BETTER LEGAL AND BUSINESS PRACTICE FOR PSYCHIATRISTS AND PSYCHOTHERAPISTS – California Edition (formerly entitled LAWYERING BULLETIN) is published 15 times annually for the annual subscription fee of $289, but the special introductory rate of $247.50 is in effect through December 31, 2000.  The single issue price is $16.50 through December 31^st.  Visa and MasterCard are accepted. 

         

This newsletter is provided only for information purposes to psychiatrists and psychotherapists to raise general questions to consider at their option.  Each clinician’s practice has its own unique problems that this publication is not meant to address.  This publication is not intended as legal or professional advice.  Readers should not act or refrain from acting based on information in this publication without seeking professional advice.  The information in this publication is provided on an “As Is” basis.  Deborah Michelle Sanders Publications, Inc. (“DMSPI”)  does not warrant or guarantee the accuracy, completeness, or suitability of any information in this publication for any purpose.  DMSPI disclaims all warranties, either express or implied, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose.  In no event will DMSPI incur any duty or obligation to any reader.  In no event will DMSPI be liable for any direct, indirect, special, incidental, consequential or punitive damages, including, but not limited to, third-party claims or lost profits arising from this publication, however caused and on any theory of liability.

 

Deborah Michelle Sanders, Esq., P. O. Box 642335, San Francisco, CA  94164-2335; 415-563-7458 Telephone; 415-563-3246 Fax; Deborah.Sanders@att.net.  BOARD OF ADVISORS:  Mark I. Levy, M.D. (Mill Valley); Rahn Y. Minagawa, Ph.D. (San Jose & San Diego); Richard G. Rappaport, M.D. (La Costa).                                                        ISSN 1527-7933

© Deborah Michelle Sanders  Publications, Inc. 2000

CONTENTS 

         Article:

Mark I. Levy, M.D. asks

Background:

Often in contested disability cases, the plaintiff alleges that they have a DSM-IV Axis I psychiatric condition that is disabling them from working and the defendant argues that they have no Axis I disorder, only an Axis II personality disorder which is a pre-existing and life long condition that is not necessarily disabling.

Questions:

1.                   Does the existence of a Personality Disorder co-existing with a claim of disability necessarily imply that the two are causally related?

2.                   What about volition?  When is a plaintiff with a Personality Disorder choosing volitionally to not work, vs. being prevented from working due to a disabling condition?  Are there any legal guidelines, case law or legal tests of the volitional component?

These questions are not addressed in terms by the courts.  I have therefore modified the questions.  (A table of cases discussed here and other cases in which the courts have discussed personality disorders, comprising thirteen pages, is available as a separate publication for the regular issue price of $16.50.)

Question 1:  What distinguishes persons whose disability discrimination cases are reported from all those with disputes?

The answer that I would give falls into three parts:  (a) the conduct of the employees, (b) the nature of their psychological makeup and (c) interpersonal factors.

(a)                 Most disability discrimination cases turn on the issue of specific employee conduct.  There is no “insanity defense” in the workplace.

In 1997 in Kansas, a police officer with a history of suicide attempts, diagnosed with bipolar disorder, PTSD and borderline personality disorder, had been assigned to a desk job as a reasonable accommodation for his disability.   This is the background to Houck v City of Prairie Village (#30 on the table of cases).  This leading case is often cited, even though it is not precedent in the Ninth Circuit or CA.  One afternoon, he and his wife were together at home and “wrestling over a gun.  Plaintiff hit his wife.  Eventually, plaintiff’s wife left the bedroom.  Plaintiff told her to ‘call 911.’  After exiting the bedroom, plaintiff’s wife heard a gunshot in the bedroom and then called 911….”  (Apparently, he did not actually shoot himself.)  When the police arrived, at some point, plaintiff pushed an officer “off the steps of the house and into some bushes.”  He was arrested for domestic violence and battery on a peace officer.  (He was taken to jail for a short time and then hospitalized.)  His employment was terminated and he sued.  “Plaintiff claims that his firing was discrimination because his alleged misconduct was caused by his disability.  This claim must be rejected.  A person who commits a criminal act as a result of a disabling condition is not excused from the employment consequences of the criminal act because of the disability. [my emphasis]” 

