Search

Psychiatric advance directives (PADs) were introduced in the 1980s as legal instruments for psychiatric patients to retain some choice over their own mental health treatment during periods of decisional incapacity. However, PADs are nested in larger structures of mental health law and policy that protect the interests of parties other than the patient, and which, in situations of conflict involving the treatment of incapacitated patients, tend to favor the clinician's professional judgment over the patient's manifest wishes to avoid standard treatment. Thus, PADs are trumped by civil commitment law and may also be legally overridden by clinicians who, acting in good faith, consider PAD instructions to be inconsistent with accepted clinical standards of care. We discuss philosophical-ethical and legal issues surrounding overriding PADs and offer analysis of the possible future of legal cases in which the question of overriding PADs and fiscal concerns may collide.

Humanities teaching was introduced at Stony Brook University School of Medicine by Edmund Pellegrino, the first dean of the Medical School and founder of the Health Sciences Center. Since 1990, "Medicine in Society" has been a substantial presence throughout the curriculum, introducing students to the perspectives of a wide range of humanities disciplines as they apply to health care, and continuing as a sustained presence throughout the four years of training. Medicine in Society serves as a reminder that medicine is a human and communal endeavor, situated in sociocultural contexts, reliant on human values, and articulated most often through narratives. The authors describe the structure and function of the Medicine in Society curriculum and the Institute for Medicine in Contemporary Society, summarize their evaluation of the program, and outline their plans for meeting current and future challenges.

The impact of legal factors on medical treatment decisions for dying patients has been studied in the USA for years. However, it is unknown how legal factors may affect similar medical decisions in other countries. This exploratory study compared responses between two populations of physicians, from Denmark (n = 62) and the USA (n = 301), who regularly treat terminally ill patients in tertiary care medical centers. We investigated whether Danish and US physicians differed significantly in their attitudes about the influence of law on treatment decisions for terminally ill patients. The Danish physicians demonstrated significantly better knowledge of medical law relevant to end-of-life treatment than did US physicians. The Danish sample also reported significantly lower levels of legal defensiveness than the US sample. These findings are consistent with our previous research showing that, among US physicians, legal defensiveness and knowledge of medical law are inversely related.

Does legal defensiveness significantly influence physicians' assessments of medical futility, in ways that may adversely affect the rights of patients and their family members to make their own health care decisions at the end of life? This exploratory study addresses that question with attitudinal data from a survey of 301 physicians practicing in academic medical centers in Texas. The majority of respondents indicated that the probability of success defining futile treatment should hypothetically be lower for patients with potential to benefit more from life-sustaining medical intervention (e.g. typically patients who are sentient), and higher for patients with less potential to benefit (e.g. patients in a persistent vegetative state). That is to say, physicians normally perceive longer odds to be worth pursuing for greater potential gain - a position that seems logically consonant with patients' rational self-interest. However, physicians with an attitude of extreme legal defensiveness did not fit this pattern. Rather, they tended to define futility in a manner that would maximize the physician's latitude to justifiably oppose patient preferences for end-of-life treatment abatement. These findings suggest that some physicians assume an adversarial position in their consideration of medical futility issues - an attitude that anticipates conflict with terminally-ill patients or their surrogates. The analysis presented here is not definitive, but at least raises the question of whether some physicians may inappropriately use their prerogative over medical futility as a means to guard their professional autonomy against perceived threats.

The authors consider the ethical issues involved in a case in which an elderly man suffering from recurrent, treatment-resistant depression expressed a wish to forgo life-sustaining treatment should it become necessary. The patient had no immediate life-threatening medical conditions but was in danger of becoming malnourished and dehydrated. The authors conclude that unrelieved suffering resulting from depression, when combined with repeated treatment failures, may justify refusal of life-sustaining treatment in very rare cases.

Major advances in predictive genetic testing resulting from the Human Genome Initiative could change significantly the routine practice of family medicine. Family physicians should be aware that increased genetic information may affect patients' abilities to acquire and maintain insurance and employment and that interested parties will have incentives to seek this information. The social consequences of genetic information, as well as increased health promotion efforts, may raise problems of informed consent and confidentiality. In addition to their ethical implications, these developments will also affect the practice of family physicians in practical ways such as record keeping. We discuss cases that illustrate the potential impact of these emerging technologies on the practice of family medicine.

Basic research will spur development of genetic tests that are capable of presymptomatic prediction of disease, disability, and premature death in presently asymptomatic individuals. Concerns have been expressed about potential harms related to the use of genetic test results, especially loss of confidentiality, eugenics, and discrimination. Existing laws and administrative policies may not be sufficient to assure that genetic information is used fairly. To provide factual information and conceptual principles upon which sound social policy can be based, the Human Genome Initiative established an Ethical, Legal, and Social Issues Program. Among the first areas to be identified as a priority for study was insurance. This paper provides a review of life, health, and disability insurance systems, including basic principles, risk classification, and market and regulatory issues, and examines the potential impact of genetic information on the insurance industry.

In this study, we investigated physicians' attitudes, knowledge, and reported practices regarding the effects of perceived legal constraints on the abatement of life-sustaining treatment from patients who are clearly dying. A factor in assessing these issues is the concept of defensive medicine -- that is the perception that doctors are being forced to order every possible laboratory test and second opinion, or to continue providing non-beneficial life-sustaining treatment, solely to protect themselves from future legal claims. This perception appears widespread among practicing physicians. However, we believe that defensive medicine represents only part of a complex constellation of factors that comprise physicians' reluctance to abate treatment. This phenomenon encompasses medical, legal, social, psychological, and spiritual factors interacting in ways that are not fully understood. We remain cognizant of the potential impact of all these factors. For purposes of this article, however, we have chosen to focus on legal and psychological aspects of physicians' reluctance to abate treatment and the corresponding ethical implications.

Surveys have shown that a substantial proportion of the population has prepared an advance directive. The purpose of this exploratory study was to assess the existence and nature of hospital policy regarding these documents. A survey questionnaire was sent to 394 randomly selected hospitals in the United States. Of the 219 responding hospitals, 146 (67%) reported having a formal policy regarding advance directives. The large majority of those with a policy require the patient to notify the hospital of an advance directive, while only 4% of the respondents actively inquire about these documents. Hospitals in states with legislation that sanctions advance directives were significantly more likely to have a formal policy regarding these documents than hospitals in states without such legislation. Forty-six percent of the respondents reported having an ethics committee; however, the presence of an ethics committee was not significantly associated with the presence of a formal policy. Of the 69 hospitals that had both a formal policy and an ethics committee, only 30 (43%) reported that the policy had been reviewed by the ethics committee. Ethical and legal issues regarding hospital policy on advance directives are discussed. Hospitals should adopt formal policies to ask all adult patients at the time of admission whether they have prepared a living will, durable power of attorney, or similar document; and ethics committees should play a more active role in policy development.