Trial and Error at the End of Life--No Harm Done?

English law gives the competent patient the right to refuselife-saving medical treatment, either contemporaneously or inan advance directive, and a physician commits a battery whentreating a patient who validly refused treatment. However, withregard to the details of a physician's liability, many questionsremain unanswered, and it is not at all clear under what circumstancesa patient's tort action for unwanted life-saving treatment willsucceed, and what remedies would be available to the patient.The article suggests that a physician should be liable in batteryfor administering life-saving treatment, even if he/she haddoubts about the validity of the patient's treatment refusal,unless a defence of reasonable mistake can be established. Furthermore,in case of a battery which resulted in keeping the patient alive,the patient should not only be able to claim nominal damages,but general and special damages, including mental and physicalpain and suffering caused by the prolongation of the patient'slife, should equally be available.     

Brief for bioethicists for privacy as amicus curiae supporting appellees

Amicus, an ad hoc group of philosophers, theologians, attorneys, and physicians, believe that adults should consult their doctor when making personal decisions. The doctor-patient relationship would be protected under the Constitution. In "Griswold v. Connecticut," the Supreme Court said that a state law which forbid married couples from using contraceptives was unconstitutional; that the couples should have a right to privacy. In "Roe," the Supreme Court recognized that a patient and her doctor should have privacy. In "Doe v. Bolton," the Supreme Court found that the State of Georgia was violating the patients' and physician's freedom. In "Planned Parenthood of Missouri v. Danforth," the Supreme Court said that a general informed consent provision was alright because it did not take away the abortion decision. The post- Roe state laws were ways to control doctors and patients so that a particular philosophical view could be imposed. The major question in Webster is whether personal decisions should be made by doctors and patients or the state. Both parties must agree to the decision. Section 188.205 of the Missouri law was before the Court in Webster. This section makes it illegal for public funds to be used to encourage a woman to have an abortion that wasn't necessary to save her life. There are medical conditions for which abortion is reasonable - Tay-Sachs disease, for instance. The child usually dies by 3 years of age. Without genetic screening, many at-risk couples would abort all pregnancies. 95% of all prenatal screenings are negative. State medical treatment decisions are arbitrary and impersonal. Having control over important personal decisions is necessary for freedom.     

The moral status of wrongful life claims

A wrongful life action is a claim brought by a disabled child who asserts that but for a physician's negligence he or she would not have been born, thereby being spared the suffering of life. The action is inherently controversial because the alternative to an impaired life is non-existence. Lord Griffiths has described such claims as 'utterly offensive; there should be rejoicing that the hospital's mistake bestowed the gift of life upon the child.' This paper cuts through the rhetoric that the debate has generated and analyses whether there is a sound doctrinal basis for recognizing wrongful life actions.     

Anticipatory refusals and the action of 'wrongful living'

After years of debate, opinion among bioethicists and medical lawyers seems to have accepted that anticipatory refusals of medical treatment can, and furthermore should, be accorded the same legal status as contemporaneous refusals. But what would be the legal repercussions for a medic who treated an incompetent patient in contravention of such a directive? What remedies would be available to the claimant whose life had been extended contrary to his express wishes? This issue has never been explicitly addressed by the UK courts, but this paper looks at some of the conclusions and inferences we can perhaps draw from other, possible analogous areas of law. It also considers several North American cases that have addressed this issue, and asks what lessons we can learn therefrom.     

Patient information on drug therapy. A problem of medical malpractice law: between product safety and user safety

Medicinal products are associated with risks as well as potential therapeutic benefits. This is reflected by the legal requirements for patient information on drug therapy which can be differentiated into general product information, regulated by pharmaceutical (i. e. product safety) law, and individual patient information on the treatment with the product, which is subject to medical malpractice law. The physician's duty to inform the patient comprises therapeutic information as well as information required for informed consent. Therapeutic information intends to empower the patient to comply with the requirements of treatment and to protect him/her against preventable danger and risk; it is part of the medical treatment, aimed at the individual patient and his/her personal situation. Information required for informed consent enables the patient to a self-determined decision on the treatment offered; it can be divided into information on the course of treatment and risk information. Product information and treatment information complement each other; the former should be the basis of individual information on the concrete treatment, provided by the physician in a mandatory oral conversation with the patient. Product information cannot replace the physician's individual information about the treatment.     