Early in disability discrimination litigation, before there was an Americans with Disabilities Act (ADA), when there was only the Rehabilitation Act of 1973, there was a different ethos.  Doe v New York University, et al. (#5 on the table; this case is only of historical interest and is not good law) involved medical education, not employment, but the case was all about conduct.  When Jane Doe applied to NYU Medical School, she “was accepted after falsely representing that she did not have any chronic or recurrent illnesses or emotional problems.  In fact she, while gifted academically, had suffered for many years from serious psychiatric and mental disorders, which evidenced themselves in the form of numerous self-destructive acts and attacks upon others.”  Specifically, she had borderline personality disorder and one expression was that she repeatedly self-mutilated in the presence of treating physicians and later university personnel.  Eventually, she was given a leave of absence with the understanding that she would have to apply for readmission.  Litigation ensued.  She then took a job with the federal Dept. of Health, Education and Welfare and its Office of Civil Rights (independently?) investigated her complaint against NYU and found that she had been unlawfully discriminated against.  Thereupon, NYU’s federal funding was in jeopardy, so of course much more litigation ensued -- and she was readmitted.  While the Court of Appeals held that a “substantial risk” to the safety of others was a factor the trial court must evaluate as the case wore on, she won the right to go to trial.  There were no more reported decisions; my understanding is that she completed school.  Thereafter, the Supreme Court of the U.S. decided School Board of Nassau County, Florida, et al. v Arline, concerning an elementary school teacher with recurrent tuberculosis, holding that persons with contagious diseases are within the scope of disability discrimination protection, but that the trial court would have to determine whether Arline was “otherwise qualified” for her job because “[a] person who poses a significant risk of communicating an infectious disease to others in the workplace will not be otherwise qualified for his or her job if reasonable accommodation will not eliminate that risk.”   Of course, Ms Arline had committed no conduct that posed a “substantial risk” to her students, but the Supreme Court’s holding had made Doe bad law, because the Doe court had not had, so to speak, the legal back-up to be able to remove Doe from school on account of her demonstrated disruptiveness and potential harm to patients.   

Congress, in writing the ADA, instituted law that safety considerations involving conduct that is a “direct threat” are valid factual underpinnings to a winning defense against a discrimination suit.

Conduct that has given rise to upheld dismissals of employees can range widely. All of the cases in this paragraph were decided outside the Ninth Circuit and CA; they are not precedent here. In Newberry v East Texas State University (#16), a professor with obsessive-compulsive disorder had simply worked a limited schedule and had railed against colleagues and otherwise harrassed them.  The truckdriver with chronic paranoid schizophrenia in Tokar v City of Chicago (#24) had specific racist fixations that led her employer to fear that she might intentionally plow her truck into an innocent bystander who was a person of what was to her the wrong color.  Threats to co-workers occurred in Palmer v Circuit Court (#25), Breiland v Advance Circuits, Inc. (#29), and Hardy v Sears, Roebuck and Co. (#33).  See also the discussion of being AWOL in my answer to Question 2. 

(b)                 There are few reported decisions in disability discrimination disputes that do not involve a person who presents with either a personality disorder or Axis I substance abuse, certain paraphilias, or an impulse-control disorder (or both).  The specified Axis I conditions do not show up  less frequently than the personality disorders.  Of course, decisions do not set forth all of the evidence in the case, so the psychiatric reports are not well reflected (a full DSM Dx is given in only one of the 35 cases on the chart, #4), and therefore it is very possible that the plaintiffs whose Axis I disorders are referred to may also have a personality disorder.   (The universe referred to in the first sentence is of course much larger than the set of cases in the chart, which is restricted to those in which the magic words “personality disorder” were specified by the court in some context, thus being susceptible to retrieval by computerized search.)

(c)                 Whether or not a dispute goes so far as to result in a reported decision turns on interpersonal factors.

An employee with a decent capacity to relate will have built up over time bonds in the workplace, that, upon symptomatic eruption will give him or her “credit” that will yield him or her “slack.”  Fitness-for-duty evaluations are triggered as there is lesser on-going relatedness (except of course in the case of actual workplace violence).  When an employee returns to work after leave for illness, (s)he is given time to adjust if (s)he has made friends on any level.  Therefore, for most employees who have been ill, disputes are worked out with more or less hard feelings and there is nothing to “make a federal case of.”

