Cigarette Packaging and Smokers’ Rights

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I had the delightful opportunity at the beginning of the summer to deliver a conference paper in Portugal.  Lisbon’s cobblestone alleyways and bustling riverfront were exciting, but odd as it might seem, Portuguese cigarette packaging also caught my eye.

All cigarette packs in Portugal have graphic images related to the dangers of smoking cigarettes: rotted teeth, amputated toes, diseased lungs, stitched-up chests, and naked corpses sprawled out on coroners’ metal tables.  The images and the accompanying verbal warnings take up the fronts and backs of the packs, and brand names such as “Marlboro” appear only on the narrow bottoms of the packs.

None of the Portuguese smokers to whom I spoke – and there were plenty – seemed particularly offended by the packaging.  So-called “scare messages,” after all, are genuinely intended to get smokers to stop.  They are consistent with the World Health Organization’ s directives regarding cigarette packaging, and graphic images appear on cigarette packs in most European countries.

What about graphic images in the United States?  It briefly seemed that they would begin appearing after the passage of the Family Smoking Prevention and Tobacco Control Act in 2009.  The Act in fact mandated them, and the Food and Drug Administration (FDA) formally approved nine graphic images that it considered especially likely to make people afraid of smoking.

However, the tobacco industry and assorted neo-liberal pundits immediately rose up in arms.  The former, of course, worried about its profits, and the latter championed the “right to smoke.”  The graphic warnings, the pundits argued, interfered with freedom of choice.  They were the efforts of the nefarious “nanny state.” Continue reading “Cigarette Packaging and Smokers’ Rights”

Informed Consent

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White hospital bedsSeveral years ago, the Wisconsin veterinary state convention focused on the legal standard of informed consent in the profession. Lawyers explained that this meant that veterinarians needed to provide all options to owners and that owners make the decision as to what options to pursue. Although this seemed simple enough, and certainly some veterinarians already practiced some degree of informed consent, some veterinarians were understandably concerned about discussing a “no treatment” option and some veterinarians practice in situations where discussions with owners may be difficult (e.g., production medicine) or the time involved would defeat the purpose of their services (e.g., high-volume spay/neuter clinics). But the take-home message was that veterinarians are not the responsible parties for making the decisions for clients and that veterinarians need to provide all of the options, and all of the information that clients need to make decisions. Informed consent protects both parties to the transaction.

Informed consent provides transparency. In the veterinary profession, owners are held directly responsible for the decisions and charges incurred. When an owner is informed about diagnostic or treatment options, this includes the cost involved with the options. Informed consent means discussing what the diagnostics or treatments entail, the prognosis or outcome expected, and the costs involved. In fact, most veterinarians provide written estimates for procedures or hospitalization and may require a deposit. Although this may seem insensitive in some way—to require a deposit to provide care—the estimate can be the reality check an owner may need and, again, the owner client is the responsible party.

Informed consent is also the standard in the human medical profession, but the human medical profession does not provide estimates and doesn’t seem to even know, or admit to knowing, what price tag attaches to options. Much is said about the failures of human medicine. Some of this can be attributed to allowing the profession to not be transparent—to not providing information. Continue reading “Informed Consent”

Mental Health, Substance Abuse, and Wellness in the Legal Profession: Change is Necessary

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Symbol of a heart with a jagged line representing an EKG printout superimposed over it, in order to represent the concept of "wellbeing"Last week, the American Bar Association (“ABA”) designated and celebrated October 10th, 2018 as National Mental Health Day for Law Schools.[1] This date coincided with the World Mental Health Day.[2] The ABA’s National Mental Health Day for Law Schools serves as a vital reminder that the legal profession is not immune from mental health problems. In fact, the numbers themselves highlight just how important discussing and tackling mental health and wellness are to both law schools and the legal profession in general. Both law students and lawyers suffer in large numbers from mental illness and substance abuse. Therefore, it is important to address these concerns and to help both law students and attorneys live a life that focuses on their wellbeing.

