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.     

The medical review officer: a potential role for the medical examiner

Drug use in the workplace is a problem, both in terms of public health and expense. Workplace drug testing programs serve as deterrents to drug use. Model programs, such as that of the Department of Transportation, use urine screening and are federally regulated or follow federal standards. An essential participant in this process is the medical review officer (MRO), a licensed physician who interprets the laboratory results generated from a workplace drug testing program. As a result of their training and experience with toxicology, collection of evidence, testimony, and recognition of the physical signs of drug abuse, medical examiners and forensic pathologists are well suited to serve as MROs. Recent regulations require the completion of training courses and MRO certification as prerequisites for participation in federal drug testing programs. Several courses are available to train physicians to participate as MROs.     

The development of drug trade and drug control in the Netherlands: a historical perspective

Drug trade is widely seen as a phenomenon rather new to the Netherlands. However, at the beginning of the 20th century the Dutch pharmaceutical industries were already extensively involved in the production of both opiates and cocaine, and they went on exporting large quantities of these drugs after the Opium Act (1919) took force. Until the 1960s, arrests were not at all common, and these largely affected minority groups like Chinese opium smokers and black marijuana users. Since then, drug control efforts have increased by leaps and bounds. At first, cannabis was the main target; then the focus turned to heroin, and that was later joined by cocaine. This paper traces the history of the drug trade and drug control in the Netherlands, with emphasis on their development in Amsterdam. The conclusion is reached that, in spite of drastic changes in both drug trade and drug control, certain ideologies, constructs and strategies have remained remarkably stable.