Independence or autonomy: which is the goal?

At times in psychiatric treatment practice in the United States, the notion of individualism or independence (an American ideal) is confused with autonomy (a rights goal). Client autonomy is defined as the ability of clients to make their own choices. When the societal ideal of independence overrides individual autonomy, inclusion and client well-being may be jeopardized. A case will be presented to illustrate these points. We make recommendations for professional education to protect client rights through understanding the distinction between autonomy and independence.     

Sexually violent predators and civil commitment: is selection evidence based?

Sexual offenses represent an alarming proportion of crimes committed yearly. To address these concerns, several states, including South Carolina (SC), have enacted laws requiring sexually violent predators (SVPs) to be civilly committed to treatment. To date, no published study has examined sexual offenders recommended for treatment in SC. This study used a specially designed statewide database (SC-SVP research database) to determine which offender and offense characteristics were associated with increased likelihood of being recommended for civil commitment. Factors correlated with being more likely to be recommended included: being of a younger age at time of evaluation, prior sex convictions, having related and unrelated victims, a higher number of victims, frequent substance use, and a history of suicide attempts. Prior sex convictions, having both related and non-related victims, and a higher total number of victims align with characteristics associated with sexual recidivism. Frequent substance abuse and a history of suicide attempts do not mirror previous findings regarding sexual recidivism. These findings present new information regarding the civil commitment process of offenders being committed to the SC-SVP treatment program, characterize types of offenders committed to SC-SVP treatment program, and provide a foundation for using a computerized database in conducting sex offender research.     

Moral hazard in health insurance: are consumer-directed plans the answer?

The concept of moral hazard in relation to health insurance is an area that has both haunted and fascinated economists, policy-makers, and payers almost since the first health insurance plans were offered by employers. Through the years since Kenneth Arrow's groundbreaking work in 1963, the health care industry has been looking for the proper level of cost-share for patient insureds that will affect their health care choices. The approach of some newer plan offerings, termed 'consumer-directed' or 'consumer-driven' plans by their promoters, seem to have the potential of affecting moral hazard in health insurance.     

Drowning without aspiration: is this an appropriate diagnosis?

It has been reported that 10-15% of drowning victims do not aspirate water. We have revisited the original studies quoted to reach this conclusion and find it is without foundation. Sudden cardiac standstill is known to occur on land and, therefore, may also occur when the victim is in water. In the absence of the common finding of significant pulmonary edema in the victim's respiratory system, to conclude his or her death was caused by "drowning without aspiration" is unwise. All causes of sudden death that might occur in which respiration may not take place should receive serious consideration when examining bodies with such findings that are found in water.     

Reconstructing the hymen: mutilation or restoration?

Female genital mutilation (FGM)--previously known as female circumcision--was criminalised in many countries in the 1990s. This occurred mainly in Western nations and responded to the perception that FGM was intended to subjugate women and was an abuse of human rights. However, other female genital surgical procedures have a totally different intent and are designed to restore the integrity of the hymen, correct deformity or simply enhance the appearance of the female genitalia. Such procedures, unlike FGM, are performed on women who have reached the age of consent and who request the surgery themselves. Restoring the integrity of the hymen (so-called "hymenoplasty") can erase evidence of the sexual history of a woman. "Revirgination" may have particular importance to women contemplating marriage in cultures where a high value is placed on virginity Some commentators have equated hymenoplasty with corrective surgery intended to restore the condition of female circumcision--techniques which are prohibited by most Australian criminal statutes. However, the medical, ethical and human rights arguments against FGM are not easily extended to revirgination and other cosmetic genital surgery. This article examines whether revirgination surgery has effectively been criminalised in Australia and whether this is appropriate from a medical and ethical perspective.     

The jurisdictional bar provision: who is an appropriate relator?

After explaining the role of the qui tam litigation and demonstrating its importance to fighting Medicare fraud and abuse, this article provides a detailed explanation of various court interpretations of the jurisdictional bar provision of the False Claims Act, a common and contentious statutory pitfall for qui tam litigators. The author provides a thorough evaluation of the law among different circuits to assist litigators in choosing favorable jurisdictions to increase their likelihood of success.     

