The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: part 2 (Queensland)

This is the second article in a series of three that examines the legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity. This article considers the position in Queensland, including the parens patriae jurisdiction of the Supreme Court. A review of the law in this State reveals that medical professionals play significant legal roles in these decisions. However, the law is problematic in a number of respects and this is likely to impede medical professionals' legal knowledge in this area. The article examines the level of training medical professionals receive on issues such as advance health directives and substitute decision-making, and the available empirical evidence as to the state of medical professionals' knowledge of the law at the end of life. It concludes that there are gaps in legal knowledge and that law reform is needed in Queensland.     

Patient competence and professional incompetence: disagreements in capacity assessments in one Australian jurisdiction, and their educational implications

The determination of capacity to make medical, personal and financial decisions has significant individual and social implications. Medical and other health professionals are traditionally relied on by courts and tribunals to provide clinical and psychometric evidence of the presence or absence of capacity, or competence. Concern has long been expressed over the variability of these assessments. A survey of 285 decisions of the Queensland Guardianship and Assessment Tribunal (GAAT) between 2005 and 2008 was conducted to estimate the incidence of disagreement between health professionals in capacity assessments; to provide examples of conflicting assessments and models of assessment used; and to consider the educational implications of disagreements. While the final capacity determinations by the GAAT appear sound, this case series, and other studies in the capacity literature, strongly suggest the need to improve the education of health professionals, especially doctors, at undergraduate and postgraduate levels, in the practical assessment of capacity as a fundamental clinical skill.     

Challenging Australia's "closed" model of neonatal care: the need for reform following Re baby D (No 2)

The withdrawal or withholding of life-sustaining treatment to compromised newborns is a subject of controversy in countries where there is now highly advanced neonatal care to keep such newborns alive. The topic has generated comparatively less debate in Australia, where case law is sparse and parents and clinicians themselves make decisions regarding the cessation of care, largely free from extemal oversight. The recent case of Re Baby D (No 2) [2011] FamCA 176 endorses this "closed" approach to neonatal decision-making. This article critically discusses some of its implications and makes suggestions for reform to ensure meaningful oversight of decisions to withdraw or withhold treatment. The authors argue that the judgment fails to address some fundamental issues, such as ensuring that those with the responsibility to make decisions are doing so on a "best interests" basis. This is important because, in a society where disability remains stigmatised and poorly understood, there is no opportunity under the approach adopted in Baby D to guarantee adequate protection of the rights of individuals born with physical or intellectual impairments.     

The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: part 1 (New South Wales)

This is the first article in a series of three that examines the legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity. This article considers the position in New South Wales. A review of the law in this State reveals that medical professionals play significant legal roles in these decisions. However, the law is problematic in a number of respects and this is likely to impede medical professionals' legal knowledge in this area. The article examines the level of training medical professionals receive on issues such as advance directives and substitute decision-making, and the available empirical evidence as to the state of medical professionals' knowledge of the law at the end of life. It concludes that there are gaps in legal knowledge and that law reform is needed in New South Wales.     

The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: Part 3 (Victoria)

This is the final article in a series of three that examines the legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity. This article considers the position in Victoria. A review of the law in this State reveals that medical professionals play significant legal roles in these decisions. However, the law is problematic in a number of respects and this is likely to impede medical professionals' legal knowledge in this area. The article examines the level of training that medical professionals receive on issues such as refusal of treatment certificates and substitute decision-making, and the available empirical evidence as to the state of medical professionals' knowledge of the law at the end of life. It concludes that there are gaps in legal knowledge and that law reform is needed in Victoria. The article also draws together themes from the series as a whole, including conclusions about the need for more and better medical education and about law reform generally.     