Unless of course, the employee is litigous.  While there is a component of what I noticed DSM refers to [obviously not with regard to the non-existent diagnostic construct of being litigous!] as an “antagonism v agreeableness” personality trait involved, in my experience, it is the sociological factor of the people who advise the employee that tips the balance.  There are the “kibbitzers” such as a union representative, friends – or possibly even a therapist – who lack full knowledge of what the employee would be getting into if (s)he were to litigate, but who nonetheless discuss with the employee his or her grievances.  Following such talk, the employee may decide to go to an attorney.  The lawyer is of course the gate-keeper to the courts for almost all plaintiffs.  While (s)he decides whether the case is strong enough to be worth bringing to court, and while (s)he has a duty to explain to the client all of the client’s financial responsibilities and the attorney’s concommitant duties to guard the client’s funds, lawyers do not have any duty whatsoever to initiate disclosure of the risks (and benefits) of litigating.  (Health professionals have a duty to obtain consent because of the historic root of a surgeon’s operating as being an assault and battery if otherwise done.)  This fact naturally imposes a steep rise in the likelihood of a lawsuit’s being filed if an employee happens to consult an attorney, in comparison to its likelihood for an unrepresented employee.  In actuality, 97-98.5% of all employment disability discrimination cases (that go to the Equal Employment Opportunity Commission and/or on to court) are resolved in favor of the employer; in actuality, any litigant who raises the issue of having a mental illness is opening himself or herself to meticulous examination of his or her private life – it would therefore seem meet for the attorney to be required to provide a cost-benefit analysis before proceeding, but such is not the law.

Question 2: How have the courts dealt with conduct reflecting the motivation not to work?

Within the sphere of disability discrimination law, motivation not to work has been discussed in the case law as conduct, specifically (a) being AWOL and (b) making inconsistent representations of whether or not one is able to work.

(a)                 Under these two cases, termination for being absent without leave is not disability discrimination.

Case I:  Plaintiff “was terminated and not reinstated because she abandoned her job.  That this job abandonment may have been the result of a previously undisclosed … bipolar … disorder does not constitute either disability discrimination or a refusal to provide a reasonable accommodation to a mental disorder,” Brundage v Hahn , #2 (CA Court of Appeal, Second Appellate District [Los Angeles], 1997).  Three months after she received medical leave for substance abuse treatment, she failed to report to work and did not contact her employer for six weeks.  During that time, she was terminated.  “Because …[the employer] did not know about Brundage’s manic-depressive disorder, it could not have terminated her because of that disorder.”  She argued that reinstatement would be the appropriate reasonable accommodation for her disability.  The court held that “‘[r]easonable accommodation’ does not include excusing a failure to control a controllable disability or giving an employee a ‘second chance’ to control the disability in the future….  Brundage does not ask that her disability be accommodated, she asks that job abandonment allegedly arising from the failure to control the disability be forgiven.  The ADA does not mandate giving a second chance to an employee who abandoned her job.”

Case II:  In Ellison v Northwest Airlines, Inc., et al., #4 , a 1996 case from a federal trial court in the Ninth Circuit, plaintiff had an adjustment disorder or severe depression with accompanying anxiety or Major depression, recurrent vs. dysthymic disorder/Mixed personality disorder with histrionic, dependent, narcissistic, paranoid, and antisocial traits.  (He had failed to file his lawsuit within the required filing time period.  He argued that an dispensation “ought to apply here on account of his ‘severe mental condition.’”  However, during the earlier period of his illness, he took action on a union grievance, a workers’ compensation claim, a medical malpractice suit and brought his ADA claim before the Equal Employment Opportunity Commission.  Later in the course of his illness, his treating physician said that his “condition ‘seemed to improve’ and was ‘generally better.’”  So the court ruled against him and barred his claim.)  Although the case was already disposed of  as not having been filed in time, the court also held that “there is no evidence Defendants terminated him because of his mental illness.”  Plaintiff had been terminated after approximately seven weeks of being absent without leave, nine days of which was after the return-to-work date that the hospital psychiatrist had specified.  Plaintiff’s supervisor “fired Plaintiff because Plaintiff ‘was absent without leave …[for eight days] based on …[the hospital psychiatrist’s] letter stating that [Plaintiff] would be able to return to work on … [a given day].”  The court quoted a case with similar facts:  “The Postal Service did not fire Miller because of his [mental] illness.  It fired him because even though his psychiatrist had pronounced him able to return to work, he did not return.  Miller’s superiors had no reason to believe that he was prevented from returning by his mental illness.”

