Those Who Hesitate Are Lost: The Case for Setting Behavioral Health Treatment and Disability Standards, Part I

There are multiple factors that impede the implementation of standards into the behavioral health (BH) treatment and disability processes. The combination of physical and psychological conditions as well as the influence of psychosocial issues has consistently been identified as having negative effects on treatment and treatment outcomes. Further, the wide-spread lack of standardization causes a multitude of problems throughout both BH processes. The focus of this first article in a three-part series will examine the explosion of behavioral health claims and the major factors, such as comorbid physical conditions and psychosocial issues, associated with these types of claims. In addition, the overarching theme of lack of standardization will begin to be explored in regard to the problematic definition of disability, communication difficulties between treating professionals and disability insurers and agencies as well as the introduction of bias into the BH treatment and disability processes.     

Those Who Hesitate are Lost: The Case for Setting Behavioral Health Treatment and Disability Standards, Part III

The first and second articles in this 3-part series discussed systematic issues related to multiple standardization problems and their compounding impact on the state and federal disability systems. In addition, the lack of standardization negatively influencing the behavioral health (BH) training and treatment processes may have the potential to cause harm not only to the individual receiving professional care but also to the clinician providing the treatment. In the final article of the series, I make recommendations for systemic changes for the field as well as for potentially revising previous models toward moving the Behavioral Health treatment and disability systems into more of a biopsychosocial approach. However, conclusions emphasize that successful implementation of recommendations and models require the involvement of all of the stakeholders in promoting better outcomes and in facilitating individuals; return to the workplace.     

Patient competence and professional incompetence: disagreements in capacity assessments in one Australian jurisdiction, and their educational implications

The determination of capacity to make medical, personal and financial decisions has significant individual and social implications. Medical and other health professionals are traditionally relied on by courts and tribunals to provide clinical and psychometric evidence of the presence or absence of capacity, or competence. Concern has long been expressed over the variability of these assessments. A survey of 285 decisions of the Queensland Guardianship and Assessment Tribunal (GAAT) between 2005 and 2008 was conducted to estimate the incidence of disagreement between health professionals in capacity assessments; to provide examples of conflicting assessments and models of assessment used; and to consider the educational implications of disagreements. While the final capacity determinations by the GAAT appear sound, this case series, and other studies in the capacity literature, strongly suggest the need to improve the education of health professionals, especially doctors, at undergraduate and postgraduate levels, in the practical assessment of capacity as a fundamental clinical skill.     

The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: part 2 (Queensland)

This is the second article in a series of three that examines the legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity. This article considers the position in Queensland, including the parens patriae jurisdiction of the Supreme Court. A review of the law in this State reveals that medical professionals play significant legal roles in these decisions. However, the law is problematic in a number of respects and this is likely to impede medical professionals' legal knowledge in this area. The article examines the level of training medical professionals receive on issues such as advance health directives and substitute decision-making, and the available empirical evidence as to the state of medical professionals' knowledge of the law at the end of life. It concludes that there are gaps in legal knowledge and that law reform is needed in Queensland.     

The influence of personal history of abuse and gender on clinicians' judgments of child abuse

Two extra-legal factors were examined for their influence on professionals' decisions to report child abuse: having been abused as a child oneself, and the gender of the child, the parent, and the professional. One hundred and one men and women who worked regularly with children in mental health settings rated a series of scenarios presented as cases from a protective service agency. Participants made several judgments regarding the case including the severity of the parent's behavior, the likely effect on the child, whether the situation was abusive, and whether the case should be reported to a social service agency. Despite some interpretive limitations, the results generally support the hypothesis that extra-legal factors influence the perceptions of professionals who are mandated to report a suspected incident of abuse.     

GUEST EDITOR'S INTRODUCTION TO SPECIAL ISSUE ON ATTACHMENT THEORY,SEPARATION, AND DIVORCE: FORGING COHERENT UNDERSTANDINGS FOR FAMILY LAW

Every day in family law courts and mediation rooms across the world, complex decisions are made about postseparation parenting that affect the developmental outcomes of countless children. Attorneys, judges, parents, and even mental health professionals are often poorly equipped to accurately apply developmental knowledge to these decisions, including knowledge from the vast field of attachment theory. A mounting body of research from developmental psychology and neuroscience confirms attachment relationships to be a central axis of the child's developmental pathway, in every family, in every culture throughout the world. The health of a child's attachments can influence multiple and far‐reaching outcomes. As such, attachment theory and knowledge deserve a place in the family court's deliberations and planning for children, but to date, that place remains ill defined. Inconsistencies and misunderstandings, conundrums and complexities of applying attachment knowledge to divorce and separation matters are evident throughout the field. This Special Issue went in search of a shared praxis of meaning about attachment. The resulting collection of papers and interviews documents the views of multiple, eminent attachment experts, who discuss advances in the theory and consider guidelines for legal and mental health practitioners in applying attachment concepts to post‐separation decision making. This opening paper charts the course of this project and summarizes the major points of convergence.     

