Rationing Legal Services: Can Bioethics Help? My new article forthcoming in the Journal of Legal Analysis

There is a deepening crisis in the funding of legal services in the United States. The House of Representatives has proposed cutting the budget of the Legal Services Corporation (LSC), one of the main funders of legal assistance to America’s poor, to an all time low in inflation-adjusted terms. Other sources of funding, such as Interest on Lawyers Trust Account (IOLTA) are also way down due to low interest rates. More than 135 state and local organizations providing LSC assistance are now in a precarious position. The community was already decimated by the last round of cuts in January 2011, that led to the laying off of 1,226 lawyers and support staff at LSC-funded organizations, and 81,000 fewer low-income Americans receiving aid. This is all occurring at a time of extremely high unemployment and state budget cuts in services supporting low-income people, meaning demand for many of these services is going up.

The deepening crisis in funding of legal services only makes more pressing and manifest a sad reality: There is and always will be persistent scarcity in the availability of both criminal and civil legal assistance. Given this persistent scarcity, this Article will focus on how existing Legal Service Providers (LSPs), both civil and criminal, should ration their services when they cannot help everyone. To illustrate the difficulty these issues involve, consider two types of LSPs, the Public Defender Service and Connecticut Legal Services, that I discuss in greater depth below. Should the Public Defender Service favor offenders under the age of 25 instead of those older than 55? Should other public defenders offices with death eligible offenses favor those facing the death penalty over those facing life sentences? How should Connecticut Legal Services prioritize its civil cases and clients? Should it favor clients with cases better suited for impact litigation over those that fall in the direct service category? Should either institution prioritize those with the most need? Or, should they allocate by lottery?

These are but a small number of the difficult questions faced by those who have to ration legal services. Very little has been said as to what principles should govern the rationing of legal services. This is surprising given that civil and criminal LSPs are often funded through a mixture of government funding and charitable support in such a way that they should be answerable on questions of justice, and because their decisions whether or not to support a client is likely to have significant effects on that person’s life prospects. Thus, it seems as though the rationing decisions of LSPs deserve significant ethical scrutiny.

In my new article Rationing Legal Services, forthcoming in the peer-reviewed Journal of Legal Analysis (and available for free download in draft form now), I seek to remedy this deficit in the existing literature by engaging in a comprehensive analysis of how LSPs should allocate their resources given the reality of persistent scarcity. Luckily, this work does not have to begin at square one. There is a developed literature in bioethics on the allocation of persistently scarce medical goods (such as organs, ICU beds, and vaccine doses) that I use to illuminate the problems facing LSPs and the potential rationing principles they might adopt.

The Ethics of Bike Shares: Some Tough Distributive Justice Questions about Helmets, Fatalities, and Obesity/Heart Disease

Boston recently followed many other world cities in implementing a bike share program. As the New York Times recently reported, North American cities face a dilemma: if the European experience is any guide, for bike shares to take off the city must do away with the helmet requirement. That turns out to be not a health versus leisure trade-off, but a complex health vs. health trade-off. As the New York Times puts it:

In the United States the notion that bike helmets promote health and safety by preventing head injuries is taken as pretty near God’s truth. Un-helmeted cyclists are regarded as irresponsible, like people who smoke. Cities are aggressive in helmet promotion. But many European health experts have taken a very different view: Yes, there are studies that show that if you fall off a bicycle at a certain speed and hit your head, a helmet can reduce your risk of serious head injury. But such falls off bikes are rare — exceedingly so in mature urban cycling systems. On the other hand, many researchers say, if you force or pressure people to wear helmets, you discourage them from riding bicycles. That means more obesity, heart disease and diabetes. And — Catch-22 — a result is fewer ordinary cyclists on the road, which makes it harder to develop a safe bicycling network.

Suppose hypothetically we came to the conclusion that more life years would be lost to obesity/heart disease related injuries from forbidding helmet laws than would be saved from putting helmets in place, would that justify doing away with our helmet laws? Does it matter that the injuries cause immediate death/injury in the un-helmeted case but are gradual to accumulate as to obesity and heart disease in the helmet case? That might in turn depend on whether we believe in the “rule of rescue” and whether we think of it as merely a rule about allocating aid versus preventing harm in the first place. If most bicyclists who are injured are younger, given the typical profile of the city biker, is there a dimension of age-weighting that might be relevant. Or, in fact, given that those who do not use bikes now due to the helmet laws will be older when they suffer from obesity/heart disease give us a reason to think age-weighting is inappropriate in this domain. This is somewhat similar to the arguments offered in the Age Discrimination in Employment Act (ADEA) context, that unlike Title VII or the ADA we will ALL (if things go well) eventually be old, so protection for the old benefits everyone. However, those who get hit by cars without helmets will likely die young. Finally, what role for choice, responsibility, resistance to the nanny state, etc?

