A middle stone age worked bone industry from Katanda, Upper Semliki Valley, Zaire.

Three archaeological sites at Katanda on the Upper Semliki River in the Western Rift Valley of Zaire have provided evidence for a well-developed bone industry in a Middle Stone Age context. Artifacts include both barbed and unbarbed points as well as a daggerlike object. Dating by both direct and indirect means indicate an age of approximately 90,000 years or older. Together with abundant fish (primarily catfish) remains, the bone technology indicates that a complex subsistence specialization had developed in Africa by this time. The level of behavioral competence required is consistent with that of upper Paleolithic Homo sapiens sapiens. These data support an African origin of behaviorally as well as biologically modern humans.

The patient-physician relationship and the allocation of scarce resources: a law and economics approach.

Patients with insufficient financial resources place physicians in a conflict of interest between the patients' needs and the financial interests of the physician, other patients, and society. Not only must physicians act ethically, but they must avoid liability for violating their legal duties to their patients. The traditional rules of contract and malpractice law that govern the patient-physician relationship do not provide satisfactory guidelines. Better answers are found in the rules of fiduciary law, but only with regard to direct conflicts between patients and physicians and only at the risk of reducing patient access to care. Certain types of legislative action can resolve these conflicts by altering the traditional legal rules, but care must be taken to preserve patient-physician trust, which the legal rules were designed to enhance.

The effect of genomics on health services management: ethical and legal perspectives.

The growing use of genetic testing for diagnostic and predictive purposes, and for the purpose of selecting therapeutic regimens with better risk-benefit ratios for patients, raises numerous legal and ethical challenges. Researchers and institutional review boards must pay careful attention to the need to obtain informed consent from subjects. The FDA will face increased pressure to more carefully regulate the accuracy of genetic testing. Clinicians will need to safeguard the privacy and confidentiality of sensitive patient information, especially when testing is performed in settings in which the information may be readily accessible to insurers and employers. Novel genomic treatments may increase liability for drug manufacturers, but physicians and other healthcare providers, including health plans' drug formularies, will bear the primary liability risk. Difficult questions of distributive justice also must be faced if third-party payers resist covering genomic services because of their cost. Down the road, more aggressive gene therapy techniques and the ability to test for non-disease traits will tax our notions of fairness, equality, and the limits of professional authority.

Encouraging donation of organs for transplantation by requiring request.

Requiring hospitals to request permission from next-of-kin to harvest organs from a deceased patient is a positive step toward reducing the shortage of organs for transplantation. The "required request" laws, however, should rely on immunity from liability rather than criminal sanctions to encourage compliance.

Rationing expensive lifesaving medical treatments.

In the last fifteen years, medical technology has made significant and spectacular advances. Hemodialysis, coronary artery bypass graft surgery, CT scanners, and organ transplants are among the treatments now available to patients. In recent months, in fact, the media has reported the increased use of artificial hearts, heart transplants, and liver transplants. These technological advances, however, have been accompanied by troublesome legal and ethical issues. For example, someone must decide which patients will receive a medical resource when demand exceeds supply. Similarly, and more commonly, someone must decide whether the significant number of patients who cannot afford an available treatment should receive it despite the cost. In response to these troublesome issues, hospitals, doctors, and commentators have either proposed or implemented rationing systems based on criteria such as the social worth of the patient, likelihood of survival after the operation, and ability to pay. In this Article, Professor Mehlman examines the possible systems for rationing expensive lifesaving medical technologies. First, he concludes that the costs of any rationing system probably exceed its benefits. Consequently, he rejects the rationing of expensive but available lifesaving medical technologies. Second, he argues that the increased availability of the technologies and the recent expansion of patient rights to sue will result in a substantial number of judicial challenges to rationing. Finally, he suggests detailed criteria to aid the courts in deciding whether a resource has been improperly rationed.

How will we regulate genetic enhancement?

Genetic enhancement technologies present difficult and novel regulatory issues, including the problem of measuring and comparing risks and benefits and dealing with the impact of these technologies on social values. This Article describes and evaluates the potential approaches that may be taken to regulate these technologies. The author concludes that a variety of approaches will be necessary, involving self-regulation, government restrictions on access and use, licensing, and a national lottery.

Hominid molars from a Middle Stone Age level at the Mumba Rock Shelter, Tanzania.

Three hominid molars were recovered from a depth of 7.0-7.1 meters in the Mumba Shelter at Lake Eyasi, northern Tanzania. Geological context of the finds and archaeological data indicate that people with a Middle Stone Age technology were using the Mumba locality intermittently whenever retreat of lake waters allowed access to the site. Uranium series dates suggest an age on the order of 130,000 years bp for the teeth and stone tools. Based on morphological analyses, the dental remains probably belonged to one individual and appear to be the crowns of two upper permanent M2s and one lower permanent M2. Crown areas are very small, even in comparison to the variation exhibited by recent African populations. Crown patterns have no archaic features. These teeth are smaller than any verifiable archaic Homo sapiens examples; thus, they may represent early anatomically modern Homo sapiens.

When do health care decisions discriminate against persons with disabilities?

Recent interpretations of laws prohibiting discrimination against persons with disabilities indicate that these laws will play a greater role in health care decision making than previously anticipated. This article employs lessons from other areas of antidiscrimination law to examine these developments and to provide a framework for making health care decisions that are consistent with these new legal interpretations. This article addresses decisions in individual cases, treatment policies adopted by health care providers, and coverage programs of third-party payers, both public and private.

The artificial heart: is it a wise option for health care?

Through Interdisciplinary Grand Rounds we hope to analyze new directions in the organization and delivery of health and medical care. Discussion will focus on current trends, their impact on the health care field and attempts to find solutions to the problems they present. These discussions are selected from the interdisciplinary conferences held at Case Western Reserve University, Cleveland, Ohio. Prepared from transcriptions, they are edited by the presenters and by the Health Matrix editorial staff. The following presentation was co-sponsored by the CWRU Medical School Committee for Student Representatives and the Student Bar Association of the CWRU Law School.