Joumnal ofmedical ethics, 1991, 17, 150-155

The diffusion of medical technology: freeenterprise and regulatory models in the USAA Everette James, Seymour Perry, Susan E Warner, John E Chapman, Richard M ZanerVanderbilt University, Nashville, Tennessee and Georgetown University, Washington DC, USA

Authors' abstractThe diffusion oftechnology in the US has taken place inan environment of both regulation and free enterprise.Each has been subject to manipulation by doctors andmedical administrators that has fostered unprecedentedethical dilemmas and legal challenges. Understandingthese developments and historical precedents may allow amore rational diffusion policyfor medical technology in thefuture.

The diffusion of costly and sophisticated medicaltechnology poses a formidable issue for those entrustedwith the formation of health care policy. Efforts tostem the rising cost of health care have often beendirected at those areas of the delivery system with highunit costs, particularly at instruments for diagnosticmedical imaging. Examples are computedtomographic (CT) scanners (1), angiographic suites,machines for positron emission tomography (2), andnow devices for magnetic resonance imaging (MRI).Policies relating to health care in the United States areboth formulated and administered at the state level,and the states have a superior mandate to federallegislation (3). Thus, one has the opportunity toobserve two divergent philosophies of health carepolicy, the free enterprise (market-place) model on theone hand and regulation on the other. Each system hasinherent advantages and limitations, and posesdifferent ethical issues.

Medicine in the United States has historically beenexempt from much of the regulatory legislation andscrutiny applied to the financial world. Much of thistacit and de facto exemption went under thephilosophical rubric of the 'learned professions'exclusion. Medicine, law and other professions werejudged upon their benefit to the public welfare.However, in 1975, in the landmark case of Goldfarb vVirginia State Bar, the Supreme Court recognised that

Key wordsMedical technology diffusion; health care costs; exclusivehospital privileges; radiology; certificate of need (CON);computed tomographic (CT) scanners; magnetic resonanceimaging (MRI); free enterprise (market-place) model; tyingarrangement; regulatory process.

professions might have a significant business aspect intheir conduct and that those activities so characterisedshould fall under the regulation of the ShermanAntitrust Act of 1890 and all of the subsequent actsapplicable to business enterprise (4).The magnitude of the business of medicine was

found to represent over 10 per cent ofthe gross nationalproduct and was estimated at that time (1975) to begreater than two hundred billion dollars. The FederalTrade Commission, a government agency mandated toregulate interstate commerce, began investigatingmany of the commercial relationships in medicinewhich had been operating without external scrutinyand which had historically been accorded the privilegeof self-regulation.

Concomitant with these changes in federal policieswas one of the singular medical developments of the20th century, the introduction in the mid-1970s of x-ray CT scanners (5). Developed in England by EMI,these instruments radically changed the diagnosticinvestigation process for many conditions. The publicand the medical profession became so enamoured withthese marvellous new devices ofdiagnostic inquiry thatthe demand by patients and doctors appearedunlimited. However, the unit costs exceeded a milliondollars (US).

In an attempt to bring order to potential chaos in thediffusion of these 'CAT' scanners, certificates of need(CON) legislation was enacted by the US government.This required potential acquirers of medical facilitiesor technology above a certain monetary value todemonstrate both the clinical need for this capabilityand their qualifications for being accorded thisresponsibility of ownership. These CON requirementswere administered by state agencies and therefore werenot uniform in their regulatory effect. Additionally,they did not apply to outpatient facilities - meaningthat even when the policy-makers imposed regulation,it affected only one segment of the health care system.Doctors and entrepreneurs could purchase these unitswith impunity, as long as they were outside a hospitalfacility, and they were willing to assume the financialrisk.Another significant development of the 1970s that

continues to have great influence on the character ofmedical care in the US has been the increased difficulty

copyright. on A

ugust 30, 2020 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.17.3.150 on 1 S

eptember 1991. D

ownloaded from

A EveretteJamesJ7r, Seymour Peny, Susan E Warner, John E Chapman, RichardM Zaner 151

that doctors have in acquiring hospital privileges (6,7).Several legal decisions, including the landmark case ofDarling v Charleston Community Hospital, made it clearthat hospitals were ultimately liable for the quality ofpractice provided by their staff. Granting of hospitalprivileges became a much more regulated andrestrictive process, and the number of doctorsexcluded from these institutions that had installed themost sophisticated and costly medical imagingtechnology increased dramatically from that time. Thiscreated a new type ofdemand for access. In addition topatient demand, there was now doctor demand for allthe institutions with whom they were associated toacquire the diagnostic capabilities afforded by CTscanners and other expensive instruments.While many hospitals expended considerable

