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Suicide involves a complex set of behaviors and emotions that lead up to actions that may be based on planning and forethought or the result of impulse. While there are a host of antecedent circumstances the presence of a mood disorder, primarily depression, is the most common factor in suicide. While management of depression is recognized as important prevention strategy in depression, the means by which suicide occurs must be a critical element of prevention. Policies that lower access to the means for suicide will decrease the fatality. Guns are associated with half of suicides and the case fatality rate of gun associated suicide is over 90% compared to 7% for all other means. This emphasizes the importance of offering strategies that limit access to guns to those at higher risk for suicide. A declaration of formal self‐exclusion for access to firearms (guns and ammunition) offers the individual at greater risk for suicide to place themselves on an official list that would prevent them from purchasing lethal weapons. A person with depression, when well, might wish to enroll voluntarily to prevent themselves, when ill, from procuring a weapon to harm themselves or others. This recognizes the autonomy of the person and protects both the individual, the family, and society.

Objective to elaborate the conceptual theoreticallegal provisions and scientific recommendations for the substantiating the inefficiency of mandated disclosure. Methods general dialectic method of cognition as well as the general scientific and specific legal methods of research based on it. Results the article explores the spectacular prevalence and failure of the single most common technique for protecting personal autonomy in modern society mandated disclosure. The article has four parts 1 a comprehensive summary of the recurring use of mandated disclosures in many forms and circumstances in the areas of consumer and borrower protection patient informed consent contract formation and constitutional rights 2 a survey of the empirical literature documenting the failure of the mandated disclosure regime in informing people and in improving their decisions 3 an account of the multitude of reasons mandated disclosures fail focusing on the political dynamics underlying the enactments of these mandates the incentives of disclosers to carry them out and most importantly on the ability of disclosees to use them and 4 an argument that mandated disclosure not only fails to achieve its stated goal but also leads to unintended consequences that often harm the very people it intends to serve. Scientific novelty the article elaborates and introduces into academic sphere the substantiation of the efficiency of mandated disclosure proves the failure of the mandated disclosure regime in informing people and in improving their decisions and reveals the unintended consequences that often harm the very people it intends to serve. Practical significance the provisions ad conclusions of the article can be used in scientific lawmaking and lawenforcement activities and in the educational process of institutions of higher education.

What would happen if cost-benefit analysis (CBA) were applied to disclosure regulations? Mandated disclosure has largely escaped rigorous CBA because it looks so plausible: disclosure seems rich in benefits and low in cost. This article makes two arguments. First, it previews our thesis in More Than You Wanted to Know that disclosure laws do not deliver their anticipated benefits and thus cannot easily pass quantified CBA. Second, it describes a previously unrecognized cost of disclosure, one arising from lawmakers’ collective-action problem. With the proliferation of disclosures, each new mandate diminishes the attention that people can give to other information, including all other disclosures. The problem for CBA is lawmakers’ inability to coordinate laws across different fields and jurisdictions. This article illustrates this regulatory failure by examining the rigorous cost-effectiveness analysis conducted by the Consumer Financial Protection Bureau for its recent mortgage disclosure regulation.

The ultimate aim of health care policy is good care at good prices. Managed care failed to achieve this goal through influencing providers, so health policy has turned to the only market-based option left: treating patients like consumers. Health insurance and tax policy now pressure patients to spend their own money when they select health plans, providers, and treatments. Expecting patients to choose what they need at the price they want, consumerists believe that market competition will constrain costs while optimizing quality. This classic form of consumerism is today’s health policy watchword. This article evaluates consumerism and the regulatory mechanism of which it is essentially an example – legally mandated disclosure of information. We do so by assessing the crucial assumptions about human nature on which consumerism and mandated disclosure depend. Consumerism operates in a variety of contexts in a variety of ways with a variety of aims. To assess so protean a thing, we ask what a patient’s life would really be like in a consumerist world. The literature abounds in theories about how medical consumers should behave. We look for empirical evidence about how real people actually buy health plans, choose providers, and select treatments. We conclude that consumerism is unlikely to accomplish its goals. Consumerism’s prerequisites are too many and too demanding. First, consumers must have choices that include the coverage, care-takers, and care they want. Second, reliable information about those choices must be available. Third, information must be put before consumers in helpful ways, especially by doctors. Fourth, the information must be complete and comprehensible enough for consumers to use it. Fifth, consumers must understand what they are told. Sixth, consumers must actually analyze the information and do so well enough to make good choices. Our review of the empirical evidence concludes that these pre­requisites cannot be met reliably most of the time. At every stage people encounter daunting hurdles. Like so many other dreams of controlling costs and giving patients control, consumerism is doomed to disappoint. This does not mean that consumerist tools should never be used. If all that consumerism accomplished is to raise general cost-consciousness among patients, still, it could make a substantial contribution to the larger cost-control efforts by insurers and the government. Once patients bear responsibility for much day-to-day spending on their health needs, they should be increasingly sensitized to the difficult trade-offs that abound in medical care and might even begin to understand that public and private health insurers have a legitimate interest in controlling medical spending.