Effects of purchaser competition in the Dutch health system: is the glass half full or half empty?

In 2006, the Dutch health insurance system was radically reformed to strengthen competition among health insurers as purchasers of health services. This article considers whether purchaser competition has improved efficiency in health-care provision. Although supply and price regulation still dominates the allocation of health services, purchaser competition has already significantly affected the provision of hospital care, pharmaceuticals and primary care, as well as efforts to gather and disseminate information about quality of care. From this perspective, the glass is half full. However, based on the crude performance indicators available, the reforms have not yet demonstrated significant effects on the performance of the Dutch health system. From this perspective the glass is half empty. The article concludes that the effectiveness of purchaser competition depends crucially on the success of ongoing efforts to improve performance indicators, product classification and the risk equalisation scheme.     

Is there an acceptable answer to rising medical malpractice premiums?

This article explores the key issues involved in the attempts at reform of the present medical malpractice system. Investigating the effects that federal tort reform legislation would have on physicians, patients, lawyers, and the medical malpractice insurers, Dr. Gunnar succinctly outlines the issues surrounding the present "crisis in healthcare" and explores the separate interests involved. The article examines the economic forces influencing the medical malpractice insurance industry, reviews previous tort reform, and predicts the future of federal tort reform legislation. Dr. Gunnar concludes by proposing alternatives for malpractice reform.     

The Construction of Terms of Facultative Reinsurance Contracts: is Wasa v Lexington the Exception or the Rule?

Do reinsurers insure the liability faced by the reinsured under its original insurance contract? Where the reinsurance and direct insurance policies are written in identical terms, is it enough for the reinsured to prove its liability under the original insurance policy in order to make a successful claim against its reinsurers? These questions are crucial, because they determine whether the terms of the reinsurance are to be construed identically to those of the direct policy even though they have different governing laws. The issues came before the House of Lords in Wasa International Insurance Co Ltd v Lexington Insurance Co [2009] UKHL 40 and the answers were provided in a judgment delivered on 30 July 2009, the last day of the operation of the House of Lords as a court. This note discusses the nature of facultative reinsurance contracts in the light of their Lordships' ruling.     

That tool is rubbish!…or is it?

Digital forensic practitioners often utilise a range of tools throughout their casework in order to access, identify and analyse relevant data, making them a vital part of conducting thorough, efficient and accurate digital examinations of device content and datasets. Whilst their importance cannot be understated, there is also no guarantee that their functionality is free from error, where similarly, no practitioner can 100% assure that their performance is flawless. Should an error occur during an investigation, assuming that it has been identified, then determining the cause of it is important for the purposes of ensuring quality control in both the immediate investigation and for longer-term practice improvements. Perhaps anecdotally, a starting position in any postmortem review of an error may be to suspect that any tools used may be at fault, where recent narratives and initiatives have enforced the need to evaluate all tools prior to them being used in any live investigation. Yet, in addition, an error may occur as a result of a practitioner’s investigative conduct. This work discusses the concept of ‘fault-attribution’, focusing on the roles of the forensic tool and practitioner, and proposes a series of principles for determining responsibility for an investigative error.     

Oxycodone intoxication in an infant: accidental or intentional exposure?

A case is presented of a 10 month old male who went into cardiac arrest at a local store. The infant subsequently expired and was autopsied at the Office of the Chief Medical Examiner, State of Maryland. The only remarkable finding was the detection of oxycodone in the postmortem specimens; the blood and liver oxycodone concentrations were 0.6 mg/L and 1.6 mg/kg, respectively. Oxycodone was identified and quantitated by gas chromatography-nitrogen-phosphorus detection and confirmed by full scan electron ionization gas chromatography-mass spectrometry. The medical examiner ruled that the cause of death was oxycodone intoxication, and the manner of death was homicide. The key toxicologic question in this case was whether or not it was reasonable for the infant to be exposed to oxycodone exclusively through breast milk or through an alternate source. It was concluded that, at best, there were serious concerns about the likelihood of drug exposure through consumption of breast milk.