The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: Part 3 (Victoria)

This is the final article in a series of three that examines the legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity. This article considers the position in Victoria. A review of the law in this State reveals that medical professionals play significant legal roles in these decisions. However, the law is problematic in a number of respects and this is likely to impede medical professionals' legal knowledge in this area. The article examines the level of training that medical professionals receive on issues such as refusal of treatment certificates and substitute decision-making, and the available empirical evidence as to the state of medical professionals' knowledge of the law at the end of life. It concludes that there are gaps in legal knowledge and that law reform is needed in Victoria. The article also draws together themes from the series as a whole, including conclusions about the need for more and better medical education and about law reform generally.     

关于《道路交通事故受伤人员伤残评定》中若干技术难题的处理办法(下)

由于《道路交通事故受伤人员伤残评定》中许多条文的规定比较笼统和原则,在理解和掌握上尚有一定的困难。为此,作者参考国家有关鉴定标准和临床医学有关器官功能障碍分级方法,并结合作者在伤残评定中所积累的经验,提出有关评定标准的细则,旨在推动鉴定工作的统一和规范,确保鉴定结论的公正和科学。     

关于《道路交通事故受伤人员伤残评定》中若干技术难题的处理办法(上)

由于《道路交通事故受伤人员伤残评定》中许多条文的规定比较笼统和原则,在理解和掌握上尚有一定的困难。为此,作者参考国家有关鉴定标准和临床医学有关器官功能障碍分级方法,并结合作者在伤残评定中所积累的经验,提出有关评定标准的细则,旨在推动鉴定工作的统一和规范,确保鉴定结论的公正和科学。     

The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: part 1 (New South Wales)

This is the first article in a series of three that examines the legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity. This article considers the position in New South Wales. A review of the law in this State reveals that medical professionals play significant legal roles in these decisions. However, the law is problematic in a number of respects and this is likely to impede medical professionals' legal knowledge in this area. The article examines the level of training medical professionals receive on issues such as advance directives and substitute decision-making, and the available empirical evidence as to the state of medical professionals' knowledge of the law at the end of life. It concludes that there are gaps in legal knowledge and that law reform is needed in New South Wales.     

There's Nothing New in Dying Now: Will Welfare Attorney Decision Making at End of Life Make a Real Difference?

Advance care planning is a way to express value‐based preferences in order to guide future treatment decisions following loss of decision‐making capacity. It aims to ensure that one's critical values continue to influence healthcare decisions, particularly at end of life. The Mental Capacity Act 2005 permits adults with capacity to appoint welfare attorneys to act as their proxy decision‐makers following loss of capacity. A focus group study was used to explore the views and perceptions of lawyers and health professionals to attorney decision making at end of life. Whilst participants gave a guarded welcome to the introduction of healthcare and welfare attorneys, potential challenges were identified, based upon professional norms and expectations. A shared consensus was that the realization of the full potential of proxy decision making was likely to be a theoretical, rather than real, benefit. Opinions were divided on elemental tenets such as prospective autonomy, best interests, and the potential for conflict.     

A cognitive perspective on ethnicity,race, and termination of parental rights

The determination of parental “fitness” in termination of parental rights cases is open to much judicial discretion and, thus, potentially open to bias. Even if judges look to mental health professionals as expert witnesses, misattributions of racial and ethnic cues may still be likely given the poor state of our parenting models and the lack of ethnically and racially relevant normative data and measurement instruments. A social cognitive framework is used to examine the potential for bias in the nature of categories of information that judges and mental health evaluators currently use to make decisions. Recommendations for research and practice that might enhance judicial and mental health evaluator sensitivity to racial and ethnic differences in interaction, family structure, and parenting practices are reviewed.     

Medical Samaritans: is there a duty to treat?

