Advanced directives,the right to die and the common law: recent problems with blood transfusions

The Australian common law suffers from a lack of judicial authority on the right to die, in particular the right of patients to make anticipatory decisions to refuse treatment. Recent cases concerning the right of patients to refuse life-saving blood transfusions have highlighted the need for a substantial judicial clarification of this area. This article critically examines one of the most recent Australian cases in detail and compares its approach with those from other common countries. After taking this comparative analysis the article puts forth a common law model of anticipatory decision-making and examines how that model might work in the context of current legislative frameworks.     

Public Management 1995: The Year That Was

Until it was discontinued in 1988, the Australian Journal of Public Administration published an administrative chronicle intended to document the events of the past year in state and commonwealth administrations.
This administrative essay, the first of a projected annual series, has a different, although related purpose. It is organised on a thematic, rather than a state-by-state basis, and attempts to describe and to illuminate the main issues in public administration in Australia as they emerged through the events of 1995.
In a short essay, detail must necessarily be sacrificed in order to capture the main trends. Nevertheless, the major features of the administrative landscape, as they appeared during 1995, have been faithfully recorded.     

The Transformation of Bureaucracy? Structural Change in the Commonwealth Public Service 1983-93

Commentators have predicted bureaucratic organisations would undergo substantial change as a result of social and economic pressures. We ask whether reforms to the Australian public service over the 1983–93 period exemplify this process.
We use the methods of organisational analysis to characterise the direction of change, basing our assessment on the standard structural variables of complexity, formalisation and centralisation, together with a cultural variable. We find evidence that, overall, departments of state in the APS were becoming less bureaucratic in their structure, culture and internal function in the 1983–93 period. However, the effect was not uniform across departments, or unambiguous — formalisation, for example, increased in some respects and decreased in others. Centralisation increased overall, despite devolution of some decision-making.     

Adolescent psychiatric inpatients: Characteristics,outcome, and comparison between discharged patients from a specialized adolescent unit and nonspecialized units

We have recently studied the outcome of school-aged children treated in day hospital and inpatient psychiatric units using four operationally defined preadmission child and parent/family variables as predictors of outcome. Our studies have provided considerable support for these preadmission variables singly and/or in combination in predicting poor outcome in school-aged children in these hospital settings. The present study describes the prevalence of these variables and their ability to predict outcome in two groups of adolescent psychiatric inpatients in the same hospital: one group placed on a specialized adolescent unit and one group placed on other inpatient psychiatric units. The findings indicate that overall there is a lower prevalence of the preadmission variables in the adolescent group compared to the school-aged inpatient group. In the adolescent group, only the preadmission variable of severe aggressive/destructive behavior predicted poor outcome. There appears to be a greater prevalence of severe behavioral disturbance in the group of adolescents discharged from the specialized adolescent unit compared to adolescents discharged from other psychiatric units, and an associated poorer outcome in the former group. Possible reasons for these findings and their implications for the hospital-based evaluation and treatment of aggressive and severely disturbed adolescents are discussed.This paper was presented in part at the 144th annual meeting of the American Psychiatric Association, May 1991.Received M.D. from Albert Einstein College of Medicine. Research interests are outcome of youth treated in psychiatric programs, aggression and conduct disorder, and children of substance-abusing parents.Received M.A. in psychology from the New School for Social Research. Research interests are psychobiology, affective disorders, and metabolic regulation.     

Simulating Emotional Responses in Posttraumatic Stress Disorder: An fMRI Study

This study tested the extent to which coached participants can simulate the neural responses of participants with posttraumatic stress disorder (PTSD) when they are presented with signals of fear. Functional magnetic resonance imaging (fMRI) was used to study blood oxygenation level-dependent signal during the presentations of fearful and neutral faces under both conscious and nonconscious (masked) conditions. Participants comprised 12 patients with PTSD and 12 trauma-exposed controls who were instructed to simulate PTSD. During conscious fear processing, simulators showed greater activation in the left amygdala and medial prefrontal cortex (MPFC) than PTSD participants. By contrast, during nonconscious processing, PTSD participants had greater MPFC activation than simulators. These findings suggest that coached simulators produce a profile of ‘over-responding’ to fear when controlled conscious processing is possible, but are not able to simulate the exaggerated medial prefrontal responses observed in PTSD participants under conditions of nonconscious processing.     

Health‐care reform and the dimensions of professional autonomy

Abstract: A “managed competition” model was introduced in the Canadian province of Ontario as part of the government's reform of home care. With this model, it was assumed that competitive forces would encourage quality while driving down costs. While such reforms often achieve cost controls by constraining the incomes and practices of health‐care workers, there has been relatively little analysis of the extent to which self‐governing health‐care professionals, particularly those outside of medicine and nursing, may experience a decline in their ability to control the content and context of their professional work. In this article, the authors analyse the results of thirty‐six in‐depth interviews with representatives of Community Care Access Centres (CCACs), the organizations that purchase and coordinate the delivery of home‐care services, and rehabilitation provider agencies to examine the impact of Ontario's managed competition reform on rehabilitation professionals. Findings suggest that the impact of the reform varied across the economic, political, and clinical dimensions of professional autonomy and that, despite a general loss of autonomy under the managed competition model, market forces also served to mitigate the loss of autonomy, thus contributing to a remarkable resilience of professional autonomy. Sommaire: Un modèle de « concurrence dirigée » a été introduit récemment dans la province canadienne de l'Ontario dans le cadre de la réforme gouvernementale des soins à domicile. Avec ce modèle, il était présumé que les forces de la concurrence encourageraient la qualité tout en faisant baisser les coûts. Alors que de telles réformes parviennent souvent à maîtriser les coûts en réduisant les revenus et les pratiques des travailleurs de la santé, il y a eu relativement peu d'analyses de faites sur la mesure dans laquelle les professionnels de la santé autonomes, particulièrement ceux qui exercent en dehors de la médecine et de la profession infirmière, connaissent une perte de contrôle sur le contenu et le contexte de leur travail professionnel. Dans le présent article, les auteurs analysent les résultats de trente‐six entrevues en profondeur menées auprès de représentants des Centres d'accès aux soins communautaires (CASC), organismes qui achètent et coordonnent la prestation des services de soins à domicile, et organismes de prestation de soins de réadaptation, afin d'examiner les conséquences de la réforme de la concurrence dirigée de l'Ontario sur les professionnels de la réadaptation. Les résultats laissent entendre que l'effet de la réforme a varié en fonction des dimensions économiques, politiques et cliniques de l'autonomie professionnelle et que, malgré une perte d'autonomie générale liée au modèle de concurrence dirigée, les forces du marché ont également permis d'atténuer la perte d'autonomie, contribuant ainsi à la remarquable résilience dont font preuve ces professionnels en la matiére.     

Learning the Limits of Power: Privatization and State-Labor Interactions in Mexico

Despite repeated conflict with organized labor, the government of Carlos Salinas de Gortari (1988–94) pushed an aggressive divestment agenda that transformed Mexico into Latin America's leading privatizer. Explanations of Salinas's achievements typically emphasize centralized presidential power (including control over the ruling party) and autonomy; technocratic and political savvy; and weak labor opposition. This article questions such a pure "capacity-outcome" approach. Of equal importance are the learning effects of repeated interaction between the state and labor, which changed the course of divestment struggles and thereby influenced their outcomes. Lessons learned in successive confrontations led to patterns of interaction conducive to widescale privatization. The article develops this argument through comparative analysis of major divestment episodes in the aviation, mining, steel, and telecommunications sectors.