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PubMed1997

Medical conditions & driving: legal requirements & approach of neurologists.

Licensing of drivers with health problems, particularly epilepsy, has medical, social and legal implications that vary from country to country. Legislation and medical guidelines are based as much on empirical as on statistical data. A questionnaire regarding neurological disorders and driving was given to all adult neurologists in Canada (n = 494) and an assessment made of opinions of neurologists working under mandatory reporting legislation compared to those in a discretionary reporting environment. Of 289 (59%) neurologists responding, 50% reported patients with seizures to the Department of Motor Vehicles compared to only 4% for stroke/TIA, 26% for dementia and 8% for other neurological disorders (p < .0001). In the five provinces with mandatory reporting laws, seizures were reported most of the time by 84% compared to only 19% in the five provinces with discretionary reporting laws (p < .0001). An overall minority agreed with mandatory reporting (44%) but this percentage differed in the provinces with and without mandatory reporting legislation (63% vs. 37%, p < .0001). Seizure disorders are selectively reported more often than other neurological conditions. There is considerable variability in the attitude and practice of neurologists in regard to reporting of medical conditions.

Adult↗
PubMed1987

Factors associated with involuntary admission to psychiatric facilities in Newfoundland.

To assess what factors determine the involuntary status of psychiatric patients, we reviewed the case records of 5729 patients consecutively admitted to one of four inpatient psychiatric facilities, including a mental hospital, in St. John's between October 1975 and October 1978. Of the 5729 patients 5005 (87.4%) were voluntary and 724 (12.6%) involuntary. Involuntary patients were more likely than voluntary patients to be male, single and unemployed and to have been referred by police or transferred from another facility to the mental hospital, where most of the involuntary admissions occurred. They had higher rates of previous admissions to a psychiatric facility and of suicidal and violent behaviour, were more likely to have a diagnosis of schizophrenia or mania and were less likely to be suffering from depression or a neurotic disorder. In correspondence with differences in diagnosis, involuntary patients stayed in hospital more than twice as long as voluntary patients, were less likely to receive electroconvulsive therapy, minor tranquillizers and antidepressants, and were more likely to receive neuroleptics and lithium carbonate. Stepwise logistic regression analysis revealed that only the source of referral and a diagnosis of neurotic disorder had an independent effect on admission status. The findings are discussed in the context of the controversy over the parens patriae approach v. the legal approach to involuntary admission of psychiatric patients.

Adult↗
PubMed1987

Reibl v. Hughes: the consent issue.

Inviolability of the person is the basic principle underpinning the concept of consent to treatment. Although it is not a new concept, consent has become a major medico-legal issue because of a shift, within the doctor/patient relationship, towards more autonomy for the patient and less paternalism from the doctor. This change has been given further impetus by legal decisions such as Reibl v. Hughes and Hopp v. Lepp. In this paper the author reviews the nature of the changes and the impact of the legal decisions on the doctor/patient relationship. He concludes that a legal approach to consent is sterile if it is a substitute to open communication between the doctor and the patient, or to their acceptance of a principle of "equality of two participants". Consent is based on the basic principal of the inviolability of the person, that is, the right, at all times, of every individual not to have his body tampered with without his permission or agreement, and to be the whole decision-maker on matters that affect his physical integrity. This right is not absolute: it may be abrogated by the state for health or judicial reasons, or the person may not be in a position to exercise it, such as when unconscious or because of mental disability. This paper will review present Canadian laws on consent. It will contrast the legal approach to consent to the ethical-humanistic approach which could be developed within the context of the doctor/patient relationship.

Canada↗
PubMed1996

Darren's case: narrative ethics in Perri Klass's Other Women's Children.

During the past fifteen years, the relationship between literature and medical ethics has evolved from the occasional use of stories as a substitute for the traditional case study in medical ethics to the emergence of a narrative approach to ethical analysis and decision making. Thus far, literary theory has been more important to narrative medical ethics than have works of literature themselves. Perri Klass's novel Other Women's Children deserves special scrutiny, however, because an analysis of it demonstrates ways that a narrative approach could enhance traditional philosophical and legal approaches to resolving ethical dilemmas in medicine.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

International human rights and women's reproductive health.

Neglect of women's reproductive health, perpetuated by law, is part of a larger, systematic discrimination against women. Laws obstruct women's access to reproductive health services. Laws protective of women's reproductive health are rarely or inadequately implemented. Moreover, few laws or policies facilitate women's reproductive health services. Epidemiological evidence and feminist legal methods provide insight into the law's neglect of women's reproductive health and expose long-held beliefs in the law's neutrality that harm women fundamentally. Empirical evidence can be used to evaluate how effectively laws are implemented and whether alternative legal approaches exist that would provide greater protection of individual rights. International human rights treaties, including those discussed in this article, are being applied increasingly to expose how laws that obstruct women's access to reproductive health services violate their basic rights.