This article argues that doctors and other health care professionals should be obliged to provide emergency treatment to those in immediate and nearby need regardless of the absence of any prior professional relationship between the parties. It concludes that the common law should accordingly recognize a specific duty of 'medical rescue'. It examines some of the conventional objections to affirmative duties, finding them unconvincing in this particular context. It draws on two recent appellate decisions, one Australian and the other English, for support, as well as on more general arguments concerning moral sentiment, professional ethics, public expectation, and respect for human rights.     

病历法律评估研究

由于病历在医疗纠纷处理中具有核心证据价值,因而在医疗纠纷愈演愈烈的大背景下,医患双方对病历的证据效力的争执也变得日益复杂。由于法律专业人士不具有医学专业知识,因而对病历的真伪及证据价值的判断显得无能为力,为了正确判断病历的证据价值,为了更好地使用病历作为认定案件事实的依据,因而迫切需要启动病历法律评估。病历法律评价应当坚持全面性、整体性、规范性和不苛求的原则,由有相关专业知识和背景的专业人士依照法定程序,采用专业评估方法,对病历的完整性、规范性和客观性进行评价,并提出专业性的评估意见。     

The Usage of the AMA <Emphasis Type="Italic">Guides</Emphasis> for the Determination of Psychological Injury Within the State and Federal Workers’ Compensation Systems

Psychological injuries, like physical injuries, may occur within the workplace. If those injuries are reported to be a result of a triggering event in the workplace, then a workers’ compensation (WC) claim may be filed by the individual. State WC and the federal WC systems have laws and rules in place to address workplace psychological injury claims. However, because each State has its own WC State laws as does the federal WC system, there is no current standardization in defining either psychological injury or in defining disability. This is because each system has its own definitions. A few States allow workplace psychological injury claims. Some States do not accept WC psychological injury claims. The remaining States recognize workplace psychological injuries but with specific limitations. The federal WC system allows WC psychological injury claims. There are problematic issues that occur in the State and federal WC systems. These issues are utilizing outdated terminology, employing outdated diagnostic criteria, and allowing documentation submission and professional opinion that does not comport with current professional standards of care. In addition, the need for a definitive answer to address causation is not always possible to address with regard to psychological injury. These types of issues introduce imprecision into the determination of psychological injuries. To address these concerns, the American Medical Association developed the Guides to the Evaluation of Permanent Impairment as a means to take a more scientific approach to the assessment of impairment. This stance was a move away from the poorly defined term, “disability”. The focus was on evaluating the individual’s functioning in terms of impairment. The AMA holds that this is a more objective method that provides a balance between clinical opinion and the utilization of a more scientific methodology that increased precision in the determination of psychological injury and purported impairment in functioning that may have resulted from the injury. The American Medical Association’s Guides to the Evaluation of Permanent Impairment are utilized by many States and the federal WC systems to assist in the evaluation of psychological impairment in functioning and in the WC claims process. Some States opt to use earlier editions of the Guides. Other States and the federal WC system require the usage of the most current edition of the Guides. A few States opt to forego the usage of the Guides altogether and develop State-specific guidelines. The complexities that arise within the WC systems as well as usage of the Guides to evaluate and assess psychological injury are explored as well as potential solutions to address the imprecision that occurs within the WC systems.     

我国视损伤残疾评定标准问题研究

视损伤评价是制定视损伤残疾标准、统一标准适用的基础。由于基本问题缺乏界定与研究,导致我国残疾标准制定困难、理解适用混乱,影响了鉴定意见的科学性。应解决视功能含义、确定视残疾与个体残疾的关系、拣选检验指标、开展视残疾生存质量调查和一体评价视损伤等主要问题,加强残疾理论与法学、临床医学等其他学科的交叉研究,建立适合我国社会发展需求的残疾评价体系,促进残疾评定的科学化和标准化。     

Reconciling Autonomy and Beneficence in Treatment Decision-Making for Companion Animal Patients

This article explores how the concept of consent to medical treatment applies in the veterinary context, and aims to evaluate normative justifications for owner consent to treatment of animal patients. We trace the evolution of the test for valid consent in human health decision-making, against a backdrop of increased recognition of the importance of patient rights and a gradual judicial espousal of a doctrine of informed consent grounded in a particular understanding of autonomy. We argue that, notwithstanding the adoption of a similar discourse of informed consent in professional veterinary codes, notions of autonomy and informed consent are not easily transferrable to the veterinary medicine context, given inter alia the tripartite relationship between veterinary professional, owner and animal patient. We suggest that a more appropriate, albeit inexact, analogy may be drawn with paediatric practice which is premised on a similarly tripartite relationship and where decisions must be reached in the best interests of the child. However, acknowledging the legal status of animals as property and how consent to veterinary treatment is predicated on the animal owner’s willingness and ability to pay, we propose that the appropriate response is for veterinary professionals generally to accept the client’s choice, provided this is informed. Yet such client autonomy must be limited where animal welfare concerns exist, so that beneficence continues to play an important role in the veterinary context. We suggest that this ‘middle road’ should be reflected in professional veterinary guidance.     

