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PubMed1995

Responsibility to or for in the physician-patient relationship?

The threat of malpractice litigation in the United States is encouraging physicians again to assume responsibility for their patients. The fundamental ethical problem, however, is that this approach denies the patient's moral agency. In this essay, responsibility to patients, rather than for them, is discussed as an alternative to the emerging neo-paternalism. Responsibility to avoids the ethical problems of assuming responsibility for moral agents and could reduce the threat of litigation as well.

Decision Making↗
PubMed1983

Informed consent: what does it mean?

The editorial in the September 1982 issue of this journal and many articles before and since have addressed the problem of informed consent. Is it possible? Is it a useful concept? Is there anything new to be said about it? In this article the basic rationale of the rule (patient autonomy) is explained and the extent of the rule explored. Various exceptions have been offered by the law and an attempt is made to catalogue the chief of these. A number of specially vulnerable groups are then identified, the most important, and vexed, being children. How can informed consent be secured in the case of young patients? Finally, a few problems are mentioned in an attempt to get this subject back to reality. The appeal to the principle primum non nocere may be medical paternalism in disguise. Informed consent is the competing principle that reminds us of the primacy of human autonomy. A pointer is given to the future: even the use of sound recordings to explain medical procedures and to activate informed consent so that it may become a reality and not just a lawyer's myth, should be considered.

Australia↗
PubMed2006

Economics on trial: the use and abuse of economic methods in third party tobacco litigation.

OBJECTIVE: To analyse how the tobacco industry responded to economic models and methods used in third party payer tobacco litigation that has occurred since 1994. METHODS: Identified 12 third party payer cases and reviewed the transcripts using WinMax qualitative software. Focused on defendant's opening and closing statements, followed by trial testimony, depositions, and plaintiff's transcripts. RESULTS: Tobacco industry defendants tried to create doubt and confusion about whether or not smoking caused disease and by extension led to health care costs; argued that the economic models used were not legitimate and were not appropriate for estimating the costs incurred by plaintiffs; and criticised the data sources used because they did not consist of the individuals whose health care costs were being sought. CONCLUSIONS: Faced with a new and unprecedented wave of anti-tobacco litigation from third party payers, the tobacco industry tried to adapt strategies that had been used successfully in the past-creation of unfounded doubt and confusion, and manipulation of the discovery process to force plaintiffs to withdraw or concede defeat. The strategies failed because credible economic models of the health care costs of smoking had been developed that were able to quantify the damages to a large group of health care recipients, because plaintiff's attorneys were able to commit significant resources and willing to undertake substantial financial risk to defend their new legal approaches, and because previous arguments related to individual responsibility were deemed irrelevant in third party litigation.

Cost of Illness↗
PubMed1983

Are lawyers enemies of psychiatrists? A survey of civil commitment counsel and judges.

The author surveyed 101 attorneys and judges involved in civil commitment procedures to answer the question of how they view psychiatrists, mental hospitals, and the mentally ill. She found that these lawyers and judges tended to view psychiatrists in favorable terms, that their attitudes toward mental hospitals reflected their perception of the weaknesses of these hospitals and their view of hospitalization as a last resort, and that they tended to reject negative statements about the mentally ill. She discusses the effect of these attitudes on the behavior of lawyers and judges toward psychiatrists and the mentally ill in civil commitment hearings.

Attitude↗
PubMed1983

Behavioral precipitants to civil commitment.

The authors examined retrospectively the prehospitalization behavior of 66 voluntary and involuntary psychiatric patients to determine precipitating factors in each person's hospitalization. Involuntary patients had engaged in dangerous acts directed against others more frequently than had voluntary patients. However, very little significant harm was caused by members of either group.

Commitment of Persons with Psychiatric Disorders↗
PubMed1984

Two decades of involuntary hospitalization legislation.

In 10 of the 13 cases the author examined, after passage of a state statute affecting involuntary admission to state psychiatric hospitals the percentage of involuntary admissions changed significantly in the direction intended by the legislature. The findings support the hypothesis that state laws significantly influence involuntary admission rates and, consequently, clinical practice. The findings also demonstrate that legislative intent in the late 1960s and early 1970s supported restriction of involuntary hospitalization and that a move toward liberalization of its use occurred in the late 1970s. The author recommends greater involvement by psychiatrists in the formulation of legislation that has an influence on their clinical work.