(b)                 Under these four cases, making inconsistent representations on whether or not one is able to work can have various results, depending on what exactly was stated.

Case I:  The Supreme Court of the U.S. held in 1999 in Cleveland v Policy Management Systems Corp. that “pursuit, and receipt, of …[Social Security Disability Insurance Benefits] does not automatically estop [“stop”] the recipient from pursuing an ADA claim.  Nor does the law erect a strong presumption against the recipient’s success under the ADA.  Nonetheless, an ADA plaintiff cannot simply ignore her SSDI contention that she was too disabled to work….  [S]he must explain why that SSDI contention is consistent with her ADA claim that she could ‘perform the essential functions’ of her previous job, at least with ‘reasonable accommodation.’ …  In her brief in this Court, Cleveland explains the discrepancy between her SSDI statements that she was ‘totally disabled’ and her ADA claim ….  The first statements, she says, ‘were made … [to the Social Security Administration, which] does not consider the effect that reasonable workplace accommodations would have on the ability to work.’…  Moreover, she claims the SSDI statements were ‘accurate statements’ if examined ‘in the time period in which they were made.’ … The parties should have the opportunity in the trial court to present, or to contest, these explanations….”

Case II:  (One month before the Cleveland decision, the Ninth Circuit issued a set of opinions in a state disability insurance benefits case, Fredenburg v Contra Costa County Dept. of Health Services (#1).  Cleveland does not make Fredenburg bad law, because Cleveland concerns federal Social Security Disability Insurance Benefits, and contains no language that can be generalized to state benefits.  Furthermore, Cleveland’s description of the inconsistent statements it considers is straightforward, indicating that the inconsistency reflected the complexity of reality, whereas in Fredenburg, as you will read, there is much questioning of whether the plaintiff was genuine in her representations.  In any event, the majority opinion in Fredenburg allows inconsistent statements to be explained, just as Cleveland does.)

This is what went on in Fredenburg.  A plaintiff therapist or (depending on the page on which you’re reading) psychiatrist  with (according to the majority opinion) paranoia and major depression or (according to the dissent) adjustment disorder and “personality disorder” won the right to go to trial.  She had been placed on indefinite leave without pay when she “had on-the-job difficulties with co-workers,” and she received six months’ worth of State Disability Insurance benefits.  At that time, “a state psychiatrist found her capable of returning to work.   Fredenburg attempted to have the benefits continued, certifying … that she was still disabled and incapable of doing her regular work, but she was unsuccessful….  The following month, Fredenburg sought to return to work.”  She refused to undergo the requested fitness-for-duty examination , so was not allowed to return.  She then sued for disability discrimination.  The trial court threw out her suit on the ground that she had made inconsistent statements about whether she was able to work.  This is what the majority held: 

Fredenburg was not playing fast and loose with, or committing fraud on, the court.  Her case illustrates the problems faced by a worker in her position.  Her employer concluded that she could not perform her job….  She disagreed with her employer’s determination and unsuccessfully challenged it.  Then, without pay because of her asserted disability, she applied for temporary disability benefits and received them.  What else was she to do?  When those benefits were terminated because the state decided she was no longer disabled, she disagreed but was unsuccessful….  She then asked her employer to take her back, and the employer refused.  So she brought suit under the ADA, claiming that she was able to perform her job.  It is true that Fredenberg took inconsistent positions during this saga, but her employer and the state, considered together, were not treating her consistently either.  She has not denied any of the representations she made; the court has not been misled….

We wish to make clear, however, that … Fredenburg certainly would not be entitled to retain disability benefits and, at the same time, recover back pay for the same period on her claim that her employer violated the ADA….  Our ruling relieves Fredenburg of an untenable choice between disability benefits and an ADA claim…, but it does not permit a double recovery based on inconsistent positions.

Three judges heard this case, and there are three opinions.  Here is the second one, technically a “concurring opinion.”

I write separately only to stress that … the [trial] court is at liberty to determine … whether … Fredenburg’s claims fail [as] a matter of law….