Statistics on Attorneys

In comparison to other professions, lawyers themselves experience higher rates of mental health issues and substance abuse. Attorneys are the most frequently depressed occupational group in the United States, and they are 3.6 times more likely to suffer from depression in comparison to non-lawyers.[3] In a study of roughly 13,000 practicing attorneys conducted by the ABA Commission on Lawyer Assistance Programs and Hazelden Betty Ford Foundation, 28% of the attorneys reported experiencing depression, 23% reported experiencing stress, and 19% reported experiencing anxiety.[4] Of these participants, 21% are qualified as problem drinkers, and they “experience problematic drinking that is hazardous, harmful, or otherwise generally consistent with alcohol use disorders at a rate much higher than other populations.”[5]

This same study found that younger attorneys, rather than older attorneys, are at a greater risk for experiencing these issues. Continue reading “Mental Health, Substance Abuse, and Wellness in the Legal Profession: Change is Necessary”

Marquette Law Review Article Featured in Prescription Painkiller Exposé

Posted on Categories Congress & Congressional Power, Health Care, Marquette Law School, President & Executive Branch, Public2 Comments on Marquette Law Review Article Featured in Prescription Painkiller Exposé

In cooperation with 60 Minutes, the Washington Post has published a fascinating new story about the behind-the-scenes efforts of actors in the pharmaceuticals business to soften regulatory enforcement at the just the time that the nation’s opioid problems were reaching epidemic proportions. The story would be an engaging read for anyone, but Marquette folks may note a particular point of interest: the Post prominently quotes a forthcoming article in the Marquette Law Review.

According to the Post story, the federal Drug Enforcement Administration has long had authority to block suspiciously large shipments of prescription painkillers that pose an imminent danger to the community. In the late years of the Bush Administration and early years of the Obama Administration, the DEA became increasingly aggressive in using this authority to target businesses that were involved in questionable ways with the distribution of opioids. The Post reports that these businesses pushed back, initially finding some success through lobbying the Department of Justice. However, they seemingly had their greatest success when Congress passed, and President Obama signed into law, changes to the DEA’s enforcement standards and procedures.

This legislation is the subject of the Marquette Law Review piece, authored by John Mulrooney and Katherine Legel. Mulrooney is an administrative law judge with the DEA. Legel, a graduate of Marquette Law School, was a judicial law clerk with the DEA. Of the 2016 law, they write, “If it had been the intent of Congress to completely eliminate the DEA’s ability to ever impose an immediate suspension on distributors or manufacturers, it would be difficult to conceive of a more effective vehicle for achieving that goal.” This and other aspects of the law review article are noted in the Post’s reporting. Student-editors who have been working on the article should feel gratified to see the piece playing such a prominent role in the ongoing efforts of journalists, policymakers, and academics to better understand the multitude of factors that may be contributing to the current opioid crisis.

Israel Reflections 2017–Treating Terrorists and Other Medical Challenges

Posted on Categories Health Care, Human Rights, International Law & Diplomacy, Marquette Law School, PublicLeave a comment» on Israel Reflections 2017–Treating Terrorists and Other Medical Challenges

Television camras and microphones surround Dr. Ofer Merin dressed in doctor's scrubs.One other new visit this year was with Dr. Ofer Merin, a commander of the Israel Defense Force (IDF) Medical Field Unit and emergency room doctor at Shaare Zedek Medical Center in Jerusalem.   As student Margo Clark notes, his roles often require both flexibility and understand beyond our immediate biases.

Dr. Ofer Merin is the Chief of the IDF Field Hospital, which travels to different countries to offer assistance in times of need. One example of the IDF Field Hospital’s greatest accomplishments is its ability to be the only field hospital from a foreign country to help the Japanese people after they were devastated by a tsunami. Their success comes from the amount of flexibility and understanding that Dr. Merin and his team work under. Rather than pushing their own system, Dr. Merin and his team worked under and around Japanese law. Under Japanese law, it is illegal for a foreign doctor to treat a Japanese citizen.  The team was flexible and put the Japanese people first. Their flexibility is exemplified by their assisting and enabling Japanese doctors to treat the large number of Japanese people who were in need. By foregoing their egos and putting understanding and flexibility first, Dr. Merin and his team were the only foreign field hospital team to be allowed to help the Japanese people.  Here is a MSNBC news report showing the IDF work in Haiti from 2010.

Dr. Merin’s flexibility and understanding is continually shown in his additional role as the Deputy Director of the Shaare Zedek Medical Center. This center is known for simultaneously treating terrorists and the victims of their attacks. It is excessively difficult to imagine how hard it must be to treat a terrorist. However, Dr. Merin understands the consequences of both treating and not treating terrorists and being beyond reproach as far as bias towards his patients. As a doctor, he is an example of following the Hippocratic oath and doing no harm under stressful conditions where many would be tempted to be biased and fail their duties as doctors. His example is important because if he can work without bias towards terrorists, doctors everywhere should use his example to attempt to work without any sort of bias. Continue reading “Israel Reflections 2017–Treating Terrorists and Other Medical Challenges”