When patients pay for care out-of-pocket, physicians must balance their professional obligations to serve with the commercial demands of medical practice. Consumer-directed health care makes this problem newly pressing, but law and ethics have thought for millennia about how doctors should bill patients.At various points in European history, the law restricted doctors' ability to bill for their services, but this legal aversion to commercializing medicine did not take root in the American colonies. Rather, US law has always treated selling medical services the way it treats other sales. Yet doctors acted differently in a crucial way. Driven by the economics of medical practice before the spread of health insurance, doctors charged patients according to what they thought each patient could afford. The use of sliding fee scales persisted until widespread health insurance drove a standardization of fees. CURRENT PRACTICE: Today, encouraged by Medicare rules and managed care discounts, providers use a perverse form of a sliding scale that charges the most to patients who can afford the least. Primary care physicians typically charge uninsured patients one third to one half more than they receive from insurers for basic office or hospital visits, and markups are substantially higher (2 to 2.5 times) for high-tech tests and specialists' invasive procedures.Ethical and professional principles might require providers to return to discounting fees for patients in straitened circumstances, but imposing such a duty formally (by law or by ethical code) on doctors would be harder both in principle and in practice than to impose such a duty on hospitals. Still, professional ethics should encourage physicians to give patients in economic trouble at least the benefit of the lowest rate they accept from an established payer.

We undertook a qualitative e-mail survey of federally-funded principal investigators of their views of the US human subjects protection system, intended to identify the range of investigator attitudes. This was an exploratory study with a 14% response rate. Twenty-eight principal investigators responded; their comments were analyzed to show underlying themes, which are here presented along with supporting quotations. There was consensus that it is important to protect human subjects from research abuse, but disagreement over how well the IRB system is functioning. Some researchers felt that the system is effective and serves its purpose well. Of those who support the system, some endorse its methods, purpose, and daily functioning, as they experience it, without reservation. Others, while expressing some frustration, feel that the purpose is important and their local IRB does its best to make a difficult system work well. Those investigators who were more harshly critical commented on multiple flaws in the system, including (1) consent forms that are inappropriate and incomprehensible, (2) an emphasis on minutiae, and (3) concern with protecting the institution more than research subjects. Respondents told us that the IRB system is a particular burden for research in neurology, emergency medical conditions, repositories, and social sciences in general; a more comprehensive study might identify other problematic areas. Significant concern was expressed about the cost, inefficiency, and irrationality of IRB review. The IRB system works well for some researchers, but our results indicate that other investigators feel the costs outweigh the benefits.