resources in an attempt to meet these demands, therewere inherent risks. Institutions incurred substantialdebts for equipment whose efficacy had yet to be fullyestablished, and whose technological half-life wasunknown. The financial schemes employed to acquireand amortise these units were varied and sometimesincompletely understood by doctors and hospitaladministrators. Some institutions made financialassumptions regarding compensation that were sofavourable as almost to ensure profitability. Thesecomplexities may have initially acted as a barrier todiffusion of this technology, but, if so, it wasincomplete and short-lived. Regulation did act,however, to make institutional acquisition of thisinstrumentation geographically non-homogeneous,creating a medical technological circumstance of 'havesand have-nots' (8).The number of legal challenges by doctors to

hospital privilege denial has also increaseddramatically. Doctors now believe that in order tomaintain professional and fiscal viability they and theirpatients must have access to this technology. Thismeans that doctors must secure staff privileges at thosefacilities where these devices have been approved bythe CON agency and are in clinical use. Additionally,the securing of exclusive privileges by certain specialtygroups for both performance and interpretation ofthese technological procedures by contract has resultedin many legal challenges (9,10). Some institutions hadto gain approval for the acquisition of these devices inorder to qualify for compensation from third partypayers for those procedures performed on thesemachines.While this form of regulation did indeed limit some

unstructured diffusion of the x-ray CT scanners, it didso in a very erratic manner and only in the institutionalsetting. 'Fugitive' CT scanners were acquired inoutpatient facilities and private offices - oftencompeting unfairly with institutions because a CONwas not needed and the lengthy and rigorous process ofreceiving approval could be avoided.

Additionally, doctors often found themselves in anovel ethical dilemma. In order to finance theacquisition of these x-ray CT devices and, later, MRI

scanners for private outpatient use, partnerships wereformed under the appellation of 'imaging centres'.Often, a group of doctors (the imaging team) wouldenter into a financial arrangement whereby they wouldbecome the general partners in this economic ventureand their referring doctors would become the limitedpartners. This would be a business with definiteeconomic implications for the doctors, who would havea vested financial interest in the economic viability oftheir commercial enterprise, the imaging centre. Theproperty was usually acquired and the installationfinanced by a loan from commercial financial agencies,and the technology was leased from the manufactureror from a lending agency specialising in the financingof such equipment. General partners were at risk forthe general financial welfare of the venture, whereasthe limited partners were liable only for their initialinvestment.The ethical considerations are that access of their

patients to this necessary resource is secured, but thedoctors are financially involved in circumstances forwhich there is no historical precedent. The need toutilise, and the temptation to over-utilise, the facility toassure its economic welfare are readily apparent.Additionally, doctors who have no financial interest inthe imaging centre may find that their patients' accessis limited by the preferential treatment of the patientsof the partners in the enterprise. Many ethicists andpolicy-makers in the US have reasoned that this onlyappears to be free enterprise. In fact the fiduciarycapacity of the doctors allows them so to determine theacquisition and use of the instrumentation that itrepresents a tacit monopoly, and this is more of anadaptation to intended regulation than the ebb andflow of market-place activity. This has been viewed asa 'tying arrangement', whereby free choice by thepatient is precluded by the financial arrangements ofhis or her doctor.The series of activities described above were the

focus of much public attention in the US forapproximately four to five years in the late 1970s due tothe phenomenon of x-ray computed tomography,although implications for other facilities such asangiographic suites, radiation oncology treatmentcentres, and digital radiology laboratories (11) werealso significantly affected. By the early 1980s,however, the use of CT scanners had becomewidespread and they were no longer an importanthealth policy issue. CON agencies became more liberalin their requirements, and in some states wereabandoned, as their operational costs were notappropriated from public funds, and doctor andpatient expectations for these 'wonder devices' becamemore realistic as clinical experiences became widelyreported. These clinical analyses provided somemedical guidelines for the rational distribution of thistechnology. The ethical choices then assumed a moretraditional medical posture, and economicconsideration reverted to the traditional 'patientwelfare' character.