Children’s Hospital Chief Says Her “North Star” Is Good Health for All Kids

Posted on Categories Health Care, Milwaukee, Public, Speakers at MarquetteLeave a comment» on Children’s Hospital Chief Says Her “North Star” Is Good Health for All Kids

When Peggy Troy returned to the Milwaukee area about eight years ago to become president and CEO of Children’s Hospital of Wisconsin, she was struck by the disparities in children’s health she found. She had been a hospital executive in Memphis and expected that things were better overall in Milwaukee. But when it came to medical issues affecting thousands of children in high-poverty neighborhoods, that wasn’t really the case. The disparities in Milwaukee’s central city were some of the worst in the nation.

Since then, Troy has been a central figure in accelerating the efforts by Children’s and many community partners to improve the overall health of children in Milwaukee and throughout Wisconsin. While the national reputation of Children’s for its medical work has continued to rise, the mission statement for the institution goes beyond delivering care for patients. It is to make Wisconsin’s children the healthiest in the nation.

That broader mission was Troy’s focus during an “On the Issues with Mike Gousha” program at Marquette Law School on Thursday.   Continue reading “Children’s Hospital Chief Says Her “North Star” Is Good Health for All Kids”

That Extra Incentive

Posted on Categories Business Regulation, Federal Civil Litigation, Health Care, Labor & Employment Law, PublicLeave a comment» on That Extra Incentive

Most of us are familiar with wellness programs—programs sponsored by our employer or health plan that try to incentivize us to eat healthier, sleep well, and get more exercise.  If you’re anything like me, it helps to have that extra push or incentive, especially around the holidays when sweets abound, to stay on track—or at least, to not stray too far from health goals. Most of these programs have the added advantage of lowering health care costs, both by providing financial incentives to reduce immediate costs to the individual employees and by boosting the overall health of the employees as a whole, which could reduce future health care costs.   However, extensive technical regulations and recent litigation by the AARP make implementing health and wellness programs increasingly tricky for employers.

Title II of the Genetic Information Nondiscrimination Act of 2008 (“GINA”) and the regulations promulgated by the U.S. Equal Employment Opportunity Commission (the “EEOC”) thereunder, generally prohibit “an employer [from] request[ing], require[ing], or purchas[ing] genetic information [which includes an individual’s family medical history] with respect to an employee or a family member of the employee.”  42 U.S.C. § 2000ff–1(b). However, there is an exception for wellness programs, as long as employers jump through a set of hoops. 29 CFR § 1635.8(b)(2).  While not without its own problems and excesses, the exception in the EEOC regulations at least allows employers to provide incentives to those employees willing to participate in employer-sponsored wellness programs.

The AARP doesn’t like this whole “incentive” idea to begin with. It recently filed a lawsuit against the EEOC in an attempt to vacate the regulations entirely.  AARP v. U.S. Equal Employment Opportunity Commission, No. 1:16-cv-02113 (D. D.C. 2016) (hereafter the “AARP Complaint”).  This actually might not be a bad idea, except for the fact that the AARP thinks that the regulations do not have enough hoops.  In fact, the AARP would prefer that the regulations abolish any permission for any incentives or penalties to induce participation in employer-sponsored wellness programs. The AARP alleges in its complaint that all employer incentives or penalties to induce participation in employer-sponsored wellness programs violate Title I of the ADA and Title II of GINA.  AARP Complaint at 3Continue reading “That Extra Incentive”

Supreme Court Roundup Part Two: King v. Burwell

Posted on Categories Constitutional Law, Health Care, Judges & Judicial Process, Marquette Law School, Public, U.S. Supreme CourtLeave a comment» on Supreme Court Roundup Part Two: King v. Burwell

Obama_signs_health_care-20100323On October 5, I participated in an event at the Marquette University Law School entitled “Supreme Court Roundup” with Cato Institute Scholar Ilya Shapiro.  The event was sponsored by the Law School Chapters of the Federalist Society and the American Constitution Society.  A previous post contained my remarks on Obergefell v. Hodges (the “Gay Marriage case”).  What follows are my prepared remarks on King v. Burwell (the “Obamacare case”).

The issue in this case was whether the Affordable Care Act’s tax credits are available in States that have a federal health insurance exchange rather than a state exchange. In Section 36A, the Affordable Care Act (commonly known as “Obamacare”) states that tax credits “shall be allowed” for any “applicable taxpayer.” Then, in Section 36B, the Act provides that the amount of the tax credit depends in part on whether the taxpayer has enrolled in an insurance plan through “an Exchange established by the State.” (emphasis added).

