Ethical decisions at the edge

Medicine grows incrementally in its ability to treat patients and at the growing edge it poses problems about the appropriateness of treatments that are different from those where good practice conforms to widely agreed standards. The growth of access to medical knowledge and the diversity of contemporary theoretical and clinical medicine have spawned deep divisions in the profession and divergent opinions about what constitutes reasonable care. That hallmark of acceptable practice is also under pressures from the threat of litigation, a highly commercialised contemporary medical environment, patient demands based on medical journalism and the internet and the exponential growth of bio-medical technology. Patient empowerment can result in complaints arising in new and complex areas and expert opinion can often differ markedly depending on where on the medical spectrum the experts are aligned. This column lays out some broad-brush principles to assess the adequacy of medical advice in such a climate.     

Palliative pain therapy at the end of life and forensic medicine issues.

An 83-year-old woman with a history of Alzheimer's disease and breast cancer died at home while receiving palliative pain therapy with oral morphine from her family for metastatic breast cancer. Allegations of mistreatment were made, and this case was ultimately referred to the Office of the Chief Medical Examiner, State of Maryland. An autopsy failed to identify any injuries or residual cancer, leaving no anatomic explanation for the pain that had been presumed to be metastatic breast carcinoma involving bone. The blood free morphine concentration was 5,200 ng/ml, and the total morphine concentration was 15,000 ng/ml. This case demonstrates the challenges and difficulties in forensic medicine when faced with the interpretation of toxicologic results at the end of life.     

Gardner; Re BWV: resolved and unresolved issues at end of life

The Medical Treatment Act 1988 (Vic) gives statutory recognition to a patient's (or their agent or guardian if incompetent) right to refuse medical treatment. The case of Gardner; Re BWV confirmed that medical treatment as defined under the Act included artificial nutrition and hydration and as such could be withdrawn, notwithstanding that this would result in the patient's death. This article analyses Gardner; Re BWV and argues that, by deliberately dealing narrowly with the issues at hand, both the Victorian Civil and Administrative Tribunal at first instance and the Victorian Supreme Court knowingly left BWV to die from dehydration over a period of weeks. By not addressing these issues, the tribunal, and more particularly the Supreme Court, lost an opportunity for a reform of the law, so urgently needed at end of life, which would have allowed for "mercy killing", thus sparing BWV and her family the lingering death she was given.     

Sentencing Guidelines and focal concerns: The effect of sentencing policy as a practical constraint on sentencing decisions

Contemporary research on criminal sentencing has analyzed sentencing under numerous sentencing policies, yet the effect of sentencing policy on outcomes and disparity is not known. A variety of sentencing guidelines systems, one of the more common sentencing policies, exists throughout the country. In addition, recent Supreme Court decisions regarding sentencing guidelines are likely to produce alterations to several state sentencing policies over the next few years. Using data from the state of Florida, the current study examines the effects of policy transformation on sentencing disparity within the focal concerns of sentencing perspective. The authors view sentencing guidelines as a practical constraint on sentencing decisions that influence other key variables. The results indicate that sentencing policy transformation has an important effect on both sentencing decisions and on the factors that shape those decisions. The findings suggest that future sentencing research and theoretical development would benefit from incorporating measures of policy differences in its analyses.