copyright. on A

ugust 30, 2020 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.17.3.150 on 1 S

eptember 1991. D

ownloaded from

152 The diffusion ofmedical technology: free enterprise and regulatory models in the USA

However, the previously described phenomenonwas to arise again in the early to mid-1980s with theclinical introduction of MRI (12). Although theprocess of nuclear magnetic resonance (NMR) as ananalytic technique for biological materials had beenindependently described by Block and Purcell in the1940s (for which they received the Nobel Prize in1952), the utilisation of this methodology to createimages of nuclei in the human body only became areality in the late 1970s. By the early 1980s, severalfamous institutions in England, Scotland and theUnited States were exploring clinical uses of thesedevices to diagnose fundamental chemical andphysiological changes reflecting both health anddisease (13). The public enthusiasm for MRI was equalto if not greater than that engendered by the CTscanner, and the demand for these devices fromdoctors and the informed public was commensurate.Because radio-frequency waves were employed as theenergy utilised to create the image signal rather thanionising radiation, the biological implications for MRIwere profoundly different from, and compared veryfavourably with, devices using ionising radiation. Intheory, the potential biological burden with MRI wasfelt to be much less than with computed tomographicor conventional radiographic or radionuclidediagnostic studies. However, experimental data andclinical experience was lacking in regard to the effectsof this energy form on the human body. Thus, therewere inherent risks in proliferation and diffusion ofthese revolutionary instruments.

In addition to the CON process, it was decided thatprior to approved clinical introduction, leading toreimbursement by third party payers, this form ofdiagnostic procedure (MRI) had first to be evaluatedby the Federal Drug Administration (FDA), the Officeof Technology Assessment (OTA) and the Health CareFinancing Agency (HCFA). Manufacturers were tosubmit to the FDA their clinical prototype experienceat different magnet strengths (for example: 0.5 teslaand 1.5 tesla) and for different anatomical areas (brain,abdomen, etc) in order to get agency approval. Thirdparty payers could elect to compensate doctors andinstitutions for the studies, depending upon approvalfrom the regulatory agencies. Many policy-makers feltthat this form of multi-agency regulation wouldobviate many of the economic incentives and mightassist in avoiding the ethical dilemmas to which doctorshad succumbed with computed tomography.While this regulatory process had inherent

difficulties and was rigorous in its administration, theperceived demand forMRI by patients and doctors wasso great that instrument manufacturers and leadingmedical institutions engaged in a monumentalcollaborative effort to meet these requirements in orderto acquire these devices. In financial terms, thesefacilities cost several million dollars per unit topurchase and were extremely difficult to place onmedical sites due to the necessity of radio-frequencyshielding for the instrument itself (14). This

environment created some momentary concern amonginstitutions, as they were reluctant to purchase suchexpensive devices if the possibility existed that theywould not subsequently be reimbursed for the studiesperformed. On the other hand, doctor and publicfascination with the technology and potentialcapability ofMRI reached an unprecedented level andthe lay literature and public awareness of the supposedvirtues of this technique made the acquisition bymedical facilities extremely compelling. Many healthcare facilities entered willingly into the necessaryprocess to meet the regulations. The imaging centrescenario was revisited with even greater intensity thanwith computed tomography.

Soon the rapid diffusion ofMRI devices became theconcern of health policy groups (15). Medicine anddoctors entered again into a number of financialarrangements that posed serious ethical questions.Despite the efforts of doctors to remain unbiased andnot to refer their patients for studies in facilities thatthey owned, there obviously remained a strongfinancial incentive to do so. Competition for referralsbegan to involve marketing techniques that were oftenso aggressive they also posed ethical dilemmas fordoctors.The health care analysts and policy-makers in the

US who oppose regulatory schemes as a nationalstrategy are in favour of the traditional free-enterprisesystem and the market-place model (16). They believethat the health-care delivery-system, albeit quitecomplex, is a large and powerful business and shouldoperate according to the principles of supply anddemand. These proponents believe that theaccommodations and realities of the market-place willbest serve the consumer public and that regulation ofhealth care will create inequities in this system that areboth false and unfair. Such fundamental virtues as self-determination, free enterprise and consumerparticipation are cited as inherent virtues by thechampions of this health-policy model.To some extent, the business model of free

