Regulating medical futility: neither excessive patient's autonomy nor physician's paternalism

In the era of an aging population and escalating healthcare costs, the futility debate has become the object of extended critical attention. The issue has divided experts in relevant fields into two camps. The proponents of medical futility defend the physician's exclusive right to determine the futility of treatment and decide whether treatment should be withheld or withdrawn. On the other hand, opponents believe that a discourse of power lies at the heart of the futility debate. They believe that medical futility was constructed, in part, as a means of enhancing the physician's domination in a context wherein medical authority was threatened. This paper presents some current approaches to the futility debate and highlights positions taken by physicians and bioethicists. It concludes that establishing an operational guideline, either at hospital or national level, is a critical requirement for resolving problems posed by futility. It suggests that policies should not be based on either excessive patient's autonomy or physician's paternalism.     

Physicians' confusion demonstrated by competency requests

A study was performed at a Veteran's Administration (VA) Hospital of the requests for competency evaluations made by medical and surgical services to a psychiatric consultant service. Since less than half the requests were found to be appropriate and specific, this study emphasizes the need for forensic psychiatrists to educate our nonpsychiatric colleagues about the problems engendered by confusion regarding competency. To do so, psychiatrists as well as other physicians and mental health professionals must be trained in discriminating between different types of competencies and the criteria appropriate for each. Because of continuing legal developments, it is becoming increasingly essential to be precise not only about the specific purpose for a competency request but also about the criteria necessary for evaluating different types of competencies. Forensic psychiatrists could play an important role in the education process to clarify the confusion. This study highlights the need for clarity and education concerning competency issues.     

Competence to give informed consent for medical procedures

This study shows that referrals to psychiatry for evaluation for competence to give informed consent generally were made on patients who refused medical treatment. In this sample of referred patients, the only patients found to be incompetent to give informed consent were those with organic brain syndromes. No one with either schizophrenia or depression was found to be incompetent. It is possible that schizophrenic and depressed patients may generally be competent to give informed consent to medical treatment. This finding might be true notwithstanding the fact that many such patients have been found in other studies to be incompetent to consent to voluntary psychiatric treatment. For example, a patient may have delusions that others can read his mind and thoughts, but he still can understand that he needs dialysis for renal failure. Alternatively, it may be relatively rare that an emergency procedure is necessary before a patient's psychosis can be brought under control and consequently internists and surgeons themselves may prefer to wait. The significance of the results is unclear. Because of active interest in the doctrine of informed consent for psychiatric and medical patients by both physicians and attorneys and the few studies within this population, there is a strong need for more study regarding competence to give informed consent. Further study is especially important for psychotic patients for whom psychiatric consultation is not requested.(ABSTRACT TRUNCATED AT 250 WORDS)     

Forgotten Children of Immigration and Family Law: How The Absence of Legal Aid Affects Children in the United States

The absence of government‐appointed legal counsel in immigration proceedings adversely affects large numbers of children in the United States. Children born in the United States to parents without citizenship status (U.S.‐born children of noncitizen parents or UCNP) are harmed by a parent's detention and removal. Unaccompanied alien children (UAC) who have entered the country without legal status are adversely affected by their own detention and removal. The possibility of obtaining relief from removal is drastically diminished by the lack of legal representation. Currently UAC and immigrant parents are not entitled to court‐appointed attorneys. Any meaningful change in immigration law, such as a federal statutory amendment to provide UAC and immigrant parents with government‐appointed counsel is unlikely due to the present political dissension in Congress regarding this issue. Because UAC and immigrant parents are not entitled to government‐funded legal representation, a pro bono legal service system has developed, but is unable to meet the present need adequately. For immigrant parents, this Note proposes the adoption of a statute to allow the appointment of court liaisons in family court proceedings. The court liaison is a nonattorney who is familiar with the processes of the family court and ensures that immigrant parents are fully informed regarding all pertinent family court proceedings. For UAC, this Note proposes an amendment to the William Wilberforce Trafficking Victims Protection Reauthorization Act to mandate the appointment of a child advocate to all UAC. The child advocate is not a lawyer, but works with the UAC's attorney to provide the child with legal representation and advocacy.

Key Points for the Family Court Community:
• UCNP confront the loss of parents to detention and removal. Children are condemned to limbo, torn between absent biological parents and placement in foster care.
• The recent surge in the number of UAC who enter the United States by crossing the border from Mexico has been described as a humanitarian crisis. These children often remain alone without legal protection, vulnerable to detention and removal.
• Ideally, UAC and the immigrant parents would be provided with government‐funded legal representation in immigration proceedings. In the absence of the federal statutory reform necessary to make that a reality, state statutory reform to allow for the provision of court liaison programs for immigrant parents and federal statutory reform to allow the appointment of child advocates for UAC can begin to offer children and families needed legal support and advocacy.