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PubMed2000

Reefer madness: legal & moral issues surrounding the medical prescription of marijuana.

California, Arizona, and several other states have recently legalized medical marijuana. My goal in this paper is to demonstrate that even if one grants the opponents of legalization many of their contentious assumptions, the federal government is still obligated to take several specific steps toward the legalization of medical marijuana. I defend this claim against a variety of objections, including the claims: that marijuana is unsafe, that marijuana cannot be adequately tested or produced as a drug, that the availability of synthetic THC makes marijuana superfluous, and especially that legalizing medical marijuana will increase recreational use by 'sending the wrong message.' I then go on to argue that given the intransigent position of the federal government on this issue, state governments are justified in unilaterally legalizing medical marijuana as an act of civil disobedience. A large portion of this paper consists of an extensive response to the objection that legalizing medical marijuana will 'send the wrong message'--which I take to be the primary impediment to legalization. This objection basically claims that the consequences of withholding legalization (especially preventing increased recreational use) are superior to those of legalizing medical marijuana. I argue that legalization is justified even if one were to grant both that the harms of legalization outweighed its benefits and that utilitarianism is true. This requires a subtle and somewhat extended discussion of utilitarian moral and political theory.

Cannabis↗
PubMedDate not supplied

After the slippery slope: Dutch experiences on regulating active euthanasia.

"When a country legalizes active euthanasia, it puts itself on a slippery slope from where it may well go further downward." If true, this is a forceful argument in the battle of those who try to prevent euthanasia from becoming legal. The force of any slippery slope argument, however, is by definition limited by its reference to future developments which cannot empirically be sustained. Experience in the Netherlands--where a law regulating active euthanasia was accepted in April 2001--may shed light on the strengths as well as the weaknesses of the slippery slope argument in the context of the euthanasia debate. This paper consists of three parts. First, it clarifies the Dutch legislation on euthanasia and explains the cultural context in which it originated. Second, it looks at the argument of the slippery slope. A logical and an empirical version are distinguished, and the latter, though philosophically less interesting, proves to be most relevant in the discussion on euthanasia. Thirdly, it addresses the question whether Dutch experiences in the process of legalizing euthanasia justify the fear of the slippery slope. The conclusion is that Dutch experiences justify some caution.

Empirical Research↗
PubMed2005

[Legal involvement in psychiatric care].

In an amendment to the law regarding the treatment of the Mental Health patient in 1991, authority was given to the regional psychiatrists' committee to oversee compulsory orders for psychiatric hospitalization and compulsory orders for outpatient psychiatric treatment--and the extension of these orders. On 1st of June 2002 a pilot study was started in the Jerusalem region, in which mental health patients were to be represented by lawyers employed by the Ministry of Justice. The pilot study began as an initiative of the Ministry of Justice, in agreement with the Ministry of Health. We describe 3 cases which demonstrate that the procedure of legal representation lacks the necessary balance between medical and legal considerations. The decision of the regional psychiatrists' committee or the court is liable to worsen the patients' mental health status and even to accelerate aggression towards self or others. In rare cases a premature discharge based on legal considerations rather than medical evaluation may result in suicide, as demonstrated in one of the vignettes. The article discusses the unbalanced approach of legal versus medical consideration, preference of "liberty" over health and the "wish" of the patient rather than his well-being. The article considers the unbalanced approach of the legal system to appeals of therapists against the decision of the regional psychiatrists' committee, where prosecutors of the state decided an appeal of this kind over the staff treating the patient has no precedence. That was presented as justification that it should be rejected. A pilot study compared between patients discharged from compulsory hospitalization through regional psychiatrists' committee or court and patients discharged on a medical basis without legal interference. The study showed a shorter stay in the community in the first group (42%) compared to 75% stay in the community in the second group, after six months. We are of the opinion that the current provision of legal assistance is lacking the necessary balance between medical and legal considerations; the 'wish for freedom' as a default, although illogical, is within the new system of legal aid, and is more considerate and important than the 'best interests' of the patient and his health.