Are You My Mother? (Guest Post for Kimberly Mutcherson)

[Editorial Note: This Post is by Kimberly Mutcherson]

Some states have come to terms with commercial surrogacy and create standards to protect parties to contracts and the children born of those contracts. New Jersey, however, just can’t seem to get it right when it comes to surrogacy arrangements. I suppose that is no surprise coming from the state that brought us one of the nation’s most notorious surrogacy related custody disputes—the 1988 Baby M. case. Over 20 years after Baby M., our state courts continue to run scared from the reality of 3rd party reproduction.  The latest blow to sensible policy related to surrogacy comes from an October 2012 New Jersey Supreme Court decision in a case called, In Re: The Parentage of a Child by T.J.S. and A.L.S. The facts are fairly simple within the world of assisted reproduction. A married man and woman hired a gestational surrogate to carry an embryo formed from the husband’s sperm and an egg purchased from an anonymous source. The only two people in this arrangement who were interested in being parents to the child born of this pregnancy were the husband and wife.

To protect their interests and those of the gestational surrogate who, after all, was not looking to add another child to her household, the intended parents sought a pre-birth order from family court. That order was a declaration of parentage, which would have allowed the names of the intended parents to appear on the child’s birth certificate after the gestational carrier voluntarily relinquished her rights to the child. By statute, the relinquishment of parental rights could not take place until 72-hours after the child’s birth. As was contemplated by the agreement between the parties, three days after the child’s birth, the surrogate relinquished her rights after which the pre-birth order required the release of a birth certificate with the names of the intended parents. Here is where things got loopy. The State Registrar got wind of the pre-birth order and moved to vacate the portion of the order as to the issuance of the birth certificate. New Jersey, thus, took the position that the intended mother in a gestational surrogacy arrangement who has no genetic tie to a child cannot be listed on the child’s birth certificate and must complete an adoption procedure in order to secure a legal relationship with the child.

In contrast to this set of circumstance, the New Jersey Parentage Act allows a man to be the legal father of child, without an adoption, where he consents to his wife being artificially inseminated with another man’s sperm. If you are a father with no genetic connection to a child and your wife carries the baby, you are the father and she is the mother. If you are a wife with no genetic connection to a child and a gestational surrogate carries the child, you are a legal stranger to that child unless and until you complete an adoption procedure.The intended parents argued in the Appellate Division that this distinction violated equal protection. The court disagreed and an equally divided Supreme Court upheld this decision when it could not find a majority on either side of the issue.

What we are left with in New Jersey is a system that is failing families.

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Architecture for those with Disabilities

My colleague Jonathan Lazar who studies the way in which the web creates barriers to people with disabilities mentioned to me a neat program/event that may be of interest to some BOH readers in the Boston area: As part of the Architecture Boston Expo currently going on there is a Universal Design: Accessibility Exhibit, which features two spaces for attendees to navigate. One is made up using universal design features, the other features “common” design errors (sometimes quite subtle) making it difficult or impossible to use.

Architects and other attendees are put in a wheelchair and asked to try to make use of both spaces. The idea is that by experiencing the space as would someone with a disability, architects will be better able to understand the ways in which their small decisions have big impacts on people’s lives.

I thought this was a really interesting and novel approach to the problem, and one wonders whether architecture schools should make these kinds of experiences part of the curriculum?

It’s the End of the University as We Know It?!!? On MOOCs and Attestation

I am writing this from Malaysia where I am touring hospitals as part of my book in progress on medical tourism. I may try to blog on the trip a bit next week, but for now I want to continue my thoughts from my last blog post prompted by our conference on Financial Conflicts of Interest In Research Universities.  Shortly after my post the New York Times ran a long story on Massive Open Online Courses (MOOC)s, such as Coursera, EdX and the like which enroll thousands of students in online courses that incorporate, among other things, recorded lectures in bite sized portions. Full disclosure, I teach in a MOOC of sorts: I teach NY and MA Civil Procedure for the bar-prep company Themis, although this is not as a substitute for university courses. Bar prep has long beem MOOC-y.

MOOCs are, I think, a major form of disruptive innovation for  universities. Suppose I taught the first-year introduction to economics course at my local university. Suppose we have five professors lecturing in that course, as we did at the University of Toronto where I did my undergraduate education (and took such a course). The course is a lecture course. Why have five faculty members teach it? Why not merely record *the best* lecturer of the group and have him record the course and make it available to all the students, ready to be scaled up? But why stop at my faculty? Why not find the best introductory economics lecturer in the U.S., record her, and license it to all faculties across the country?

