"What do you Mean I Cannot Consent For My Grandmother's Medical Procedure?": Key Issues With State Default Surrogate Decision Making Laws

When a patient is unable to make medical decisions, a health care surrogate must be designated to make decisions on the patient's behalf. Studies show that fewer than 20% of patients have completed health care representative forms to legally designate a surrogate. Without a prior designation, surrogates are determined via state statute. Currently, there is no up-to-date comprehensive evaluation of state surrogate legislation. A survey of state legislative codes was conducted to determine: 1) whether the state has a default surrogate statute; 2) who is included as an acceptable legal surrogate; and 3) whether there is a hierarchy to determine a final decision-maker. Currently, 36 states have enacted some form of surrogate statute. There is little consistency between states regarding who may serve as a surrogate decision- maker. The key challenges with state laws include: 1) a narrow list of persons who qualify as allowable legal surrogates; and 2) a lack of a hierarchy to determine a final decision-maker. The results of this survey show that state surrogate decision making laws have many flaws which could affect patient care. The narrow construction of state laws can leave patients in situations where they either have no qualified surrogate under the law, or where they have multiple surrogates with competing interests who may be unable to reach consensus on the patient's medical care. State laws need to be changed so that they accurately reflect the realities of clinical practice and expanded to allow a broader spectrum of potential surrogates

Report from the pandemic influenza project: expert panel meetings

This report was prepared by the Indiana University Center for Bioethics under contract with the Indiana State Department of Health as a part of the project “Translating Ethics Advice into Practice: Public and Professional Outreach about Pandemic Influenza Planning in Indiana.” The views expressed in this document are those of the authors and may not necessarily reflect the opinions of the Center for Bioethics, Indiana University, or the Indiana State Department of Health.The Indiana University Center for Bioethics convened expert panels for each of the four topics of the Technical Advisory Documents (TADs): altered standards of care, triage, vaccine and antiviral allocation, and healthcare workforce management. The goal of each meeting was to assess the relevance and applicability of the recommendations put forth by the TADs. Participants were encouraged to apply the seven ethical points and assess the feasibility of the recommendations by examining case studies intended to portray real world ethical dilemmas. Engagement from the public was critical for each panel to learn the full ethical and social implications of pandemic influenza preparedness and planning.Indiana University Center for Bioethics; Indiana State Department of Healt

The development of vocabulary exercises to accompany social studies textbooks in the intermediate grades.

Thesis (Ed.M.)--Boston Universit

A Conscience Sensitive Approach To Ethics and Teaching Caring Attitudes

An I.U. Conscience Project and HELP Collaboration. The article describes models for teaching ethics and caring attitudes to undergraduate medical students in both formal and informal medical education curriculum. Competency based curriculum is discussed

Conscience Sensitive Medical Education

Medicine is a moral enterprise, and young people who enter professional school are presumed to be morally astute, as well as intellectually capable. Thoughtful students quickly grasp the fact that what we can do in medicine usually outpaces the consensus of what we ought to do, and one of the earliest questions these students ask is how they should go about honoring their individual consciences in the face of patients, peers or teachers who profess divergent values, or request services that jar the young professional’s sense of ought-ness. Medical educators readily acknowledge the need, indeed the moral requirement, to teach ethics, but struggle to ascertain the most effective, efficient and compelling way to present the material and engage the moral reasoning of students who are already inundated with basic and advanced science studies (Self & Baldwin, 1994). Students appreciate hearing about case stories, but do not want much in the way of philosophical theory. Most students at our institution have backgrounds in biology or chemistry; few have taken any courses in literature, philosophy, religion, ethics or other humanities. The handful of lectures and small-group case-based discussions related to ethical dilemmas in medicine offered in the curriculum are helpful, but often fail to prepare the young physician adequately for a life in which moral questions daily will present themselves. We are piloting an approach to moral teaching in medicine based on an examination of conscience formation and functioning, and the understanding of the intersection of personal conscience with professional medical and ethical values. We believe that conscience theory and language may be a useful addition to the traditional approaches to dilemma resolution that involve principles, theories, and case based reasoning. In this paper we will explore traditional ethical resolution methods, give a brief history and overview of Conscience Theory, and then show through case example how using Conscience Theory may allow a richer examination of the most poignant and troubling dilemmas physicians face

Progress in conscience-sensitive psychiatry: assessment, diagnosis and treatment planning