Advance directives and the persistent vegetative state in Victoria: a human rights perspective

With advances in medical technology, it is now possible to sustain the life of a person in a persistent vegetative state (PVS) until a decision is made to withhold or withdraw life-sustaining treatment. Who makes that decision? Under the Medical Treatment Act 1988 (Vic) there is no legally enforceable right for a person to choose, in advance, what intervention that person will and will not accept if he or she ends up in a PVS. The best that can be achieved is that a person can appoint an agent who is empowered to refuse medical treatment on the person's behalf in the event of incompetence. It is suggested that this mechanism ignores two fundamental human rights: self-determination and the inherent right to dignity. This article proposes the development of an advance directive mechanism that provides for a person to refuse, in advance, specified intervention, thereby respecting fundamental human rights and alleviating the existing need for an agent to second-guess a person's desires and best interests.     

The growing role of carers in the administration of medications

The roles of registered nurses, enrolled nurses, nurse practitioners and midwives in the administration of medications are subject to the legislation and regulation in their respective States and Territories in Australia. Underpinning this regulatory framework is a presumption that health professionals who come under the relevant legislation and regulations have attained the levels of competency, skill and knowledge consistent with professional standards and the protection of the public. This column considers the provisions of the Health (Drugs and Poisons) Regulation 1996 (Qld) addressing the administration of controlled and restricted drugs in light of a recent Queensland Civil and Administrative Tribunal decision.     

Severely handicapped infants with life-threatening conditions: federal intrusions into the decision not to treat

In recent years the federal government has attempted to intervene in certain family-medical decisions to withhold treatment from seriously handicapped newborns with life-threatening conditions. Invoking section 504 of the Rehabilitation Act of 1973, which prohibits discrimination against "otherwise qualified handicapped" individuals, the Reagan Administration promulgated regulations allowing federal government investigations of such decisions. Recently, the U.S. Supreme Court upheld lower court decisions invalidating these "Baby Doe" regulations. The federal government's fall-back position is reflected in the Child Abuse Prevention and Treatment Amendments of 1984, requiring states accepting funds under the Child Abuse Prevention and Treatment Act to establish and maintain procedures to assure that cases of medical neglect of handicapped infants are investigated by the states. Although the primary oversight of parental decision-making has been returned to the states where it has traditionally belonged, the federal government's definition of medical neglect of handicapped infants with life-threatening conditions is an ethically inadequate response to the complex needs of the handicapped child, the family, the medical profession, and society as a whole. After examining the relevance of Kantian, utilitarian, and Rawlsian ethical positions, the author contends that an effective governmental policy, capable of enforcement and acceptance by the public, must utilize the strengths of each philosophy and reflect the pragmatism of American society.     

Angels of mercy? The legal and professional implications of withdrawal of life-sustaining treatment by nurses in England and Wales

In circumstances where life-sustaining treatment appears merely to be drawing out the inevitable, it is usual practice for the healthcare team to withdraw aggressive life-sustaining measures, once agreement is reached with the patient and their family. Common law gives doctors several defences to allegations of criminality or malpractice in taking the key actions that withdraw treatment and result in the patient's death; however, the legal defensibility of nurses undertaking this role has not been explored. In the absence of a specific body of law related to nurses taking the actions that withdraw life-sustaining treatment, I discuss the probable legal response by considering parallel cases. Examining some of the circumstances in which doctors are allowed to take life, I argue that the legal dispensation by which doctors are permitted to perform these tasks rests largely on their identity as doctors rather than any distinctive feature of their activities themselves. This uniqueness means that medical law for nurses is quite distinct from that for doctors. While it may nevertheless give nurses practical exemption from the legal consequences of their actions in withdrawal, it depends upon a judicial view that nurses are instruments of doctors. This judicial position is at odds with nurses' professional responsibilities, which envisage them as independent professionals who are liable for their own actions, inviting potentially adverse consequences from their professional registrar.     

Comparing the Comparable: 2006 Military Commissions v. the ICTY

Both the International Criminal Tribunal for the former Yugoslaviaand the US Military Commissions were set up to respond to extraordinaryjudicial challenges. But while the Yugoslav Tribunal has soughtto uphold internationally-recognized standards of human rights,the 2006 Military Commissions have amputated many of these rightsand created serious procedural impediments for defendants. Inso doing, the drafters of the 2006 Act have ignored a long andrespectable American legal tradition prevailing from Nurembergto the ICTY.     