Attitude of Health Personnel↗
PubMed1985

The impact of broadened civil commitment standards on admissions to state mental hospitals.

In 1979, the state of Washington broadened its criteria governing the involuntary commitment of the mentally ill. This study examined the impact of the revised law on involuntary and voluntary admissions and on the type of patient admitted to state hospitals in Washington. The short-term effect of the law was an abrupt increase in involuntary commitments, with a concomitant but not offsetting decline in voluntary admissions. Although the law resulted in a substantial change in admissions policy, it does not appear to have altered the type of patient admitted to state mental hospitals in Washington.

Commitment of Persons with Psychiatric Disorders↗
PubMed1986

Posthospital mandatory outpatient treatment.

Mandatory outpatient treatment invoked after the patient has improved in the hospital is a relatively new development. Tennessee instituted this policy by statute in 1981. While people placed under the constraints of that law showed a reduction in rate of readmission, comparison with control groups failed to support the conclusion that these results are due to the forced outpatient constraints. The author discusses some procedure and policy considerations that stem from these findings.

Aftercare↗
PubMed1986

Divorce and child custody resolution: conflicting legal and psychological paradigms.

The resolution of divorce conflict, especially the determination of child custody, is a major social policy concern of both the legal and mental health professions. The differences between the adversarial and mediation legal approaches parallel the phenomenological/psychoanalytic and the family therapy models of the mental health field. A philosophical and practical relationship exists uniting the adversarial and phenomenological/psychoanalytic traditions, while mediation is strongly aligned with family systems theory and therapy. Each paradigm offers American families alternative methods of resolving disputes. A greater synthesis of paradigms is required to give effective help to divorcing couples and their children.

Adult↗
PubMed1986

A method for quantifying and comparing civil commitment processes.

The authors present a three-step civil commitment model and formulas for calculating 1) the probability of release from the commitment process and 2) the relative importance of the three steps in determining outcome. Using data from Oregon's civil commitment process, they present five examples that demonstrate how their method might be used to study and monitor civil commitment processes within and between jurisdictions. The major public policy and research implications are discussed.

Commitment of Persons with Psychiatric Disorders↗
PubMed1989

An empirical comparison of the stone and dangerousness criteria for civil commitment.

Massachusetts civil commitment criteria were compared in an emergency setting with a set of criteria developed by Dr. Alan Stone. Contrary to expectations, the Stone criteria proved to be more restrictive in a sample of 503 patients. Few patients would be newly committable under the Stone criteria; of the 35 patients committable under the Stone standard, 32 also met the current Massachusetts criteria for commitment. The clinical and policy implications of the adoption of the Stone criteria are discussed.

Adult↗
PubMed1989

An empirical study of emergency commitment.

The authors examine the emergency commitment process in one Oregon county and present data that document the impact of a local detention facility. The study reconfirms the dependence of commitment processes on the mental health system in which they occur, illustrates the relative inability of specific laws to determine the actual nature of commitment processes, provides support for the concept of community care for the people involved, and points to the need for additional research to clarify the effects of commitment procedures.

Commitment of Persons with Psychiatric Disorders↗
PubMed1991

New York under the Rivers decision: an epidemiologic study of drug treatment refusal.

OBJECTIVE: To determine the characteristics of cases of drug treatment refusal under the Rivers decision, which mandated court adjudication of such cases, the authors made a retrospective study of all applications for court review during 1 year in New York State inpatient facilities. METHOD: Sociodemographic and clinical characteristics of these 473 cases were compared with those of the 41,535 cases during the same period in which no court review was requested. RESULTS: A 1% prevalence of applications requesting court review for nonemergency administration of medication over objection was found. The patients who refused medication were more likely than the comparison patients to have a crime-associated commitment status, a diagnosis of schizophrenia, and fewer previous hospital days, and they were more likely to be discharged. Medication refusers for whom applications for court review were submitted had relatively longer hospitalizations than the rest of the patients. Almost one-third of the applications submitted were withdrawn before court hearings, yielding a 0.7% prevalence of court-reviewed applications. Ninety-two percent of these applications for medication over objection were approved with virtually no change in the requested orders. CONCLUSIONS: The study findings demonstrate that a front-end judicial determination of competency to refuse medication results in a time-consuming procedure which fails to ensure real due process or provide individualized alternative treatment. A two-tier system with in-house clinical review preceding judicial review is proposed to remedy the deficiencies of the current system.