enterprise has continued to operate in the medicaltechnology area despite attempts at regulation. TheCON process, as noted, could be avoided by placingthe instrumentation in an outpatient facility or in aprivate office. In the past decade, the 'medical imagingcentre' has been a national phenomenon (17). Thesecentres proliferated due to the availability of venturecapital, favourable tax laws on investments, andawareness of both doctors and non-doctors of thepotential profits from these facilities. The schemewhereby referring doctors would become limitedpartners with the largest investors (who were oftennon-doctors) as the general partners is a newdevelopment for the medical field - the propriety ofwhich is questionable. Participation in such anownership arrangement of a health-care facility bydoctors creates, at best, an ethical dilemma; in theUnited States, it introduces certain legal issues ofantitrust as well (18). The arrangements have been

copyright. on A

ugust 30, 2020 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.17.3.150 on 1 S

eptember 1991. D

ownloaded from

A EveretteJ7amesJr, Seymour Peny, Susan E Warner, John E Chapman, RichardM Zaner 153

challenged in the courts as: 'tying arrangements',whereby the patients' choices are limited; market-place exclusion where non-owner doctors and theirpatients are denied access; and monopolisation, inwhich other regulated health-care facilities in the samearea cannot acquire an MRI system because the clinicalneed has been precluded by the presence ofan imagingcentre (19).

In order to increase the patient population whichthese 'centres' may serve, the instrumentation issometimes housed in mobile vans that can be movedfrom site to site according to an elaboratelyprearranged schedule. 'Mobile' imaging centres notonly avoid much of the regulatory process butmarkedly increase the numbers of hospitals that canafford this capability at least on a part-time basis.Quality control in the very broadest sense has becomea major issue and an area of serious disagreement - notonly between the practising doctors and their investorsbut among referring doctors and those providing theinterpretative service (10). Medical educators havebecome rightly concerned that both patients and thelatest in medical technology will be so displaced intoremote outpatient facilities in the private sector thatthis will no longer be an available resource for medicalstudent and registrar training. Since these arecommercial operations, one might argue that they haveno responsibility for training and teaching.Additionally, if patient access is only afforded by themobile unit, cannot quality control be relaxed in orderto assure availability? One might conclude that serviceto a large patient population, even if it is not ideal, maybe preferable to service for only a few. We wouldhasten to add that precious little data are available toanalyse whether inpatient MRI achieves better qualityof medical care than MRI performed in an outpatientsetting.

Except for economic realities, the diffusion of theseimaging centres often seems to be almost unregulated;even in the regulated sector, many of the constraintscan be circumvented. The cost of medical care in theUS by the mid-1980s was above three hundred billiondollars, and there were frequent predictions that, givenexisting trends, the Medicare and Medicaid trust fundswould be bankrupt by the 1990s. Doctors wereidentified as the major decision-makers in the health-care industry; therefore, in order for any programme tobe effective in reducing this rising cost, doctors' habitsof utilisation of these capabilities would need to bechanged. This posed much more of an economicdecision than an ethical one. Measures were enacted toalter doctor behaviour, utilising financial incentives.

Policy-makers, after evaluation of the Americanreimbursement system, formulated a prospectivepayment scheme whereby an amount of funds wouldbe allocated to a certain proposed diagnosis. Shouldthis amount be exceeded, additional funds wouldeither be requested by the institution or the costswould have to be borne by the health-care facility(20,2 1). The implications of this scheme for large

expenditures to purchase capital equipment areobvious. This system, known as diagnosis-relatedgroups (DRGs), has not been operational for asufficient period to assess its long-term effect uponmedical technology diffusion. We would predict thatinstitutions might be reluctant to acquire expensivemedical imaging-devices unless they are assured thatreimbursement will be sufficient to service theassociated debt. Therefore, DRGs should act to limitmedical technology diffusion to some degree (22). Thismethodology also places doctors in a 'gatekeeper' roleby virtue ofthem having to approve diagnostic tests fortheir patients. This role is worrying for many doctorsbecause they feel they are 'rationing' care for theirpatients.More recently, policy-makers have criticised the

medical reimbursement system in the US as favouringtechnological procedures and disproportionatelyincreasing the incomes of the specialists engaged inthese practices. The so-called 'cognitive' disciplinessuch as primary care, paediatrics, general internalmedicine and psychiatry have been disadvantaged bythe current medical compensation themes in the US. Asystem of assignment of values for each medicalactivity has been proposed, and a set of relative valuescales (RVS) for all types of medical encounters isbeing developed. These resource-based relative valuescales are to be incorporated into the federally fundedmedical compensation system. One would expect thatprivate insurance companies and other third partypayers would adjust their payment schedulesaccordingly. If compensation for procedures involvingthese expensive devices appears threatened, theresistance to acquiring this instrumentation willcertainly increase.An ethical dilemma for doctors is whether they