Amendments to general regulations of the Food and Drug Administration. Direct final rule

The Food and Drug Administration (FDA) is amending certain of its general regulations to include tobacco products, where appropriate, in light of FDA's authority to regulate these products under the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act). With these amendments, tobacco products will be subject to the same general requirements that apply to other FDA-regulated products. Elsewhere in this issue of the Federal Register, we are publishing a companion proposed rule under FDA's usual procedures for notice and comment to provide a procedural framework to finalize the rule in the event we receive significant adverse comment and withdraw this direct final rule.     

Does the Statutory Regulation of Advance Decision-Making Provide Adequate Respect for Patient Autonomy?

This paper considers advance decision-making in the context of healthcare. The common law recognition of advance decisions is contrasted with new statutory provision. This paper will examine the Mental Capacity Act 2005 framework for advance decisions and lasting powers of attorney. The ‚best interests’ test and substituted judgment as criteria for proxy decision-making are compared by application to a case example. The paper examines the statutory safeguards in respect of refusals of ‚life-sustaining treatment’ and postulates that these safeguards may render respect for autonomous advance decision-making difficult to achieve in practice.     

The International Crimes Tribunal in Bangladesh and International Law

The International Crimes Tribunal in Bangladesh was re-established in 2010 in order to hold the perpetrators of the 1971 War accountable for international crimes; namely, war crimes, crimes against humanity and genocide. The Trial has already begum to operate and has been dealing with various challenges. The basis of the trial proceedings is the International Crimes (Tribunal) Act 1973. The Parliament of Bangladesh enacted the Act in accordance with international law shortly after the War. This paper assesses the key legal issues that arise from the context of the 1973 Act, and will provide a reflection on trial proceedings in light of international law. It concludes that any initiatives to address the impunity of perpetrators and offer redress to the victims of gross human rights violations should be applauded, while any trial proceedings that do not follow appropriate standards for a fair trial and offer the right of due process should be deprecated.     

What you see may not be what you get: beware of patients bearing gifts

The professional boundaries of practice for nurses and midwives are specifically addressed in professional codes of ethics and conduct, employer policies and guidelines and more frequently in the professional literature. There are many forms in which boundary violations and boundary crossings may present or circumstances in which they may occur. This column considers a recent case (involving a bequest to a registered nurse under a will) which came before the Queensland Nursing Tribunal. The decisions of the tribunal, the District Court and the Court of Appeal provide practical guidance to nurses and midwives on the importance of establishing and maintaining the professional boundaries essential to the therapeutic relationship with their patients and clients.     

Freedom of information applications as an "evergreening" tactic: Secretary, Department of Health and Ageing v iNOVA Pharmaceuticals (Australia) Pty Ltd (2010) 191 FCR 573; [2010] FCA 1442

A recent decision of the Federal Court of Australia illustrates how patent-holding pharmaceutical companies are attempting to use Australia's Freedom of Information Act 1982 (Cth) to force Australian safety, quality and efficacy regulators to disclose whether generic competitors are attempting to enter the market. In Secretary, Department of Health and Ageing v iNova Pharmaceuticals (Australia) Pty Ltd (2010) 191 FCR 573; [2010] FCA 1442 a single judge of the Federal Court overturned a decision of the Administrative Appeals Tribunal (AAT) that would have compelled the Australian Therapeutic Goods Administration (TGA) to reveal whether they were in possession of an application to register generic versions of two iNova products: imiquimod and phentermine. In its justification to the AAT for refusing to confirm or deny the existence of any application, the TGA argued that to reveal the existence of such a document would prejudice the proper administration of the National Health Act 1953 (Cth) as it could compromise the listing of a generic on the Pharmaceutical Benefits Scheme. The AAT failed to appreciate the extent to which this revelation to a competitor would have undercut 2004 amendments to the Therapeutic Goods Act 1989 (Cth) that provided penalties for evergreening tactics involving TGA notifications to drug patent-holders and 2006 amendments to the Patents Act 1990 (Cth) which protected the right of generic manufacturers to "springboard". The decision of the Federal Court is one of the first to explore the use of freedom of information legislation by patent-holders as a potential "evergreening" technique to prolong royalties by marginalising generic competition. Because of the significant amounts of money involved in ensuring rapid market entry of low-cost generic products, the issue has considerable public health significance.     