In King v. Burwell, the U.S. Supreme Court, in an opinion written by Chief Justice John Roberts, held that Section 36B allows tax credits to be used for insurance purchased on any exchange created under the Act, including insurance purchased on a federal exchange.

I want to be clear.  I make the following statement with the intent to be as objective and non-partisan as possible.  This litigation was nothing more than a post hoc attack on the Affordable Care Act, using one isolated provision of the law read out of context in order to arrive at a nonsensical meaning, which then used a manufactured theory of legislative intent – a theory without a shred of contemporaneous support in the legislative history – in a desperate attempt to prop up the nonsensical meaning.

The background of how this case arose is illuminating. Continue reading “Supreme Court Roundup Part Two: King v. Burwell”

In Eckstein Hall Session, Schimel Emphasizes Fight Against Opiate Drug Abuse

Posted on Categories Health Care, Public, Speakers at Marquette, Wisconsin Law & Legal SystemLeave a comment» on In Eckstein Hall Session, Schimel Emphasizes Fight Against Opiate Drug Abuse

Drug overdose deaths don’t usually make big headlines. But ask Brad Schimel about his priorities as Wisconsin’s still quite-new attorney general (he took office in January) and they are at the top of his priorities. Here’s a powerful reason why:

More people die each year in Wisconsin from overdoses of opiate drugs, the kind issued through prescriptions at drug stores, than die from breast cancer, traffic accidents, hand guns, or heroin combined, Schimel said during an “On the Issues with Mike Gousha” program at Eckstein Hall on Sept. 23.

Seventy percent of heroin addicts got addicted to prescription pills first, Schimel said, and seventy percent of the prescription drug addicts got pills from friends or family members, Schimel said.

Schimel announced in mid September a campaign called “A Dose of Reality” to increase awareness of the extent of prescription drug abuse in Wisconsin. He said the medical community of the state was cooperating in promoting education and more precautions not only in the general public, but in medical jobs that involve providing such drugs. Many in the medical sector are not aware of how widespread the problems of abuse are. Schimel said in announcing the campaign.

Schimel told Gousha he met many times with families of those who died of such abuse while he was Waukesha County district attorney, his job before becoming district attorney. He said it was myth that those who died were “bad kids.” Schimel said, “I’ve yet to find a parent who had the bad kid. These are good kids.” They came from a wide range of backgrounds and lifestyles. And those who die, in general, come from all parts of the state, rural, suburban and urban, and grew up in homes across the spectrum of income levels, he said.

The Dose of Reality campaign is aimed at promoting drug treatment and effective law enforcement work, as well as public education.

In his conversation with Gousha, the Law School’s distinguished fellow in law and public policy, Schimel also touched on other issues the attorney general’s office is facing.

He agreed that there appear to be conflicting provisions in federal rules related to whether Wisconsin can require people who receive public aid to purchase food to undergo drug tests. Republicans in the Legislature passed such a law this year, but it is being challenged in court.

“Ultimately that’s what courts do, they decide when there is a conflict of laws,” Schimel said. “We’re going to have this resolved there.”

Schimel also stood by his firm position on maintaining Wisconsin’s strong record of open government and access to public records. Schimel, who won office as a Republican, said sometimes it is necessary to go against the wishes of Republican law makers. In this instance, some Republicans tried to push through substantial changes in open government rules several months ago. Schimel’s opposition was a factor in those changes being pulled off the table after initially getting support.

Schimel also discussed Wisconsin’s participation in fighting tighter air pollution laws backed by the Obama administration and the slow start to a planned joint state-county-city effort to crackdown on gun crimes in Milwaukee. He commented in general terms on the John Doe investigation related to campaign activities on behalf of Gov. Scott Walker, but he did not give a direct answer to a question on whether he thought Milwaukee County District Attorney John Chisholm engaged in a “witch hunt,” as some Republicans have said.

Video of the one-hour program may be watched by clicking here.

ObamaCare Upheld . . . Again

Posted on Categories Health Care, Judges & Judicial Process, Public, U.S. Supreme Court1 Comment on ObamaCare Upheld . . . Again

1024px-William_Hogarth_004Today the U.S. Supreme Court announced its decision in the widely anticipated case of King v. Burwell, ruling that the language of the statute authorizes tax credits for individuals who use health insurance exchanges set up by the federal government as opposed to the states.  The result of the ruling is that the Affordable Care Act continues to operate and that millions of previously uninsured Americans will continue to receive health insurance under ObamaCare.  Many observers had predicted an adverse ruling from the Court, and a period of uncertainty (if not chaos) if the use of federal health insurance exchanges was struck down.  Today’s ruling by the Court means that there will be no disruption in the workings of the Affordable Care Act.  Coupled with this week’s passage of “fast track authority” for a Pacific trade bill, the ruling also cements a record of legislative accomplishment for President Obama that will add to his legacy.