One answer is the importance of the 1 on 1 faculty engagement. However, once these introductory courses get beyond a certain size (say 150) how different is the MOOC in this regard, do students really access those profs? Moreover, universities offering MOOCs might remedy this downside the same way they do for large bricks and mortar classes through discussion sessions taught by teaching assistants, often graduate school students. I fondly remember being a Teaching Fellow while at law school for Michael Sandel’s Justice course which packed hundreds of students in Sanders Theater (although to Sandel’s credit he was able to make it feel interactive even in those huge numbers). Office hours with *the* professor might be a problem, although again perhaps the other faculty members in the department *not* teaching these large classes anymore would have *more* time to meet students.

To be sure I am not arguing that MOOCs would be as good or better than the bricks and mortar classes  (although interestingly the NY Times’ stories’ report that some students that took the MOOC version of one of the courses featured in the article preferred it to the bricks and mortar version). Instead, the claim is that the resources saved by offering the MOOC and the lower pass-through costs might outweigh diminutions in quality, especially if one could find the very best lecturers.

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Institutional Corruption, Conflicts of Interest and Commitment, and Online Courses

I am writing this post from a terrific conference on Institutional Financial Conflicts of Interest In Research Universities, hosted at Harvard Law by the Petrie-Flom Center and the Edmond J. Safra Center for Ethics.

One set of fascinating questions that has been raised is when the university should reign in the ability of faculty members to take on directorships and other outside activities. While these issues have been well-known in the sciences and medicine, increasingly it has come home to roost in the law and other faculties. The Harvard Law School  recently adopted a new conflicts of interest policy, as part of a Harvard-wide revision of its policies.

Here is a question that has received less discussion from what I have seen, though it may become more pressing given Coursera, EdX, and other online teaching venues.  The New Yorker profile of my Harvard Business School colleague and world-renowned teacher Clayton Christensen reported that he has recorded videos lectures (complete with good-looking young men and women actors playing students and laughing at the right moments, what a perk!) for the University of Phoenix’s lecture series, for significant remuneration. Imagine that this series (or one of these other non-Harvard platforms) were to offer to pay half a million dollars to me to teach a 4-hour Civil Procedure (or health law or bioethics and the law course) that would in part mirror the teaching I do of the course at Harvard Law School. Should Harvard have a veto right over me doing so? Should it demand “a piece of the action” and revenue sharing agreements as a condition of letting me participate? After all, I am in some ways trading on my capitol for teaching at Harvard, and potentially also diluting the reputational value of Harvard instruction (the informercial would go “You don’t need to go to Harvard to get a lecture from a Harvard Prof! Only $9.99!”) How can the rules governing patent and other IP ownership in the  life and other sciences help us develop a sensible policy? Would or should things be different if I gave these lectures for free on YouTube rather than selling them? [Disclosure: Harvard DOES have a policy on conflicts of commitment, though I am unaware of it speaking specifically to these issues about online lectures, but happy to be corrected].

Reflections on a Recent Study Showing Sperm and Egg Donor as Übermensch/Uberfrau

Last week, I sat on a panel at the Mid-Atlantic Law and Society Association, with my wonderful colleagues Kim Mutcherson, Gaia Bernstein, Rene Almeling, and Cynthia Daniels on sperm donor anonymity. [NB: as in most of my work I will use the term “donor” because it is used in common parlance while acknowledging that “seller” is more accurate].

Among other topics discussed, Cynthia shared with us a new paper she has just published in Signs, co-authored with Erin Heidt-Forsythe, the contents of which I found fascinating and I think some BOH readers may as well. They examined the characteristics of 1,156 sperm donors from the top twelve sperm banks in the U.S., and found them to be very much (in my view) that of the ubermensch and uberfrau (in the Nazi conception of the term, not necessarily the original Neitzchean).

Among other findings they note that 44% of sperm donors are above 6 feet tall compared to 10% of American men; 61.9% have healthy weight in Body Mass Index (BMI) terms, as compared to 32% of the U.S. population; 62% had a college or higher degree compared to 26% in the U.S. population and only 2% of sperm donors had high school as their highest level of educational attainment compared to 32% of American men.

They also found that African-American and Latino donors, both underrepresented groups in sperm donor pools compared to the U.S. population, were much more likely to be listed as being on the light or medium skin tones for those groups rather than the dark side, again in variance with the distribution in the general population

They then compared these findings to a similar review of 359 egg donors recruited from eight fertility clinics.