believe they should forego a procedure for theirpatients if it will deplete the institutional resources(DRG) or even their personal income (RVS). Doctorsin the US agree that health care costs have significantimplications for the economy in general and thatchanging the pattern of their practices from hightechnology to that of more traditional medical inquirywould decrease costs. However, with patient welfare asthe primary criterion, should not technology be widelydistributed and free access provided to everyone? Thefinancial implications in terms of human value aredifficult to quantify. Patients given free choice havetraditionally selected the most technological and, thus,the most expensive form of health care. Patients wantaccess to this type of medicine, but would they if theyhad the necessary data to understand the financialimplications?

In summary, the diffusion of technology in the UShas taken place in an environment characterised byregulation on one hand and the free-enterprise ormarket-place model on the other. Each has beensubject to certain manipulation by doctors and medicaladministrators which has fostered unprecedentedethical dilemmas and legal challenges. Understanding

copyright. on A

ugust 30, 2020 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.17.3.150 on 1 S

eptember 1991. D

ownloaded from

154 The diffusion ofmedical technology: free enterprise and regulatory models in the USA

these developments and historical precedents will, itmay be hoped, allow a more rational diffusion policyfor medical technology in the future. What is apparentis that if a regulatory model is chosen, the entire health-care system should be regulated. If doctors are toimplement a regulatory system, they must be anidentifiable and significant part of the formulationprocess. Regulation is only effective if there arepenalties; the penalties should be so imposed,however, that patient welfare is not compromised bythe system. The free-enterprise system is difficult toapply to medicine because of the fiduciary capacity ofthe health-care providers and the lack of an effectivevoice for the consumer, the patient. The most likelyposture for future health-care policy in the US will beregulation through economics, which as a secondaryeffect will limit the free diffusion ofcostly technology.

AcknowledgementsWe are grateful for the advice of colleagues ViceChancellor Roscoe R Robinson of VanderbiltUniversity Medical Center; Frank Sloan, VanderbiltInstitute for Public Policy Studies; Jim Blumstein,Vanderbilt University School of Law; Terry Calvani,Federal Trade Commission; A Everette James, III,MBA/JD; Jeannette James, JD; Barbara McNeill,Harvard Medical School; Earl Steinberg, JohnsHopkins Medical Institution, and Tom Greeson of theAmerican College of Radiology. The editorial office ofthe Division of Radiological Sciences (Tom Ebers,editor) and the Center for Medical Imaging Researchwere utilised.

A Everette JamesJr, ScM, JD, MD is Senior ResearchAssociate, Vanderbilt Institute for Public Policy Studies;Lecturer in Legal Medicine, Department of MedicalAdministration; and Professor and Chairmnan,Department of Radiology and Radiological Sciences,Vanderbilt University School ofMedicine. Seymour PenyMD is Professor, Department ofCommunity and FamilyMedicine, Georgetown University School of Medicine;and Senior Fellow, Institute for Health Policy Analysis,Georgetown University. Susan E WarnerMSSW, MDivis Graduate Assistant, Center for Clinical and ResearchEthics, Vanderbilt University School ofMedicine. JohnEChapman MD is Dean of the School of Medicine andProfessor ofMedical Administration and Chairman oftheDivision, Vanderbilt University School of Medicine.Richard M Zaner PhD is Ann Geddes StahlmanProfessor ofMedical Ethics and Director ofthe CenterforClinical and Research Ethics, Vanderbilt UniversitySchool of Medicine; and Professor of Medical Ethics,Vanderbilt University Divinity School.

Please address all correspondence to Dr James,Department of Radiology and Radiological Sciences,Vanderbilt University Medical Center, Nashville, TN37232-2675, USA. Telephone: (615) 322-3357.Fax: (615) 322-3764.

References(1) James A E Jr, Anderson J H, Higgins C B, eds. Digital

image processing in radiology. Baltimore: Williams andWilkins, 1984.

(2) Kessler R M, Partain C L, Price R R, James A E Jr.Positron emission tomography: prospects for clinicalutility. Investigative radiolog 1987; 22: 529-537.

(3) James A E Jr, ed. Medical/legal issues for radiologists.Chicago: Precept Press, 1987.

(4) James A E Jr, Curran W J, Pendergrass H P, ChapmanJ E. Academic radiology, turfconflict and antitrust laws.Investigative radiology 1990; 25: 200-202.