Can Informative Traffic Signs Also Be Obligatory? Polish Constitutional Tribunal and Supreme Court Versus Traffic Signs

This article discusses a rare instance of the highest national courts explicitly addressing traffic signs in their judgments or decisions. It critically examines the standpoint expressed by the Polish Constitutional Tribunal and the Supreme Court, according to which the basic traffic sign categories in Poland—obligatory, prohibitory, informative and warning—are not separable (not disjunctive) [e.g. prima facie non-normative signs (informative or warning) can also be normative (obligatory or prohibitory)]. These courts formulated this idea when addressing the legal question concerning the applicability of legal provision penalizing failure to comply with a traffic sign to parking a car without paying a fee in an area marked by an informative sign that indicates the need to charge a fee for parking. The article analyses and criticizes the relevant standpoint of the Polish Constitutional Tribunal and the Supreme Court. It shows how many negative consequences can result from frivolous treatment and neglect of traffic signs. It also reconstructs some possible practical recommendations concerning not only traffic signs but also visualizations of legal rules in general.     

Blurred vision: How supreme court FOIA opinions on invasion of privacy have missed the target of legislative intent

The framers of the Freedom of Information Act believed that in order to make informed decisions concerning self‐rule in the democracy, citizens needed access to government information. However, the law also acknowledges the importance of protecting privacy—two of the FOIA's exemptions allow federal agencies to withhold information that would invade the privacy of individuals. The purpose of this article is to explore the legal conflict between an individual's right to privacy and the public interest in disclosure of government information. In an examination of seven United States Supreme Court decisions on this subject, this article questions whether the Court has fairly balanced the conflicting values of access and privacy within the guidelines established by Congress in the FOIA.     

Foregoing life-sustaining treatment for adult, developmentally disabled, public wards: a proposed statute.

This Article proposes a procedure for making decisions to forego life-sustaining treatment for adult, developmentally disabled, public wards who are not competent to make health care decisions. Few commentators or cases address the special considerations involved in making life-sustaining treatment decisions for this patient population. The proposal attempts to fill this gap with a patient-centered process that allows decisionmakers, without prior judicial approval, to forego life-sustaining treatment for adult, developmentally disabled, public wards who have been reliably diagnosed with specific medical conditions.     

Finger in the Dyke or the Floodgates Stemmed? Sections 29–40 of the Employment Act 2002

This article considers Sections 29–40 of the Employment Act 2002 in the context of post-War developments in labour relations culminating in the National Industrial Relations Court. It considers the development of Employment Tribunal which rather than being the last resort intended by the legislators, has become the first resort of complainants, often for trivial matters by employees; or by employers taking an extremely broad view of Gross Misconduct by employees. Due to the volume of cases and the shortage of Chairs, cases are constantly delayed and postponed. The article posits that these are the principle reason behind the framing of Sections 29–40 of the Employment Act 2002 which introduced a new Section 9(1)(a) into the Employment Tribunals Act 1995. This has given the Chair of an Employment Tribunal the authority to strike out a weak case at a Pre-Hearing Review that will strike the case out once and for all at this juncture. The aim is to encourage employers to have proper procedures and for employees to follow them. This article suggests that in fact the reforms will have the opposite effect; that they have introduced another layer of legal complexity which will further increase the number of cases brought before the Employment Tribunal.     

澳大利亚行政说明理由制度及其对我国的启发

澳大利亚行政说明理由制度包括普通法和制定法两类。在普通法上,行政说明理由制度还未成为一项普遍承认的原则,但是法院也有条件地承认其存在。在制定法上,澳大利亚的《司法审查法》和《裁判所法》对行政说明理由制度作了比较详细的规定。内容主要涉及两类:第一,提出行政说明理由申请需要具备三个实质性要件;第二,申请人必须遵守的程序要求。我国可以从立法和司法实践两方面借鉴澳大利亚的经验。