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Abortion, Circumcision, and the Politics of Documenting Informed Consent

Last week, as the New York Times reported, a fight over documenting informed consent to a particular Jewish circumcision ritual is brewing. To quote from the article:

The city Board of Health passed a regulation in September that required written parental consent before a ritual circumcision could be done. In the procedure, common among ultra-Orthodox Jews, the person performing the circumcision uses his mouth to remove blood from the incision. The oral contact, known in Hebrew as metzitzah b’peh, is considered dangerous by public health officials, because of the possibility of spreading diseases, specifically herpes. Failure to comply with the regulation could result in warnings and fines.

To be clear the New York City Board of Health has NOT outlawed the procedure, despite its herpes risk. Instead it only requires that written parental consent be given. My first reaction, and I suppose the reaction of many, is “what could possibly be wrong with that?”  On reflection, though, I began wondering what might be learned by juxtaposing this requirement against another one that is trying to influence parental choice…laws on informing women about the risks of abortion and requiring the offering or viewing of an sonogram.

As John Robertson, among others, has recently detailed:

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Nice Jotwell review of former Petrie-Flom Fellows’ article “Does Agency Funding Affect Decisionmaking?: An Empirical Assessment of the PTO’s Granting Patterns”

Over at Jotwell, Michael Carroll (American) has a very nice review of a new paper that is a collaboration between two of our former fellows at the Petrie-Flom Center, Michael Frakes (Cornell) and Melissa Wasserman (Illinois).

Their article is Does Agency Funding Affect Decisionmaking?: An Empirical Assessment of the PTO’s Granting Patterns, 66 Vand. L. Rev. (forthcoming, 2013).

Here is the abstract of that paper:

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Home HIV Testing, partner screening, the medicalization of intimacy, and responsibility for health

As the New York Times reported this week, in an article entitled “Another Use for Rapid Home H.I.V. Test: Screening Sexual Partners,” some in the public health community are exploring the ramifications for a use of the new OraQuick home HIV test that the company has been somewhat coy about: using it to test a new partner before sex, which may be particularly likely in the gay community. On November 5, 2012, the Petrie-Flom Center (in collaboration with Fenway Institute and Center for Health Law and Policy Innovation) will be hosting a great live panel (open to the public) “Advances in HIV Prevention: Legal, Clinical, and Public Health Issues,” focused in part on the OraQuick test and also on Pre-Exposure Prophylaxis (Truvada). The event will also be webcast after the fact.

Unfortunately, I’ll be in Malaysia touring hospitals as part of the research on my new book on medical tourism during the event, but I thought I’d use this forum to share some of my thoughts/questions about the use of these tests for partner screening. Here they are in a few different boxes:

The Medicalization of Intimacy: Is there something problematic about intimate sexual conduct becoming a medicalized affair to some extent? We are not all the way to the scene in Gattaca where Uma Thurman plucks a hair from Ethan Hawke to genetically profile him before deciding whether to pursue him romantically, but this use of OraQuick does interpose a medical technology into a sexual relationship. Now there may (more on that below) be public health benefits such that the development is all-things-considered for the best, but is something lost when this happens? Perhaps a separate spheres concern when technology is used to replace trust/intimacy? Or is this overblown? How will this affect the personal lives of individuals with HIV, and is that relevant?

Overreliance and the Effect on other STIs: The Times Article suggests that the designers of the test have made a specific choice as to Type 1 v. Type 2 errors: “It is nearly 100 percent accurate when it indicates that someone is not infected and, in fact, is not. But it is only about 93 percent accurate when it says that someone is not infected and the person actually does have the virus, though the body is not yet producing the antibodies that the test detects.” Will individuals who do partner screening internalize these numbers or will they go right from a negative test to no condom use, not processing the 7% risk the test is incorrect? Moreover, even if correct, will the test lead to (a) internalization of poor sexual health practices (no condoms) that users will carry over to encounters where they do not use the test, and/or (b) the spreading of non-HIV STIs like gonorrhea (the New Yorker recently gave a terrifying account of the rise of antibiotic-resistant gonorrhea)? What is the tort liability for the company in one of these situations, if any? If we think some individuals will be bad decision-makers and put themselves at greater risk for non-HIV STIs (not saying the data is there, just asking “what if” or the sake of argument) should that be relevant as to whether such tests should be available/approved? Do the numbers matter? Or is it the case that if even one person might avoid an HIV infection that would outweigh, from a policy perspective, an increase in other STIs of a large size? Those who have followed my writing and blogging on health care rationing can probably guess where I stand on the issue…

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