Defining, assigning and designing sex

This article challenges the distinction the law draws between male and female. It focuses on the legal and medical treatment of intersexual people. Analysing the nature and rate of intersexuality it argues that there is a significant number of people who cannot be described as either male or female and instead exhibit a range of sexual characteristics. Until recently the law and medicine have insisted that intersexual people should be categorized as either male or female. Surgery was performed to ensure that they had the appearance assumed to be the 'norm' for a man or woman and the law followed this medical assignment of sex. Over the last couple of years the established medical practice and the legal treatment have been challenged. This article discusses the nature of these challenges and argues that there is a strong case for rejecting the traditional legal and medical approach to intersexual people. Cosmetic surgery on intersexual babies should be delayed until the individual is old enough to be able to choose their own sexual identity, which may be neither male nor female. The insistence that every person must either be male or female is no longer supportable in medical or social terms and a much wider range of sexual identities must be recognized by the law.     

Assisted dying and the context of debate: 'medical law' versus 'end-of-life law'

This paper provides a reflective analysis of the nature of normative critiques of law generally, and within medical law specifically. It first seeks to establish the context within which critical analysis of law and legal measures takes place, and develops an argument that critiques should focus on political norms. Entailed in this claim is the contention that positions that seek to address controversial social problems can not resort simply to moral philosophy. It then provides a brief account of political liberalism that can contain and expose normative constraints on questions of moral and social contention. The focus then moves to a more direct reflection on medico-legal analysis. Considering both medical law as a discipline, and the study of end-of-life issues, the argument highlights the range of relevant issues that must be accounted for, and addresses the question of whether these are well conceived as ones of medical law. It is argued that a political framing offers a good general analytic context, but that when working in legal sub-disciplines analysts risk allowing 'locally' pertinent norms to dominate or unduly constrain wider debate. Thus it is questioned whether 'medical law' provides a coherent frame for social questions related to assisted-dying.     

PLC or TLC: is outpatient commitment the/an answer?

The lively debate over mandated community treatment in general and outpatient commitment laws (OPC) in particular has raised many issues. At its core, the debate is over how and to what extent laws should be formulated to persuade, leverage or coerce (PLC) persons with severe mental illness living in the community to comply with medications that mental health professionals believe they need. The alternative to PLC is what we call TLC (tender loving care): a strategy of using benefits - improved patient-centered treatment, entitlements and service delivery, including assertive outreach - rather than penalties or conditions on access to services, to induce compliance. We examine three aspects of the debate: (1) the empirical case for the need for OPC court orders to maintain revolving-door severely mentally ill persons in the community; (2) the normative argument over whether such orders constitute coercion, and, if so, whether that coercion is justifiable; and (3) the incentives such orders create to leverage community providers to augment resources and tailor treatment and services to entice patients to become willing participants in the management of their disorders.     

Enforcing Morality

In debating Patrick Devlin, H. L. A. Hart claimed that the “modern form” of the debate over the legal enforcement of morals centered on the “significance to be attached to the historical fact that certain conduct, no matter what, is prohibited by a positive morality.” This form of the debate was politically important in 1963 in Britain and America, and it remains politically important in these countries today and elsewhere; but it is not the philosophically most interesting form the debate can take. An older form of the debate appealed to natural law or critical morality. It centered on the question of whether political authorities could properly use the criminal law to enforce critical morality, including prohibitions on conduct that was not harmful or disrespectful to others. This paper engages with this older form of the debate. It offers some reasons for thinking that there is a presumption in favor of the view that it is a proper function of the criminal law to enforce critical morality, including that part of critical morality that is not directly concerned with preventing harm or disrespect to others. It then defends this presumption against some arguments recently pressed by Ronald Dworkin.     

The ethics of managed care: a dose of realism

This article examines the ethics of medical practice under managed care from a pragmatic perspective that gives physicians more useful guidance than existing ethical statements. The article begins by stating the authors' starting premises and framework for constructing a realistic set of ethical principles: namely, that bedside rationing in some form is permissible; that medical ethics derive from physicians' role as healers; that actual agreements usually trump hypothetical ones; that ethical statements are primarily aspirational, not regulatory; and that preserving patient trust is the primary objective. The authors then articulate the following concrete ethical guides: financial incentives should influence physicians to maximize the health of the group of patients under their care; physicians should not enter into incentive arrangements that they would be embarrassed to describe accurately to their patients or that are not in common use in the market; physicians should treat each patient impartially, without regard to source of payment, and in a manner consistent with the physician's own treatment style; if physicians depart from this ideal, they must tell their patients honestly; and it is desirable, although not mandatory, to differentiate medical treatment recommendations from insurance coverage decisions by clearly assigning authority over these different roles and by having physicians to advocate for recommended treatment that is not covered.     