Cross-Cultural Comparison↗
PubMed1986

Reproductive technology and the law in Canada.

Even leaving aside the question of the impact of reproductive technology on property law, successions, commercial law and the legal qualification to be given to some of the relationships it entails (e.g. 'deposit' of genetic material, 'lease and hire' of wombs, 'gifts' of embryos), there is no doubt that, like the discovery of the atom, no other scientific advance portends such an enormous potential for human benefits or harm. No other scientific advance will so affect the personal, intimate life of the individual person in its public or private aspects. Beginning then with the positive law (Part I), we will attempt to trace, albeit summarily, possible legal approaches to reproductive technology in Canada and to conclude with an overview of proposed reforms (Part II).

Canada↗
PubMed1994

Digital archives and communication highways in health care require a second look at the legal framework of the seventies.

The present state of the art and the state of practice regarding legal aspects of medical informatics are reported. Examples are taken from networking, archiving, and virtual reality. It is derived that the data protection concepts of the seventies are covering only some legal aspects of the application scene today and in the future. Thus a far wider legal approach is necessary. It can only be mastered if engineers and lawyers discuss future trends and derive together a new legal framework for medical computer systems in the late nineties. As computers will be everywhere from childhood to death the key issue is not to just protect an individual but to positively frame an information society.

Computer Communication Networks↗
PubMed1992

Informed consent: medical-legal update for the practitioner on recent judicial opinions applying state laws.

Physicians, in general, and surgeons, in particular, need to be aware that there is no universally applicable definition of informed consent. This paper provides a framework for understanding current, commonly accepted legal approaches and trends. State codes, state cases, and federal cases were searched manually and with the Westlaw and Lexis data bases for states with both informed consent statutes and judicial decisions interpreting those laws. Statutory definitions, where present, may be general or detailed. Legal standards for informed consent disclosure are usually either professionally based or objective. Standards for informed consent causation have been either subjective, objective, or modified-objective. Often, a physician must breech both the disclosure and the causation standards to be legally liable. Results of individual cases depend on the legislative and judicial standards adopted. Physicians need to be conversant with the general approaches to informed consent so they may better understand the applicable standards for their own jurisdictions.

Humans↗
PubMed1975

Medicolegal implications of medical records.

The problem of ownership and possession of patient's medical records has been reviewed. The apparent fallacies in the presently accepted legal doctrines regarding ownership of the patient's records by health care providers have been submitted. The legal approaches and tactics available to implement the accessibility and availability of his records to the patient have been reviewed. The problems incident to the employment of statutory enactments as a means of putting the patient's record in his possession have been considered. The various legal theories that could conceivably be utilized in establishing this right on a case-to-case basis in the courts have been presented. The medicolegal implications relating to medical records have been discussed.

Confidentiality↗
PubMed1996

Salt Enrichment of Municipal Sewage: New Prevention Approaches in Israel

Wastewater irrigation is an environmentally sound wastewater disposal practice, but sewage is more saline than the supplied fresh water and the salts are recycled together with the water. Salts have negative environmental effects on crops, soils, and groundwater. There are no inexpensive ways to remove the salts once they enter sewage, and the prevention of sewage salt enrichment is the most immediately available solution. The body of initiatives presently structured by the Ministry of the Environment of Israel are herein described, with the aim to contribute to the search for a long-term solution of salinity problems in arid countries. The new initiatives are based on: (1) search for new technologies to reduce salt consumption and discharge into sewage; (2) different technologies to cope with different situations; (3) raising the awareness of the public and industry on the environmental implications of salinity pollution; and (4) an elastic legal approach expressed through new state-of-the-art regulations. The main contributor to the salinity of sewage in Israel is the water-softening process followed by the meat koshering process. Some of the adopted technical solutions are: the discharge of the brine into the sea, the substitution of sodium by potassium salts in the ion-exchangers, the construction of centralized systems for the supply of soft water in industrial areas, the precipitation of Ca and Mg in the effluents from ion-exchangers and recycling of the NaCl solution, a reduction of the discharge of salts by the meat koshering process, and new membrane technology for salt recovery.

Journal Article↗
PubMedDate not supplied

A new attack on smoking using an old-time remedy.

