Surrogate decision-making for incompetent elderly patients: the role of informal representatives

Informal or unofficial representation refers to the practice (more common in some European jurisdictions than in others), that persons not designed by a court or by the patient himself, make medical decisions on the patient's behalf in case of their incompetence. If the law provides for this, it is usually next of kin (spouse, children, brothers and sisters, etc.) who are allowed to act in such a capacity. Informal representation raises several questions. Are family members always familiar with what their relative would have wished, ready to take responsibility, and not too much reigned by their emotions? The basic legal concern is whether there are sufficient procedural and other safeguards to protect the incompetent patient from representatives who do not serve their best interests. In addressing these issues, after a brief survey of the law in the Netherlands as compared with that in Belgium, Germany and England/Wales, we will argue that informal representation as such is not at variance with international and European standards. However, an 'informal' approach to surrogate decision-making should always go together with sufficient protection of the incompetent patient, including procedural safeguards with regard to the decision that the patient is incompetent, limits to the decision-making power of informal representatives and effective forms of conflict resolution.     

Protecting the planet: a proposal for a law of ecocide

A wide range of actions imperil the planet and threaten the future of humanity and other species. This essay notes some examples of crimes and harms damaging to the environment and human and non-human species as well as various forms of response that have called for more effective and appropriate models of justice and law than currently prevail. This leads to a discussion of several suggestions regarding the development and expression of an earth jurisprudence and to the history of a proposal that “ecocide” be recognised internationally as a crime. Analysis of documentary sources traces this idea from debates about the concept of genocide to consideration by United Nations officials as to how crimes against the environment might be defined, and shows how near such a proposal has previously come to acceptance and enactment. The article concludes with an argument for supporting a law of ecocide as the 5th Crime against Peace.     

Property and the human body: a proposal for posthumous conception

There is no greater error in law and bioethics than the continuing opposition to applying the concept of property to posthumous conception cases and the human body generally. The aim of this article is to challenge this error and the assumptions underpinning it. The language of property, conceived of as a "web of interests", can be used to capture and identify the social, moral and ethical concerns that arise in cases concerning the human body, a position that finds support from a correct reading of the early High Court of Australia's decision in Doodeward v Spence (1908) 6 CLR 406. However, a key issue on which the language of property is silent is how to quantify the various competing interests in the posthumous conception case: the concept is useful only insofar as it provides the device for capturing the entirety of the posthumous conception problem.     

Just compensation: a no-fault proposal for research-related injuries

Biomedical research, no matter how well designed and ethically conducted, carries uncertainties and exposes participants to risk of injury. Research injuries can range from the relatively minor to those that result in hospitalization, permanent disability, or even death. Participants might also suffer a range of economic harms related to their injuries. Unlike the vast majority of developed countries, which have implemented no-fault compensation systems, the United States continues to rely on the tort system to compensate injured research participants—an approach that is no longer morally defensible. Despite decades of US advisory panels advocating for no-fault compensation, little progress has been made. Accordingly, this article proposes a novel and necessary no-fault compensation system, grounded in the ethical notion of compensatory justice. This first-of-its-kind concrete proposal aims to treat like cases alike, offer fair compensation, and disburse compensation with maximum efficiency and minimum administrative cost. It also harmonizes national and international approaches—an increasingly important goal as research becomes more globalized, multi-site trials grow in number, and institutions and sponsors in the United States move to single-IRB review.     

Reconciling Quinlan and Saikewicz: decision making for the terminally ill incompetent

One of the most perplexing problems in the medicolegal field concerns the criteria on which decisions not to treat terminally ill incompetent patients should be made. These decisions traditionally have been made by physicians in hospitals--sometimes with the assistance of the patient's family--on the basis of their perceptions of the patient's "best interests." Recently, two state supreme courts have ruled on this question. The New Jersey Supreme Court, in the Quinlan case, developed a medical prognosis criterion, and permitted the patient's guardian, family, and physicians to apply it with the concurrence of a hospital "ethics committee." The Massachusetts Supreme Judicial Court, in the Saikewicz case, adopted, on different facts, the test of "substituted judgment" to be applied by a probate court after an adjudicatory hearing. The two cases have been interpreted by many in the medical profession as representing conflicting viewpoints--one supportive of traditional medical decision making and the other distrustful of it. It is the thesis of this Article that Quinlan and Saikewicz are in fundamental agreement and can be reconciled by the next state supreme court that rules on this question. Both courts enunciate a constitutional right to refuse life-sustaining treatment, based on the right to privacy. They agree that incompetents should be afforded the opportunity to exercise this right, and that certain state interests can overcome it. They agree also that physicians should be permitted to make medical judgments, and that societal judgments belong in the courts. The differences in how the opinions are perceived result from the interplay of several factors: the differences in the facts of the cases; the inarticulate use of the term "ethics committee" by the Quinlan court; the literal interpretation of the role of such a committee by the Saikewicz court; a desire for 100 percent immunity on the part of physicians and hospital administrators in Massachusetts; and advice from their counsel on how such immunity can be guaranteed. It is the author's hope that this Article will help to dispel much of the misinformation surrounding these two cases, and to refocus the debate on how decisions should be made for the terminally ill incompetent patient on the real issues regarding criteria and the decision-making process that remain to be resolved.     

Nursing culpability: a proposal for change in nursing regulation

Nurses make mistakes. They work in a complex environment which can sometimes be a contributory factor to a mistake being made. At present, Nurses' Boards in Australia have no mandate to investigate the circumstances in which a mistake is made. Their jurisdiction is limited to investigation of the individual nurse. This article sets out the argument for change in nursing legislation to allow for a broadening of the role of Nurses' Boards. It argues that an extension of their jurisdiction explicitly to allow them to investigate inadequacies in the health system would be a constructive development.