Knocking at the wrong door: insured workers' inadequate psychiatric care and workers' compensation claims

ObjectiveTo describe the prevalence of inadequately evaluated and treated psychopathology among insured workers making workers' compensation claims for psychiatric disability whose cases were reviewed by one forensic psychiatrist. To assess the relationship of inadequate evaluation and treatment to the outcomes of these workers' compensation claims.MethodsRecords of a series of 185 workers' compensation cases reviewed in 1998 and 1999 by a California forensic psychiatrist were abstracted. Patient factors (gender, Axis II pathology, psychosocial circumstances, substance abuse), case factors (psychiatric injury secondary to physical injury, or secondary to psychological stresses), type of provider (mental health, or other), adequacy of evaluation and treatment, forensic psychiatrist's recommendation, and claim outcome were categorized. The relationships between case characteristics, adequacy of care, and claim outcome were described.Results22% of cases had adequate evaluation, 48% superficial, and 30% had no evaluation. 11% had adequate treatment, 67% superficial, and 22% had no treatment. Compared to claims for psychiatric disability related to a physical injury, claims related to psychosocial stresses more often had superficial diagnostic evaluations and treatments. Those with superficial treatment were less likely to have their claim granted (19.3%) than those with no treatment (47.5%) or those with adequate treatment (36.8%). Success of claim was not related to provider type.ConclusionsThe majority of the studied workers with employer-provided health insurance who sought workers' compensation for disability due to mental illness did so inappropriately, in that the workplace did not cause the psychopathology. Their seeking workers' compensation was plausibly due to the observed inadequate evaluation and treatment available through their employer-provided health insurance. The adequacy of their care influenced the likelihood their claim would be granted. The relations observed here merit further research to establish their generality and to determine their causes.     

Death by homeopathy: issues for civil, criminal and coronial law and for health service policy

Homoeopathy has a significant clinical history, tracing its roots back to Hippocrates and more latterly to Dr Christian (Samuel) Hahnemann (1755-1843), a Saxon physician. In the last 30 years it has ridden a wave of resurgent interest and practice associated with disillusionment with orthodox medicine and the emergence of complementary therapies. However, recent years have seen a series of meta-analyses that have suggested that the therapeutic claims of homeopathy lack scientific justification. A 2010 report of the Science and Technology Committee of the United Kingdom House of Commons recommended that it cease to be a beneficiary of NHS funding because of its lack of scientific credibility. In Australia the National Health and Medical Research Council is expected to publish a statement on the ethics of health practitioners' use of homoeopathy in 2013. In India, England, New South Wales and Western Australia civil, criminal and coronial decisions have reached deeply troubling conclusions about homoeopaths and the risk that they pose for counter-therapeutic outcomes, including the causing of deaths. The legal decisions, in conjunction with the recent analyses of homoeopathy's claims, are such as to raise confronting health care and legal issues relating to matters as diverse as consumer protection and criminal liability. They suggest that the profession is not suitable for formal registration and regulation lest such a status lend to it a legitimacy that it does not warrant.     

Pedophilia on the Internet

The Internet provides adults and children with a medium for professional and personal communication throughout the world. As widespread communication in cyberspace grows exponentially, the potential for Internet-related crimes, such as cyberstalkng, has accelerated. Children are particularly vulnerable to sexual predators, such as pedophiles, on the Internet. This article reports cases of pedophiles who used the information superhighway to exploit child victims. Two models of pedophilia on the Internet are discussed: a trust-based seductive model and a direct sexual model. This article explores the role that mental health professionals may play in the assessment of Internet pedophilia. For example, mental health professionals may provide psychiatric treatment to victims of Internet pedophiles. Psychiatrists may be involved in the evaluation of perpetrators of Internet crimes in a clinical or forensic setting. Governmental agencies, the criminal justice system, school, or the media may request consultations by mental health professionals as part of a multi-disciplinary approach to prevention. Methods of government intervention are discussed.