliance. For many situations there are no yes or no answers. Some black letter rules are necessary so that conduct that should be changed is changed. In addition, they aid companies which want to comply with the spirit as well as the letter of the guidelines without putting themselves at a competitive disadvantage. The six points of the Opinion cover most situations and compliance to date has been good.(ABSTRACT TRUNCATED AT 250 WORDS)

Related parties? But I hardly know the guy

When Medicare's auditors determine that a provider is "related" to a supplier of services, to the landlord of the provider's premises, or to the seller of provider assets, costs allowable under the Medicare program are usually limited to actual costs incurred by the related party rather than the higher charges or fees the provider paid. This article will discuss the criteria used by the Medicare program to determine related parties and the available exceptions and special application situations that impact on that determination.

Anti-kickback rules place physicians in unsettled waters

The Resource-based Relative value scale, RBRVS, the sweeping reform in how physicians will be paid, is not the only change being made in Medicare. The federal government has just issued new rules and a new "Fraud Alert" interpreting Medicare's anti-kickback statute, focusing on the business relationships between medical providers and suppliers.

Industry reimbursement for entering patients into clinical trials: legal and ethical issues

Pharmaceutical manufacturers commonly contract with clinical investigators for pre-market testing of new products. The per-patient reimbursement offered to the investigator generally exceeds the per-patient costs incurred by the investigator. This excess represents a windfall that can be used to pay for travel, equipment, or supplies, or to fund research for which the investigator cannot obtain funding through peer-reviewed granting channels. This excess raises a potential conflict of interest, because it may lead the investigator to propose experimental treatment for a patient when the patient might be better served by conventional treatment or by no treatment at all. Not only does this situation pose a conflict of interest, it also is a conflict of which few patients are aware and fewer are informed. We propose that all experimental subjects be informed of the source, amount, and mechanism of funding for the experimental treatments they undergo. Further, we propose that payments from pharmaceutical manufacturers for pre-market testing of drugs go to the medical school dean rather than to the individual investigator. With this money, the dean can defray the direct as well as the indirect costs of the clinical study; the remainder, which would otherwise go directly to the investigator, should be placed in a funding pool for which the entire medical school could compete. This solution largely eliminates conflict of interest, addresses informed consent, and reasonably balances the interests of the experimental subject, the clinical investigator, the pharmaceutical manufacturer, and the academic institution.

Research involving fetal drug therapy: ethical, legal, and practical considerations

Fetal drug therapies have emerged as a promising avenue for the prevention or correction of disease during fetal or immediate postnatal life. Despite slow progress, several medications have been developed for in utero therapy of disorders which relate to fetal and neonatal pulmonary, cardiac, neurologic, and growth disorders. However, ethical and regulatory constraints require protection of the mother and fetus while causing no more than necessary additional risk. Appreciating these constraints will lead to the identification of pragmatic questions which should be answered before evaluating the efficacy and safety of a particular treatment or research proposal.