Written documents called “contracts” are appearing with increasing frequency in clinical practice and the medical literature. There are behavioral contracts for managing “difficult patients,”1 opioid contracts,2 suicide prevention contracts,3 and healthy living contracts.4 Some practices have even asked patients to sign contracts promising not to litigate or post defamatory comments on the Internet.5 Despite this widespread adoption, the use of contracts in medicine has been subject to relatively little critical appraisal. As shown in Table 1, patient contracts do different things in different clinical situations. Some serve “administrative” goals, like deterring patients from mistreating clinical personnel or diverting narcotics. Others are educational; they draw the patient’s attention solemnly to information. Others clarify expectations and foster transparency, as when a prospective organ recipient agrees to substance-abuse rules. Others – like suicide-prevention contracts – help doctors express their concern for their patients. Finally, some “Ulysses contracts” help patients hold themselves to better health practices by bolstering their willpower through a written commitment. (Ulysses in Homer’s Odyssey had his men to tie him to the ship’s mast so he could not respond to the Sirens’ song.) Table 1 Common Types of Patient Contracts Not only do “patient contracts” have myriad purposes, they have uncertain success. A Cochrane review analyzed thirty randomized trials in addiction, weight-control or medication-adherence settings.4 The endpoints included processes (e.g., adherence to treatment) and targets (e.g., blood pressure). Results were mixed, with fifteen endpoints showing a benefit of contracts compared to usual care, six favoring standard care, and twenty-six endpoints showing no difference. Even less is known about other kinds of contracts. A review of eleven observational studies found weak evidence that opioid contracts reduced narcotic diversion or misuse.6 Contracts with other aims (like suicide prevention) have not been empirically studied.7 To some extent, any patient encounter can be viewed as contractual, whereby the patient and physician agree on mutually accepted responsibilities.8 But here the term “contract” becomes problematic. In the legal context, what makes a contract different from an agreement is that contracts are intended to be enforced. So turning informal agreements into formal documents emphasizes the consequences of breach, whether explicit or implied. In some clinical settings, these consequences are clear: the doctor will no longer prescribe narcotics, or the patient will not get a liver transplant. However, does adherence to terms of the contract also become a pre-condition for continued medical care? If so, many would argue this violates physicians’ ethical obligations to not abandon patients.9 Even if not, the consequences of breach may not always be clear to patients, who may assume from the word “contract” that the relationship would be terminated. Because of these implied consequences, contracts risk fundamentally altering the patient-physician relationship – a relationship traditionally founded on unconditional loyalty.10 If patients feel their medical care could be terminated at any time for perception of non-adherence, how can they openly communicate with their physicians? This risk is heightened when, as is common, patients are asked to sign a standard form drafted by the physician, without opportunity for negotiation of the terms. And a unilateral or authoritarian style of implementing contracts may cause patients to feel threatened or coerced, and perhaps even view the contract as a “prelude to abandonment.”11 Given the inconclusive evidence of the success of these contracts and the disadvantages they can present, we have some recommendations. First, clarify terminology. Written patient-physician agreements often do not fit the usual definition of a contract, and they serve varied purposes. Second, clarify aims. For example, where the primary aim is stating non-negotiable terms (like substance-abuse criteria for transplant candidacy), it is franker to label the document an “Acknowledgement of Clinic Policies.” Third, treat the “contract” as part of a therapeutic process. A boilerplate contract is one thing, helping patients set and meet goals is another. This is the principle behind “motivational interviewing,” a technique with strong empirical support12. Finally, patients should be given resources and assistance in meeting these goals. For example, structured weight loss programs work better than just telling patients to “go diet and exercise.” In sum, “contract” is a misleading term for documents which are increasingly used in a wide variety of clinical situations, with myriad purposes and uncertain effectiveness. Although the aims of contracting may be sound, physicians need to understand the limits of contracts and the ways they can be misunderstood, to the detriment of the patient-physician relationship. Whenever possible, written agreements should be bilateral, tailored to the patient, and presented in a way that signals ongoing commitment. Otherwise we risk alienating patients and damaging the therapeutic alliance.

Instructional advance directives (i.e., living wills) have been endorsed widely as a crucial method for maintaining seriously ill patients' autonomy at the end of life. Theoretically, living wills maintain the patient's voice in treatment decisions by enhancing the ability of surrogate decision makers to make the treatment choices that patients would make for themselves if competent. For living wills to achieve their goal, the following three assumptions must be met: (a) People must complete living wills, (b) treatment preferences recorded in living wills must be authentic, and (c) surrogate decision makers must be able to interpret living wills and use them to make accurate treatment predictions. The authors review the medical and psychological literatures bearing on these assumptions and find that the available empirical evidence challenges the validity of each assumption. The authors conclude by discussing the potential benefits of advance directive use and directions for future research.