浅议李昌奎案件引起的死刑适用大争论

李昌奎案经云南省高级人民法院二审后,改判李昌奎死缓。消息一出,全国舆论哗然。该案引发了一场轰动全国的死刑适用大争论。在这场大争论中,法官认为"杀人偿命的陈旧观点也要改改了",公众则认为"杀人偿命,天经地义"。这场因李昌奎案引起的死刑适用大争论,对推动法治和正义深入人心,对促进我国的法制建设,将起到难以估量的重大意义,是一次难得的普法教育。     

Medical school forensic psychiatry units in health care delivery facilities rather than criminal justice institutions: an alternative model

We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)     

Living and dying in a post-Schiavo world

The tragic circumstances surrounding the death of Theresa Marie Schiavo have reignited discussion regarding end-of-life decisionmaking. In this Article, the author examines the current legal and ethical environment surrounding the decision to end life-sustaining treatment. Starting with the New Jersey Supreme Court's decision in In re Quinlan, the author discusses how such important issues as who should be the surrogate decisionmaker, attitudes towards artificial nutrition and dehydration, and difficulties in defining medical futility. Looking through a post-Schiavo lens, the Article examines state law addressing these issues and how these choices may be reexamined in the coming years.     

Cosmetic surgery in Australia: a risky business?

Cosmetic surgery is increasing in popularity in Australia and New Zealand, as it is across other Western countries. However, there is no systematic mechanism for gathering data about cosmetic surgery, nor about the outcomes of that surgery. This column argues that the business of cosmetic surgery in Australia has questionable marketing standards, is conducted with little scrutiny or accountability and offers patients imperfect knowledge about cosmetic procedures. It also argues that while medical practitioners debate among themselves over who should carry out cosmetic procedures, little attention has been paid to questionable advertising in the industry and even less to highlighting the real risks of undergoing cosmetic surgery. While consumers are led to believe that cosmetic surgery is accessible, affordable and safe, they are sheltered from the reality of invasive and risky surgery and from the ability to clearly discern that all cosmetic procedures carry risk. While doctors continue to undertake advertising and engage in a territorial war, they fail to address the really important issues in cosmetic surgery. These are: providing real evidence about what happens in the industry, developing stringent regulations under which the industry should operate and ensuring that all patients considering cosmetic surgery are fully informed as to the risks of that surgery.     

Limits of guardian treatment refusal: a reasonableness standard

The debate concerning the legal and ethical bases of guardian refusal of medical treatment on behalf of incompetent patients often ignores critical distinctions among types of patients and guardians. For example, patients who have expressed preferences regarding treatment while competent are distinguishable from patients who have always lacked the competency requisite to expressing a treatment preference. "Bonded guardians," whose relationship with the patient preexisted guardianship, should have a different role in the decision-making process than "non-bonded guardians," who were strangers to the patient prior to the guardian-ward relationship. This Article proposes criteria for guardian treatment refusal on behalf of incompetent patients. Under the model for guardian decision making presented here, bonded guardians should be preferred over non-bonded guardians, and bonded guardians should be allowed discretion to make treatment choices, limited only by a standard of reasonableness policed by the courts. The Author presents legal and ethical justifications for the bonded guardian's heightened role. Finally, he considers the proper roles of health professionals, hospital ethics committees, and judges in the decision-making process.     

In the matter of Christine B. Biersach. In the Ohio Court of Appeals

HOLDING: Before withdrawal of tube feeding may be permitted, a guardian must establish, by clear and convincing evidence, the treating and consulting physicians' education, training, and experience; the physician's history and experience with the patient; the fact that the physician personally examined the patient; and the opinions required by statute. Each physician should also testify to his opinion that the other physician in the matter is qualified, by reason of advanced education or training, limited practice, experience, or certification as a specialist, to make the findings and provide the opinions about the patient which are required by the statute. The consulting physician's opinion should be more than a conclusory adoption of the attending physician's opinion. Rather, it should be independently stated and, ideally, should include the reasons upon which it is based.     