This article first will explain the reasons behind and goals of state recoupment actions against the major cigarette manufacturers, their lobbying arm and trade association, and their public relations firms (collectively referred to as the "tobacco industry") for the recovery of Medicaid and other indigent care expenditures on smoking-related illnesses. These are, primarily, to relieve the heavy financial burden on state treasuries and to stop the tobacco industry from targeting children in advertising and promotions. To put this new legal approach in perspective, the article presents a brief historical background to the tobacco industry's litigation strategy: to wear down opponents through delay and intimidation, to cast doubt on science, and to wrongfully invoke the attorney-client privilege against disclosure of incriminating evidence. Next authors discuss the states' strategy: each filing one suit seeking equitable remedies under theories of restitution/unjust enrichment, indemnity, public nuisance, and injunctive relief to protect the interests of minors, instead of maintaining thousands of product liability claims on behalf of individual smokers. This will be followed by a critique of the industry's response to state actions: political attacks against attorneys general and trial lawyers and charges that the lawsuits would hurt business as well as a variety of legal challenges, including an imaginative but risky defense that if smoking indeed causes disease and attendant health care expenditures, then the tobacco industry ought to be given a credit against those expenditures for the taxes generated by its business and the "savings" which inure to the states from the premature deaths of smokers (the cost of geriatric care, for example). The article will wrap up by impressing on health officials and other readers what is at stake in these actions and what their success or failure will mean for the Medicaid program.

Adult↗
PubMed1994

Prevalence of advance directives and do-not-resuscitate orders in community nursing facilities.

OBJECTIVE: To determine the prevalence of advance directives and do-not-resuscitate (DNR) orders in nursing homes and to measure the effect of the Patient Self-Determination Act (PSDA) and patient characteristics on these prevalences. DESIGN: Cross-sectional study. SETTING: Eight rural community nursing facilities. PARTICIPANTS: Six hundred forty-one records of nursing home residents (total census of eight facilities). RESULTS: The mean age of the residents was 82.6 years and 75% were women. Thirty-seven percent were judged to have decisional capacity. Less than one third of the records revealed an advance directive (standard living will, 11.5%; other written directive, 11.1%; durable power of attorney for health care, 12%). Thirty-six percent had DNR orders. Residents with advance directives were older than those without them. Those residents with advance directives were more likely to have been admitted to the nursing home after the enactment of the PSDA (25.1% before vs 37.9% after enactment; P < .0001). There was substantial variation among facilities in both prevalences. Written rationales for DNR orders were found in only 40% of records. CONCLUSION: Enactment of the PSDA reflects increased interest in documentation of advance directives. However, in many nursing facilities, the prevalence of advance directives and DNR orders is relatively low. A greater commitment will be required by providers, residents, and their proxies if we are to change this reality.

Advance Directives↗
PubMedDate not supplied

The patient self-determination act and advance directive completion in nursing homes.

OBJECTIVES: To assess the prevalence of advance directives among nursing home residents before and after passage of the Patient Self-Determination Act (PSDA) and to identify factors associated with advance directive completion. DESIGN: Prestudy and poststudy nursing home admissions using medical record reviews and a companion cross-sectional survey of alert and oriented residents. SETTING: Six nursing homes in Connecticut. PARTICIPANTS: Residents (N = 635) from 6 randomly chosen nursing homes in the greater Hartford and greater New Haven areas. MAIN OUTCOME MEASURES: The existence of a documented advance directive, the timing of advance directive completion, and reported reasons for completion and noncompletion. RESULTS: The prevalence of advance directives documentation in nursing home medical records has increased significantly since the implementation of the PSDA (4.7% [14/300] before vs 34.7% [104/300] after PSDA; odds ratio, 10.84; P < .001). The increase in documented advance directives was significant after controlling for sociodemographic and health status factors (odds ratio, 11.5; P < .001). Residents admitted to the nursing homes from hospitals (vs from their home or other source), residents with more education, and residents paying privately for nursing home care (vs using Medicare or Medicaid benefits) were more likely to have documented advance directives. Younger residents (aged < 75 years) were less likely than older residents to have completed a directive. Among the 35 interviewed residents, the most common reason for completing an advance directive was experience with a prolonged death of a friend or family member. Only 1 of the interviewed residents reported that the information provided under the PSDA at the time of admission was an important factor in choosing to complete an advance directive. CONCLUSIONS: Nearly 35% of the residents in the post PSDA cohort had an advance directive documented in the medical record. Most residents with advance directives had completed them more than 6 months before the nursing home admission. The major effect of the PSDA for nursing homes has been to enhance the documentation of existing advance directives. Little evidence exists that providing advance directive information at the time of nursing home admission has enhanced the completion of an advance directive after admission.

Advance Care Planning↗
PubMed1983

The privilege study.

We evaluated the impact of the Texas limited privilege statute, enacted in 1979, through a questionnaire study of 121 lay persons, 79 patients receiving psychiatric outpatient treatment, and 84 psychiatrists. An almost equal percentage of lay persons and patients knew or guessed correctly that the statute existed (26% v 27%), but only 45% of the psychiatrists knew or guessed correctly that it had been enacted. Lay persons indicated that they might disclose more to a psychiatrist or psychologist if they had statutory protection, but only a few of the patients said they would have sought treatment earlier or would have disclosed more had they known of a privilege statute. Patients reported that they relied more heavily on their psychiatrists' ethics than on the statute to protect their privacy.

Adolescent↗