Commitment of Persons with Psychiatric Disorders↗
PubMed1996

Confidentiality dilemmas in group psychotherapy with substance-dependent physicians.

OBJECTIVE: The purposes of this article are 1) to review federal and state laws relevant to confidentiality in group therapy with impaired physicians and 2) to provide empirical data concerning the actual confidentiality practices and experiences of group therapists treating chemically impaired physicians. METHOD: In the clinical research phase, 25 state medical societies identified 45 rehabilitation centers as those to which the societies preferentially referred chemically impaired physicians. Fifty-one group leaders from 33 of these rehabilitation centers completed the survey questionnaire employed in this project. RESULTS: Because of the risk of potentially irreversible social and professional injury, physician patients were exceedingly concerned about breaches of confidentiality. Co-members' infractions most often involved the violator sharing with close friends and family members the name and abuse history of a fellow physician. In contrast, transgressors rarely leaked information about a co-member's drug-related illegal behaviour. CONCLUSIONS: Chemically impaired physicians would feel safer in sharing secrets in group therapy if more jurisdictions adopted legislation making co-members liable for violating confidentiality. Currently the pertinent body of law is confusing and inconsistent and provides little protection to impaired physicians who enter group therapy. The authors propose ideas for model legislation.

Confidentiality↗
PubMed1996

Psychotherapists' duties to third parties: Ramona and beyond.

OBJECTIVE: This paper explores the implications for psychotherapy of a series of court cases involving suspected childhood sexual abuse that have raised the question of when psychiatrists and other psychotherapists can be sued by third parties for their behavior in therapy. METHOD: The authors begin by considering traditional legal approaches that until now, with few exceptions, granted only patients the right to sue caregivers for negligence. Then they turn to Ramona v. Ramona, the most publicized of a new line of cases, in which the California courts allowed a father accused of abusing his daughter to sue his daughter's therapists. RESULTS: The rationale for the abandonment of the previous restrictions on liability in Ramona was that since the father was a "direct victim" of the therapists' negligence, traditional limitations on the therapists' duties toward him should not apply. Related cases have used similar logic. Inherently difficult for the courts to apply, the direct victim standard would leave therapists unclear as to how to avoid duties to third parties, other than by refusing to treat patients with family members who may be potential litigants. Moreover, aggrieved third parties essentially would have the power to bring effective treatment to a halt by filing suit or threatening to do so. CONCLUSIONS: Although concern about therapeutic practices related to memories of childhood abuse may be warranted, abandonment of traditional rules against suits by nonpatients would be ill-advised. In the meantime, therapists can take steps to lessen the probability of their becoming involved in such litigation.

Adolescent↗
PubMed2001

Factors in the use of coercive retention in civil commitment evaluations in psychiatric emergency services.

OBJECTIVE: The authors examined whether factors other than civil commitment criteria influence the involuntary retention of patients who are evaluated for civil commitment in psychiatric emergency services in California general hospitals. METHODS: Logistic regression analysis was used to determine whether admission criteria, institutional constraints, social biases, and procedural justice indicators contributed to the use of coercive retention in the evaluations of 583 patients in the psychiatric emergency services of nine California county general hospitals. RESULTS: Of the 583 patients, 109 (18.7 percent) were retained against their wishes. Clinicians relied primarily on admission criteria in making the decision to retain a patient, which suggests that patients were generally afforded procedural due process during the evaluation in the psychiatric emergency service. Staff workload was a possible factor in violations of due process. CONCLUSIONS: Psychiatric emergency services need additional resources to ensure procedural due process protection for patients who are being evaluated for civil commitment.

Adult↗