Hospitalization↗
PubMed1996

Opinions of Dutch dentists on the introduction of new legislation in the field of informed consent. A pilot study.

This article describes the results of four group discussions held with 34 Dutch dentists to examine their opinion on the introduction of new legislation in the field of some patient rights, particularly the duty to inform patients and the patient's authorization of a dental treatment procedure. From all the discussions it appears that most are ignorant of the contents of the legislation. A number of important consequences for the practice are mentioned. Amongst the negative consequences which are often named are: loss of income, a greater time investment per patient, the selection of patients, more insurance claims and an increase in administration and keeping dossiers. The positive remarks that emerge are working with protocols, an increase in the quality of care and a better education of the patient. The discussion draws attention to the legal framework of the dentist-patient relationship, although it is not yet clear how certain aspects will take shape in the daily dental practice.

Adult↗
PubMed1988

The right to refuse treatment with antipsychotic medications: retrospect and prospect.

The right to refuse antipsychotic medication is now more than a decade old. Its evolution has taken divergent forms, driven either by the needs of patients' treatment or the mandate of patients' rights. Regardless of the model employed, refusal is not uncommon, but refusing patients appear almost always to receive treatment in the end. These findings point up the essential illogic of allowing committed persons to refuse treatment that would permit their freedom to be restored. The future evolution of the right may proceed differently in federal and state courts, but whether at the level of legal theory or actual practice, some accommodation will restore the equivalence between the power to commit and the power to treat.

Commitment of Persons with Psychiatric Disorders↗
PubMedDate not supplied

Prehospital do-not-resuscitate orders: a survey of state policies in the United States.

INTRODUCTION: Many states in the United States have developed policies that enable prehospital emergency medical services (EMS) providers to withhold cardiopulmonary resuscitation (CPR) in the terminally ill. Several states also have policies that enable the implementation of do-not-resuscitate (DNR) orders. OBJECTIVES: 1) assess which states have statutes governing DNR orders for the prehospital setting; 2) determine which states authorize DNR orders in ways other than by specific state statue; and 3) define those states that had regional protocols which address prehospital DNR orders. METHODS: Survey of the state EMS directors in each of the 50 U.S. states, the District of Columbia, and Puerto Rico. RESULTS: As of 1992, specific legislation authorizing the implementation of DNR orders was in place in 11 states. In addition, six others have a legal opinion or policy allowing the implementation of DNR orders. Fourteen additional states have either working groups or legislation pending that address prehospital DNR orders. In only five were there no existing regional protocols for implementation of DNR orders in the prehospital setting. CONCLUSIONS: There exists great variation in legal authorization by states for implementation of DNR orders in the prehospital setting. Despite the existence of enabling legislation, many state, regional, or local EMS systems have implemented policies dealing with DNR orders.

Emergency Medical Services↗
PubMed2002

Clinical issues on consent: some philosophical concerns.

On occasions, laws on consent are subject to modification, largely on account of being subject to common law rather than statute-for example, in the UK. Guideline publications such as the UK Department of Health Reference Guide to Consent for Examination or Treatment are intended to provide information for clinicians on when and how to apply current laws in everyday clinical situations. While the extent to which guidelines influence clinician behaviour depends on how much they are read and followed, what is also relevant, and sometimes omitted from consideration, is discussion about underlying philosophical concepts. This paper analyses philosophical weaknesses relating to English laws on consent, the main focus of attention being applied ethics and the rights of adults with incapacity. It draws comparisons between the US and the UK, and advocates changes in English law in order to help rectify weaknesses in patient protection. Discussion includes references to Scottish law, and the use of advance directives, and it voices concerns about over-reliance on "best interests" determinations. The problem is partly one of logical analysis, and what can happen is that best interests determinations fail to show proper respect for adults lacking the capacity to consent to examination or treatment on their own behalf. This is fundamentally a matter of rights, and requires further investigation and appropriate legal remedies in order to respond to ethical deficiencies in English law as it now stands.

