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[Contribution of the Italian Society of Occupational Medicine and Industrial Health to the formulation of the EEC Directives].
There are some problems in medico-legal approach and law interpretation about AIDS. The European Community has developed a wide program for health protection at workplace, giving Directives containing interesting starting points for AIDS prevention. The author discusses the main rules to be applied in regulations and specific procedures, and stresses the contribution of the Italian Society of Occupational Medicine and Industrial Hygiene to the formulation of these Directives.
[AIDS help--evaluation of a public health movement].
The "AIDS-Hilfe" movement-more than 80 local groups are presently united in the Federal German organization of the "Deutsche AIDS-Hilfe e. V." -looks back at a more than five years of experience in the fields of prevention for different target groups, counselling, care, PR-work and representation of interests. Central point of the concept of prevention of "AIDS-Hilfe" is the unprejudiced acceptance of people with HIV/AIDS and people at risk: homosexuals, i. v. drug users, prison inmates, haemophiliacs, and people who are not monogamous. A promising AIDS prevention is confronted by various difficulties: there are waves of hysteria, there is a lack of grants from Federal funds, there is moralizing instead of taking effective measures in health policy, there is a tendency to bureaucratize, there is a restrictive legal approach to the problems of AIDS, etc. In contrast to the good results prevention has already achieved in the group of homosexual men, is a farreaching ignorance and inhumanity on the part of political and administrative authorities in matters of drug use and imprisonment. The paradigm of abstinence is responsible for i. v. drug users to contract AIDS, because low-threshold measures, such as needle-exchange programmes and drug-substitution programmes, are refused. To remind the public this fact constantly and to fight for it will be a major concern of the "AIDS-Hilfe" movement. It must always be borne in mind that "principles" are secondary and that human beings must come first.
The psychological impact of disability and illness on medical treatment decisionmaking.
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Investigators' and judges' opinions about civil commitment.
As part of our work with the Oregon Task Force on Civil Commitment, we surveyed the judges and commitment investigators involved in the state's involuntary treatment program. In Oregon the investigators recommend whether or not a commitment hearing should be held. These mental health professionals indicated that current confidentiality laws restrict their access to important information. The investigators also expressed concern about the lack of resources with which to divert clients out of the commitment system. Judges too felt that relaxing the rules of evidence would improve the quality of commitment hearings. Regarding changes in the system, investigators and judges indicated that outpatient treatment (including compliance with medications) should be required of committed patients. These professionals noted that involuntary outpatient treatment could only be enforced if the system included a mechanism for hospitalizing patients who were noncompliant. Although the investigators believed commitment criteria should be broadened so that their clients could receive treatment before becoming dangerous, judges did not generally endorse this view. We discuss the implications of these findings for new civil commitment legislation.
The impact of the right to refuse treatment in a forensic patient population: six-month review.
In December of 1987, the Wisconsin supreme court held that all involuntarily committed mental patients in the state had the right to refuse psychotropic medication unless a court held that they were incompetent to make treatment decisions. The authors studied the effects of this decision in a 165-bed forensic hospital over the first six months after implementation of the decision. They found that 29 percent of patients already on psychotropic medication initially refused further treatment as opposed to 75 percent of newly admitted patients. Of refusers, 32 percent eventually resumed taking medication voluntarily; courts overturned the refusals of all the 51 percent who maintained their refusals, after an average delay of over a month. The length of procedural delays actually increased over the six months of the study as the courts learned of the decision. The authors compare their findings with other reported studies of implementation of right to refuse treatment decisions and discuss differences between the right to refuse treatment for civilly and criminally committed patients.
Perceptions of ethical problems by forensic psychiatrists.