While judicial estoppel [the casting out from court of litigation, based on inconsistent claims in documents by the same party] applies only to a “knowing misrepresentation to or even a fraud on the court,” the holding of [the precedent the three judges are explicating] distinguishes chicanery from inadvertence or mistake….  Here we seem to confront a situation somewhere in the middle. Appellant appears to have simultaneously insisted to the state disability agency that she continued to be disabled when it sought to cut off her benefits, while seeking to maintain an ADA claim without requesting any specific accommodation [implying that she could carry out the essential functions of her job without any difficulty].   Adding further to the confusion, Fredenburg also claims discrimination based on her initial removal from work, arguing presumably that the County’s claim that she suffered from paranoia was pretextual [implying that she had no impairment that, if it substantially limited a major life function, would constitute an ADA disability].  While these inconsistent claims regarding her ability to work, return to work and inability to work might be satisfactorily explained, for example, by the nature of her psychological impairment, or the passage of time, on remand the … court is free to consider all the evidence….

The dissent is by Judge Alex Kozinski, whom you may have read as a book reviewer and serendipitous essayist for The New York Times and such.  (Endorsement of his writing style is not necessarily an endorsement of his philosophy.) 

Fredenburg repeatedly represented to the state Employment Development Department … that she was incapable of performing her regular work.  She is now claiming that she can perform her regular work, and in fact could do so all along.  There is absolutely no way to reconcile the two positions….

The simple explanation is that Fredenburg told one story in one proceeding, and then, when it didn’t get her what she wanted, she told a different and inconsistent story in another proceeding.  The majority responds to Fredenburg’s obvious mendacity with a rhetorical question:  ‘What else was she to do?’  … What Fredenburg was to do was to tell the truth at all times…. 

There is nothing Fredenburg could possibly have done to be any less forthright or more inconsistent than she was.  If this be not ‘fast and loose,’ I’m not sure what is….

Although her illness was ‘potentially’ temporary, nowhere does she allege that she was disabled during the time that she was collecting benefits, and then later got better, as did [the plaintiff in a precedent that] has no application here, and to suggest that it does belittles the claims of honest plaintiffs who admit to taking disability benefits during a leave of absence in which they seek to recover….

…By saying that prior judicial statements are to be treated just like prior statements made to a fish merchant or a fortune teller, the majority drives a stake through the heart of the doctrine of judicial estoppel….

…I cannot agree with the majority here that sworn statements on applications for disability benefits … should be granted no more weight than statements in casual conversation.  The majority’s opinion allows people to slough off prior inconsistent representations when they become inconvenient, much like a snake sheds its skin.  It is one thing to allow a plaintiff to explain how her previous representations were actually truthful and consistent with what she claims today…; it is a far different thing to look away from a plaintiff’s previous representations with a wink and a nudge because she was “forced” to lie in order to fenagle benefits from the welfare state….

That’s more foment of views than is typical for Court of Appeals decisions, and sometimes when such fecundity occurs, the law is significantly changed the next time the identical issue comes up. 

Case III:  Hatfield v Quantum Chemical Corp. (#17) is a trial court case decided outside the Ninth Circuit and CA; it is not precedent here.   Hatfield held that the plaintiff was no longer qualified to recover under the ADA since he had accepted long-term disability benefits from the employer’s carrier before the date he scheduled a back-to-work conference. 

Case IV:  In a case decided outside the Ninth Circuit and CA that is not precedent here, “the cynic might regard plaintiff’s objective as finding a defendant to sue rather than an employer to serve,” due to serial job hops truncated by workers’ compensation and other claims,  Wilson v Freightliner Corp. (#15). The plaintiff, with hospitalizations for attempted suicide and psychosis, and treatment for substance abuse and chronic schizophrenia, had made many false statements about his job and health histories on his employment application, and then made inconsistent statements in this ADA claim and in a Social Security benefits application.  Defendant not only got the case thrown out, but also the plaintiff’s attorney had to pay half the defense attorney’s fees for having made frivolous arguments like “the plaintiff’s belated suggested ‘accommodation’ – that he stand on a rolling step stool to lift and affix parts to a continuously moving axle – [which] is hardly worth the cost of the ink it requires to mention it.” 