Somewhat surprisingly, the Court voted 6-3 in favor of the Administration’s proffered reading of the statute.  Some observers had predicted a narrower margin.  Chief Justice John Roberts wrote the opinion for the majority.  The Chief Justice’s opinion also was crucial in upholding the Affordable Care Act in the NFIB v. Sebelius case in 2012, and it therefore appears that future historians will inevitably evaluate John Roberts’ career as Chief Justice in light of his prominent role in the survival of ObamaCare. Continue reading “ObamaCare Upheld . . . Again”

Predicting King v. Burwell: This Term’s Most Consequential SCOTUS Case

Posted on Categories Health Care, Public, U.S. Supreme Court1 Comment on Predicting King v. Burwell: This Term’s Most Consequential SCOTUS Case


I am just going to come out and say it:  I have been a long-time proponent of universal, single-payer style heath care for our nation. I am a firm believer that private insurance companies should play no role whatsoever in the provision of health insurance for Americans. It is for this reason that I was so dismayed when President Obama proposed a health care reform regime with the existing private health insurance infrastructure (and Medicaid) as its foundation. I was even among those political wonks who wanted Congress to vote down the Affordable Care Act (ACA) once it became apparent that the ACA exchanges were not going to offer a “public option” to exchange participants. In the years since the law’s passage, I have become an ardent supporter of the law because it is moving our nation in the direction of universal health insurance coverage.

As a law student and constitutional law scholar, I am surprised that the Supreme Court opted to take King on appeal. By the time SCOTUS granted certiorari, the circuit split had been resolved by an en banc ruling of the DC Circuit. What is more troubling is that the petitioners do not appear, by any objective standard, to have standing to bring this suit. Standing is a concept that all first year law students are well acquainted with; it is equally obvious that the petitioners have suffered no judicially cognizable injury by operation of the IRS regulation interpreting the exchange subsidies as applicable to state-run and federally-run insurance exchanges. I have read the petitioners’ standing argument — it is so ridiculous that it does not bear recital here.

Even if one is able to get past the standing issue, an interpretation of the challenged statutory language that petitioners claim limits the availability of subsides to state-run insurance exchanges runs contrary to the canons of statutory interpretation. A comprehensive law that regulates the health insurance system of an entire nation and affects a good portion of our nation’s economy should not hinge on the meaning of a term that is ambiguous in isolation, but definite and decisive when taken in the context of the statute. The term “state,” as used in the ACA, has a broad meaning that encompasses “state” in the scholarly sense of a nation-state and the customized meaning of “state” as a sub-national unit of government.

There are many moral and political arguments that one can make in favor of upholding the decisions of the DC and Fourth Circuits. As a law student writing from a legal perspective, I put these arguments to the side. What is unfortunate for the four (or more) members of the Supreme Court who voted to take up this silly challenge is that the law (and precedent) is not on their side. I predict that the Supreme Court will uphold the decisions of the DC and Fourth Circuits on a 5-4 vote, with Chief Justice Roberts joining the court’s four moderate justices.

Vaccination Uproar

Posted on Categories Family Law, Health Care, Public2 Comments on Vaccination Uproar

MeaslesDuring the past month, the American public has been bombarded with news reports about a continuing measles epidemic, as well as an extensive debate about whether measles vaccinations should be required to stop this epidemic and prevent future ones from developing.

In fact, all states require vaccinations against many contagious diseases, including measles. But there are exceptions, and the exceptions are broader in some states than others. Only a handful of states limit exceptions to medical necessity – for example, a child whose immune system is compromised by chemotherapy should not receive immunizations. Most states allow religious exemptions, so parents who are, for example, Christian Scientists need not vaccinate their children in contravention of their religious beliefs. However, about a third of the states, including Wisconsin, also allow much broader exemptions based on “conscience” or “philosophical reasons.” These broader exemption categories often can be invoked with little or no effort on a parent’s part, such as by checking a box on a form and signing it, and thus have the potential to erode the requirement if enough people choose not to vaccinate.

Continue reading “Vaccination Uproar”