A survey was undertaken of the opinions of two groups of forensic psychiatrists to determine their views regarding forensic ethical issues. Although AAPL has made significant strides for our profession by adopting ethical guidelines, some important issues have not yet been addressed, as revealed by our survey. Included were items heretofore considered too "controversial" for incorporation into guidelines, as well as items from the APA ethical framework. All APA items were evaluated as addressing ethical problems. The majority of respondents also viewed most of the "controversial" items as confronting relevant ethical problems, thereby suggesting their inclusion, in some form, in the profession's guidelines. They also appeared to favor retention of many traditional medical ethical values when functioning as a forensic psychiatrist. Clear selective discrimination existed among differing death penalty facets. Since AAPL at present does not wish to conduct its own ethics hearings, the AAPL guidelines as well as the items supported in this paper's survey would best be translated into a form consistent with the APA framework. In this way, AAPL's guidelines and also the new suggested items could readily be coordinated within the APA framework and could play a role in the APA local district branch enforcement process.
Current status of institutionalized mental health patients' right to refuse psychotropic drugs.
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Evaluation of the physicians' obligation to provide information in Denmark.
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Controversial ethical issues in forensic psychiatry: a survey.
A survey was conducted of members of the Psychiatry and Behavioral Science section of the American Academy of Forensic Sciences (AAFS) to determine their ethical concerns about controversial items. Issues were included in the survey from the American Psychiatric Association (APA) and AAFS Code of Ethics. Strong support was found for those issues. Some AAPL items from a previous version of their guidelines did not receive support. Fortunately, they have been modified in a later AAPL draft, after AAPL received this survey's results. Clarification was obtained on some ambiguous items from a previous AAFS survey. The present survey showed strong support for addressing in forensic psychiatry's ethical guidelines some issues previously considered too controversial.
Treatment refusal among forensic inpatients.
Although the United States Supreme Court has not offered a definite opinion, some states have established the qualified right of involuntarily committed patients to refuse treatment. Controversy continues between psychiatry and law over what procedural protections should be provided to patients when therapists seek to override nonemergency refusal of treatment. The authors review Oregon's administrative approach and its application to the treatment refusal of 33 state hospital forensic patients. Patient characteristics, refusal patterns, and implications of treatment refusal are also described.
U.S. physicians' perceptions of malpractice liability factors in aggressive treatment of dying patients.
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A methodology for predicting the effects of changes in civil commitment decision making.
We review a three-step civil commitment model and formulas for calculating the probability of release from commitment and the relative importance of the three steps in determining the outcome. New formulas are developed which enable predictions to be made about the effects of changes on the outcome of the three steps on the release probability. With the use of data from Oregon's civil commitment process, we present an example of the application of the methodology and conclude with a discussion of its major administrative and research implications.
The current status of medical malpractice countersuits.
The dramatic growth of medical malpractice litigation in recent decades has contributed significantly to an overall increase in health care costs in this country. Although lawmakers, physicians, and other responsible citizens have proposed numerous solutions in an effort to curb the crisis, these proposals have generally been ineffective. In this Article the Author endorses countersuits as the most appropriate response to frivolous medical malpractice actions. The Author also suggests that contingent fee systems, coupled with the economic motivation of private insurers to settle claims quickly, provide incentive for plaintiffs to initiate frivolous claims. This Article analyzes the general legal approaches available for countersuits, emphasizing recent successful actions based on malicious prosecution and abuse of process, and proposes more widespread use of these approaches.
The interface of medicine, religion, and the law: religious objections to medical treatment.
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Medicolegal causation: a source of professional misunderstanding.
The authors of this Comment--a lawyer and a physician--suggest that most physicians who are called upon to testify concerning medical issues in personal injury litigation do not understand that judges and attorneys view "causation" quite differently than do members of the medical community. For example, medical practitioners tend to be concerned with all possible causes of the patient's current medical condition, whereas legal practitioners in personal injury cases generally focus on a particular event as possibly precipitating, hastening, or aggravating a particular aspect of the patient's condition to the extent that the event in question is, in legal language, the "proximate cause" of an injurious result. The authors summarize and analyze the differences--and the occasional similarities--between the medical and the legal approaches to causation, in the hope that they will thereby (1) contribute to greater understanding by the two professions of each other's theory and practice, and (2) help the expert medical witness to be more comfortable and more effective in his courtroom role.
Legislation and practice in compulsory admission to a psychiatric hospital.
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