Unspecified Profession

Do you remember EST?  Someone named Arnold Siegel, whose profession is not stated in the opinion, but who was not a licensed therapist in CA, in 1985 “opened an offshoot of EST called The Conversation,” in NY but apparently also in CA. He “supervised” Abigail Adams, in a “‘many-faceted relationship’ in which he was her ‘teacher, therapist, counselor, tutor, employer and a person who undertook the responsibility, for money, to psychologically rescue and make her a better person, psychologically.’  Adams characterized this as a ‘consumer’ relationship.  She alleged by commencing a ‘sexual but non-dating’ relationship with her, Siegel took advantage of her vulnerability as an employee and her need for psychological help from EST.”  Siegel held a variety of insurance policies with a total of five carriers, one of which issued a malpractice policy (again, we do not know Siegel’s profession).  Naturally, none of the five want to be on the hook for defense costs (and ensuing damages), so they have been jockeying.  On October 16^th, the Court of Appeal, Second Appellate District (Los Angeles) in Commercial Underwriters Insurance Co. v Superior Court of Los Angeles County gave the malpractice carrier contribution rights from some of the other carriers, because Adams’s “stomach pain, headaches, skin problems, and infertility” are bodily injuries and because Adams had alleged that Siegel had committed one negligent act (malpractice) as well as many intentional acts.  (Intentional acts are typically outside the scope of coverage of insurance policies.)

Physician’s Alleged Malpractice – Defense of “Health Care Extender”

By having accepted a defense from her husband psychiatrist’s malpractice carrier, his widow, “who was not a therapist,” who had participated with her husband in couples therapy with a couple who became plaintiffs against her husband and her, was obligated to accept arbitration of her disputes with the malpractice carrier, Norcal Mutual Insurance Co. v. Newton, Court of Appeal, First Appellate District (San Francisco), October 10^th.  The widow had preferred to be in court.  The underlying claims have to do mostly with the specific content reported to the National Practitioner Data Bank concerning the preceding settlement of the case against her husband.

A locum tenens (temporary employment) anesthesiologist had objected to proceeding with surgery on a certain patient, due to atrial fibrillation (heartbeat aberration).  A few days later, the medical group’s shareholders decided not to renew his contract.  The anesthesiologist was given the right to go to trial, because the CA Business and Professions Code includes a section (2056(c)) that termination of employment of a physician for “advocating for medically appropriate health care … violates the public policy of this state,” Khajavi v Feather River Anesthesia Medical Group, Court of Appeal, Third Appellate District (Sutter County), October 10^th.

Employers in the Ninth Circuit have a duty to engage in an interactive process with employees who state that they have a disability, with regard to reasonable accommodations.  This is “an informal process to clarify what the individual needs and identify the appropriate accommodation.”  “A seniority system is not a per se bar to reassignment” to another job as a reasonable accommodation.  “However, a seniority system is a factor in the undue hardship analysis.”  Plaintiff will go to trial in Barnett v. U.S. Air, October 4^th.

BETTER LEGAL AND BUSINESS PRACTICE FOR PSYCHIATRISTS AND PSYCHOTHERAPISTS – California Edition (formerly entitled LAWYERING BULLETIN) is published 15 times annually for the annual subscription fee of $289, but the special introductory rate of $247.50 is in effect through December 31, 2000.  The single issue price is $16.50 through December 31^st.  Visa and MasterCard are accepted. 

         

This newsletter is provided only for information purposes to psychiatrists and psychotherapists to raise general questions to consider at their option.  Each clinician’s practice has its own unique problems that this publication is not meant to address.  This publication is not intended as legal or professional advice.  Readers should not act or refrain from acting based on information in this publication without seeking professional advice.  The information in this publication is provided on an “As Is” basis.  Deborah Michelle Sanders Publications, Inc. (“DMSPI”)  does not warrant or guarantee the accuracy, completeness, or suitability of any information in this publication for any purpose.  DMSPI disclaims all warranties, either express or implied, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose.  In no event will DMSPI incur any duty or obligation to any reader.  In no event will DMSPI be liable for any direct, indirect, special, incidental, consequential or punitive damages, including, but not limited to, third-party claims or lost profits arising from this publication, however caused and on any theory of liability.

 

Deborah Michelle Sanders, Esq., P. O. Box 642335, San Francisco, CA  94164-2335; 415-563-7458 Telephone; 415-563-3246 Fax; Deborah.Sanders@att.net.  BOARD OF ADVISORS:  Mark I. Levy, M.D. (Mill Valley); Rahn Y. Minagawa, Ph.D. (San Jose & San Diego); Richard G. Rappaport, M.D. (La Costa).                                                        ISSN 1527-7933

© Deborah Michelle Sanders  Publications, Inc. 2000