Adult↗
PubMed1996

Confidentiality in group psychotherapy: empirical findings and the law.

Empirical research suggests that group therapists generally discuss with prospective clients the importance of maintaining confidentiality, but are unlikely to inform them of the significant potential for violations of confidentiality. Therapists believe information about the risk of unauthorized disclosures will reduce the number of patients willing to enter group therapy and will inhibit the therapeutic dialogue. Therapists' failure to provide information sufficient to obtain informed consent, however, produces serious ethical problems and potential legal problems as well. The law of informed consent varies in different jurisdictions such that identical factual scenarios could produce different legal outcomes depending on the jurisdiction in which the case occurs. In spite of the proliferation of group interventions, empirical studies of confidentiality in group therapy have lagged behind similar research in individual psychotherapy.

Confidentiality↗
PubMed2005

Attitudes toward palliative care, conceptions of euthanasia and opinions about its legalization among French physicians.

We assume that actors of the professionalization process of palliative care make a special effort to demarcate it from euthanasia, and that such an effort has a significant impact on beliefs and attitudes toward euthanasia among the whole medical profession. We investigated concurrently attitudes toward palliative care, conceptions of euthanasia and opinion toward its legalization among a sample of 883 French general practitioners, oncologists and neurologists. We found four contrasted profiles of attitudes toward palliative care, which were closely correlated with being in touch with palliative care providers. Attitudes toward palliative care were closely correlated with beliefs about which medical practices should be labelled euthanasia, and these beliefs were in turn strongly associated with opinions toward euthanasia legalization. Our results suggest that the relationship between palliative care and euthanasia mixes semantic and strategic aspects, beyond cognitive and conative ones.

Adult↗
PubMed2003

Parental consent and adolescent risk behavior research.

PURPOSE: To identify methodological issues related to the use of active or passive parental consent in school-based research on adolescent risk behavior research and to propose recommendations consistent with current legal and ethical standards in the United States. METHODS: Review and synthesis of the professional literature related to adolescents and parental consent, federal regulations and guidelines in the United States, and the author's experience presenting these arguments and issues to institutional review boards and funding agencies for over 10 years. FINDINGS: The procedures used for parental consent affect a study's participation rates, costs, and selection bias. When active parental consent is required, parental permission is typically obtained for only 30%-60% of students, compared to 93%-100% when passive consent is used. Extensive follow-up may result in 55%-100% of parents giving permission, but at significant cost (typically $20-$25 per student). Active consent results in the exclusion of minorities, students having problems in school, and students already engaged in or at risk for problem behaviors. Strong methodological reasons were identified for using passive parental consent procedures when possible. Current federal regulations include four areas for possible waiver or alterations in parental consent procedures, including the use of passive parental consent. CONCLUSIONS: Health researchers must understand the methodological, legal, and ethical issues related to parental consent to produce high-quality, valid research about adolescents and to provide evidence for laws, policies, and regulations.

Adolescent↗
PubMed2000

Opinions and reactions of physicians in New Jersey regarding the Oregon Death with Dignity Act.

Physician-assisted suicide (PAS) was legalized in Oregon in 1997. In the study reported here, the authors surveyed a sample of New Jersey physicians with regard to Oregon's Death with Dignity Act and to whether similar legislation should be enacted in New Jersey. A 49-item questionnaire was sent to 563 physicians in New Jersey who were licensed in the specialties of family practice, internal medicine, surgery, psychiatry, and obstetrics/gynecology. The questionnaire contained sections pertaining to demographics, physicians' attitudes regarding PAS, and physicians' opinions on Oregon's Death with Dignity Act. A brief summary of the legislation was included in the mailing, which participants were asked to read before completing the questionnaire. Of the 191 physicians who responded to the survey, 55% agreed with legislation that would legalize PAS, and 59% said that a law similar to that enacted in Oregon should exist in New Jersey. However, only 47% of respondents indicated that they believed PAS to be consistent with the role of a physician to relieve pain and suffering. Slightly more than half of respondents indicated that they would refuse to participate in PAS and were concerned about issues such as professional and personal liability and the potential for abuse. Physicians in New Jersey will require additional information, education, and discussion of the ethical and legal implications of PAS before a law similar to that in Oregon could be proposed or considered.