Study of the relationship between episodic or continuous moral malfunctioning and psychopathology is an undeveloped field in child and adolescent psychiatry. An empirically derived theory of conscience provides a normative base from which to launch such studies. This work reviews five normative stages of functioning within five domains of conscience: conceptualization, moralization of attachment, moral-emotional responsiveness, moral valuation, and moral volition. Current professional guidelines for the doctor-patient relationship, psychiatric assessment, diagnostic categorization, and treatment planning address conscience functioning sometimes directly, sometimes indirectly, and sometimes not at all. A case report is provided to illustrate progress already made in conscience sensitive clinical psychiatry. Further advances may begin with consideration of proposed hypothetical models, comporting with recent research, which describe progressive impairment involving both delay and deviancy in conscience functioning

Preliminary Observations and Reflections on Conscience Sensitive Group Therapy

Objective: This is the first in a series of articles to characterize and critically consider recently employed forms of conscience sensitive psychiatric treatment of children and adolescents. Method: Modules were designed based upon domains of conscience functioning identified in empirical research and applied to recognized benchmarks for interventions in the treatment of psychopathology. Each module was designed to be sufficiently complete such that full participation from persons entering the cycle of modules at any point would not be compromised. One of the authors paired with interested, experienced therapists in existing programs to conduct and refine interventions in a group psycho-educational therapy format. Results: Over one hundred and fifty hours of conscience sensitive psycho-educational group therapy were conducted in therapeutic loci within a well-established, community-based continuum of care. The therapeutic loci ranged from a child and adolescent psychiatry outpatient clinic to a closed youth residential setting and included adolescent psychiatric intensive outpatient and partial hospitalization programs. Number of participants in any module varied from one in the outpatient locus to fifteen in the intensive outpatient locus. Age of participants varied from school age to late adolescent. Formal intellectual testing was not uniformly available for participants. Most however appeared to be average intellectually. Each participant had, at minimum, an initial assessment by a mental health clinician yielding a DSM IV multiaxial psychiatric diagnosis. No restrictions were placed upon participants in terms of principal or secondary diagnoses or severity of impairment although all had sufficiently severe impairment to be deemed in need of the aforementioned current and standard psychiatric or psychosocial interventions. Length of time for each of the seven modules was permitted to vary according to the stability of the participant population. Individual modules conducted in the adolescent psychiatric intensive outpatient program were limited to one hour each, whereas some modules conducted in the residential and youth day school settings extended over several sessions held once weekly. Seven modules were eventually developed and refined to comprise a full course of conscience sensitive psycho-educational group therapy. Conclusions: Each of the seven modules in its current stage of development and refinement is characterized in terms of praxis, but also considered critically in terms of treatment philosophy. Conscience sensitive group psycho-educational therapy can be conducted in child adolescent psychiatric therapeutic loci ranging from outpatient to closed residential programs. Constraining variables were encountered in the adolescent intensive outpatient program when census became large, and turnover rapid, in consequence of which the full cycle of seven modules conducted at a frequency of one per week could not be completed by many participants. This could be remedied by conducting sessions more frequently, perhaps two to three times per week, and offering a sufficient number of groups to ensure that the number of participants in each group does not exceed eight. In the outpatient setting, there were fewer referrals than had been hoped, perhaps because of limitations upon reimbursement for the total number and/or kind of therapeutic interventions, a condition which, in the local mental health community, favors individual psychotherapy over group psychotherapy. However, the possibility cannot be excluded that there have been referral biases or parental preferences in favor of groups with a more readily recognizable focus such as anger management or social skills over a novel, less familiar approach

The effect of a state health care consent law on patient care in hospitals: A survey of physicians

Objective: When a patient cannot make medical decisions for him or herself, and has not appointed a healthcare representative, default state healthcare consent laws determine who is able to make healthcare decisions for the patient. The narrow construction of some state laws leaves many patients in situations where the closest person to the patient does not qualify as a representative under the law, or where the patient has too many representatives and a consensus cannot be reached on the patient’s medical care. Methods: In order to determine how state healthcare consent laws affect patient care in hospitals, a survey of 412 Indiana physicians was conducted. Results: The data shows 53.8% of physicians experienced a delay in patient care because they were unable to identify a legally appropriate health care representative. Almost half (46.01%) of physicians experienced delay of patient care due to the inability to identify a final decision maker when disputes arose between multiple legal representatives. Conclusions: The results of this study have important implications for hospital administrators as a delay in patient care can be costly and unnecessarily utilizes hospital resources. Additionally, the results of this study have important implications for the status of state surrogate decision making laws. Amending state laws to include more potential surrogates, has the potential to minimize delays in patient care and ensure that appropriate surrogates are making medical care decisions for patients without the undue burden of court intervention

AGING, RETIREMENT, AND PAY-AS-YOU-GO PENSIONS

In this paper, we consider the effects of population aging on a pay-as-you-go financed defined contributions pension scheme. We show that when retirement decisions are endogenous, aging increases the retirement age and the steady-state level of capital. The effect on pension payouts is in general ambiguous, except for the solution of full retirement, when this effect is unambiguously negative