Parliamentary Question Times: How Legislative Accountability Mechanisms Affect Mass Political Engagement

Over time, people have been losing interest in politics. Some believe this to be one of the largest challenges facing democracy today. What causes some citizens to be more engaged than others? This paper argues that national-level political institutions are important in shaping the tone of political debate between election campaigns. Some countries have regular, accessible debates between political leaders; in others the debate is rarer and harder to follow. Parliamentary question time (QT) is a prominent forum for regular elite-level debate, and QTs featuring open, accessible debate should help induce citizens to engage with politics by providing them with an information-laden political spectacle. The data show that these open QTs are associated with higher levels of political knowledge, partisanship, and turnout.     

The fetus as a patient: emerging rights as a person?

Dramatic scientific breakthroughs in medical technology have revolutionized the physician's diagnostic prowess in the art of obstetrics. Scientific procedures now reveal previously undetectable secrets about the womb's tiny inhabitants. In the last few years, perinatologists have not only demonstrated the ability to discern fetal abnormalities of an extraordinary variety, but also have become increasingly successful in correcting many of these defects in utero. This article identifies the potential medicolegal conflicts that may arise as fetal surgery becomes an accepted medical practice. It begins by surveying the legal rights of unborn persons with a particular emphasis on the role of viability in determining those rights. The article will then examine the concept of viability as developed by the Supreme Court in Roe v. Wade and later abortion decisions and concludes that the current judicial deference to the medical community in determining viability is adequate for balancing rights in the abortion context. However, conflicts among physicians and between the other and her unborn child that may arise in the fetal surgery context suggest that viability may be an adequate benchmark for resolving such conflicts. The article concludes with a recommendation to reform the current method of resolving the critical question of when a fetus becomes viable.     

Refusing medical treatment after attempted suicide: rethinking capacity and coercive treatment in light of the Kerrie Wooltorton case

The inquest into the death of Kerrie Wooltorton in Norfolk, England, ignited extensive public debate on the scope of the common law right to refuse medical treatment where a patient is distressed, depressed or actively suicidal. In Australia, a patient's wishes need not be honoured if the patient is not legally competent, if he or she falls within the ambit of the compulsory treatment provisions in the mental health legislation, and possibly also if there is a recognised public interest in preventing suicide which is sufficient to override the patient's choice. This article argues that decisions about whether to give medical treatment despite an apparent refusal should be based solely on a determination of the patient's competence to make their own choice. However, the test for legal competence must take into account the person's agency in making the decision, and decisions which will effectively end the person's life must be shown to be thought through.     

Recent developments in medical law

The most spectacular aspect is the extremely rapid expansion of medical law. Even if there is a close connection between developments in medicine and in law, the question must be asked as to what extent new discoveries and advances in medicine play a dominant role here, and to what extent the emphasis is on the further development of law. How advances in medicine can give rise to new legal problems was most impressively demonstrated some time ago by the discussion about cerebral death. In view of the progress made in the field of re-animation and intensive care, the current question is whether or not the physician's duties and rights to maintain life should be limited in hopeless cases when patients are incapable of making decisions themselves. This is demonstrated in particular by the discussion about the binding character of "patient testaments" in which healthy subjects declare that they do not want treatment under such circumstances. The decisive factor will continue to be the presumptive will of the patient at the respective time, and this will have to be ascertained considering all circumstances prevailing at that time. New questions with regard to the ethical and legal limitation of the technically feasible also arise from the possibility of culturing embryos from legal abortions or extracorporally fertilized ova to obtain transplants, and from the possibility of implanting extracorporally fertilized ova into the uterus, perhaps that of a "hired childbearing wet-nurse." In addition to ethical and legal problems, questions of parentage would arise here similar to those already of current interest in connection with artificial heterologous insemination. For physicians practicing these methods, questions concerning liability and the limitation of professional secrecy vis-à-vis the semen donor might become the issue of law suits in the near future. Current problems of "unsuccessful sterilization" and nonperformance of an abortion through the physician's fault although abortion was indicated for eugenic reasons are, on the other hand, primarily due to the fact that the law--possibility even for acceptable reasons--establishes legal obligations for the physician which, in the last analysis, aim at preventing human life from coming into being.(ABSTRACT TRUNCATED AT 400 WORDS)