Aged↗
PubMed2000

Doctors on tribunals. A confusion of roles.

BACKGROUND: Mental health review tribunals are required to apply legal criteria within a clinical context. This can create tensions within both law and psychiatry. AIMS: To examine the role of the medical member of the tribunal as a possible mediator between the two disciplines. METHOD: Observation of tribunal hearings and panel deliberations and interviews with tribunal members were used to describe the role of the medical member. RESULTS: The dual roles imposed on the medical member as witness and decision-maker and as doctor and legal actor create formal demands and ethical conflicts that are hard, in practice, either to meet or to resolve. CONCLUSIONS: The structure for providing tribunals with access to expert psychiatric input and advice requires reconsideration.

Commitment of Persons with Psychiatric Disorders↗
PubMed2002

The Chabot case: analysis and account of Dutch perspectives.

The aims of this essay are twofold: to point out the main problems of the Chabot precedent and to report the findings of a fieldwork in the Netherlands during which some experts were asked to voice an opinion regarding the psychiatrist's conduct and the legal precedent. During the summer of 1999, twenty-eight interviews with some of the leading authorities on the euthanasia policy were conducted in the Netherlands. Multiple reasons were mentioned to either condone or condemn Chabot's practice.

Attitude↗
PubMed1992

Reporting alcohol-impaired drivers: results from a national survey of emergency physicians.

STUDY OBJECTIVE: The purpose of this exploratory study was to learn of physicians' opinions on mandatory reporting of alcohol-impaired drivers they encounter in the course of their clinical work to the police or authorities from the Division of Motor Vehicles. DESIGN AND PARTICIPANTS: Two thousand four hundred sixty-four physicians randomly selected from the American College of Emergency Physicians were sent an anonymous, one-time only, self-administered questionnaire seeking demographic information and assessing attitudes toward mandatory reporting and alcohol treatment. MEASUREMENTS AND MAIN RESULTS: One thousand fifty-five physicians returned the survey. Seventy-eight percent of respondents agreed with mandatory reporting. More than half expressed strong agreement. Through canonical discriminant analysis we are able to identify the complex factors influencing attitude toward mandatory reporting. CONCLUSION: Although our preliminary results must be interpreted with caution, it appears that with the appropriate legal safeguards, physicians are supportive of mandatory reporting of the alcohol-impaired driver encountered in the course of clinical work.

Adult↗
PubMed1991

Decision making in psychiatric civil commitment: an experimental analysis.

OBJECTIVE: Legislation in Canada and the United States that was intended to decrease the use of civil commitment has resulted in a paradoxical increase in involuntary hospital admissions. To elucidate the reasons for this increase, this study was designed to assess the relative importance of various factors involved in the decision to commit a patient. METHOD: All psychiatrists in Ontario were sent a questionnaire asking them to make commitment decisions based on hypothetical case vignettes. Four factors were systematically varied in the vignettes: the patients' legal commitability, clinical treatability, alternative resources, and psychotic symptoms. Completed questionnaires, with three vignettes each, were returned by 495 respondents. RESULTS: All four variables were statistically significant in the expected direction; legal commitability (i.e., dangerousness to self and/or others, inability to care for self) and presence of psychotic symptoms accounted for the majority of the variance in the final decision to commit. CONCLUSIONS: These results suggest that psychiatrists in Ontario rely primarily on legally mandated factors (i.e., psychosis and dangerousness) in making their decisions to commit, although a considerable amount of individual variation is also evident.

Adult↗