(5) Coulam C M, Erickson J J, Rollo F D, James A E Jr, eds.The physical basis of medical imaging. New York:Appleton-Century-Crofts, 1981.

(6) James A E Jr, Sloan F, Blumstein J, Winfield A C,Pendergrass H P. Certificate-of-need in an antitrustcontext. journal ofhealth politics, policy and law 1983; 8:314-319.

(7) James A E Jr, Winfield A C, Rollo F D, etal. An analysisof the combined effects of certificate of need legislation(CON) and changes in the granting of hospitalprivileges. Radiology 1982; 145: 229-231.

(8) James A E Jr, Sloan F A, Pendergrass H P, et al.Hospital cost regulation: some cumulative effects fromcertificate of need and diagnostic related groups.Noninvasive medical imaging 1984; 1: 259-263.

(9) James A E Jr, Sloan F A, Hamilton R, et al. Antitrustaspects of exclusive contracts in medical imaging.Radiology 1985; 156: 237-241.

(10) James A E Jr, Pendergrass H P, Robinson R, HamiltonR J, Rollo F D, Hollowell E. Exclusive physiciancontracts in hospitals: precedent cases for radiologicpractice. Administrative radiology 1987; 6: 14-17.

(11) James A E Jr, Partain C L, Pendergrass H P. Certainlegal considerations of digital radiological imaging. In:Price R R, Rollo F D, MonahanW G, James A E Jr, eds.Digital radiography: a focus on clinical utility. New York:Grune and Stratton, 1982: 121-145.

(12) James A E Jr, Gore J, James A E III, et al. Legal aspectsof MRI. In: Partain C L, Price R R, Patton J A,Kulkarni M V, James A E Jr, eds. Magnetic resonanceimaging (2nd ed). Philadelphia: W B SaundersCompany, 1988: 913-939.

(13) James A E Jr, Partain C L, Patton J A, et al. Currentstatus of magnetic resonance imaging. Southern medicaljournal 1985; 78: 580-597.

(14) Price R R, Stephens W H, Partain C L. NMR physicalprinciples. See reference (12): 971-986.

(15) International symposium: The impact of new imagingtechnology on health care, research, and teaching: 1.current status. American journal of roentgenology 1983;141: 1335-1350.

(16) James A E Jr, Price R R, Sloan F, Zaner R, Chapman J.Certain social considerations in abandoning hightechnology medical imaging. Health matrix 1987; 5: 31-34.

(17) James A E Jr, Chapman J E, Carroll F, et al. Ethicalchoices in high technology medicine: current dilemmasin diagnostic imaging. Health care instrumentation 1986;1:158-167.

(18) James A E Jr, Partain C L, Hamilton R J, et al. Acritique of the concept of MRI centers. Magneticresonance imaging 1987; 5: 71-75.

(19) James A E Jr, Linton 0, James A E III, etal. Some legalissues of turf: relation to magnetic resonance. Magneticresonance imaging 1990; 8: 1-3.

copyright. on A

ugust 30, 2020 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.17.3.150 on 1 S

eptember 1991. D

ownloaded from

A EveretteJamesJr, Seymour Peny, Susan E Warner, John E Chapman, RichardM Zaner 155

(20) James A E Jr. Intrusion of regulatory process to changethe face of radiology. Diagnostic imaging 1984; Feb: 45-46.

(21) James A E Jr, Greeson T, Price R R, et al. Legal andethical choices in a technologic discipline: imaging

centers, DRGs, and the radiologist. Investigativeradiology 1986; 21: 746-751.

(22) James A E Jr, Greeson T, Price R R, et al. Legal andethical issues in a technologic discipline: new times, newchoices. Investigative radiology 1986; 21: 673-677.

News and notes

Rationing and the TechnologicFutureAn international conference, entitled Rationing andthe Technologic Future, will be held on October28th and 29th this year at Long Beach, California.The conference will explore the experience of

healthcare rationing around the world and how eachof the US constituencies involved in paying for and/or providing healthcare deal with making rationingdecisions.The conference sponsors are the FHP

Foundation and the International Society ofTechnology Assessment in Health Care.

For further information please contact: SandraLund Gavin, Executive Director, FHPFoundation. Fax: 213 495-0317; telephone: 213590-8655; address: 401 Ocean Boulevard, #206,Long Beach, CA USA 90802.

copyright. on A

ugust 30, 2020 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.17.3.150 on 1 S

eptember 1991. D

ownloaded from