The right to refuse treatment in Oregon: A two-year statewide experience

The right to refuse treatment seems well established for psychiatric patients. Individual states, however, have very different procedures for managing this right and for overriding the refusal. Oregon's administrative procedure for override depends on an evaluation by an independent examining psychiatrist. This article empirically examines the 432 refusals leading to override requests in three Oregon psychiatric institutions in 1983 and 1984. Treatment refusal was found to be a common occurrence in all age groups. Those who refused treatment were seriously ill, unemployed, single individuals with previous psychiatric hospitalizations. Most refused treatment because of denial of their illness or delusional thinking about medication. Most refusals were overridden following the independent psychiatrist's examination. Because of the significant cost of the override procedure to the patient and the mental health system, the authors propose a new procedure which combines parts of the current procedure with a requirement that, at the time of the civil commitment hearing, the judge makes a separate decision as to the patient's competency to make treatment decisions.     

The right to refuse treatment: Paradox,pendulum and the quality of care

This clinical and theoretical overview of the right to refuse treatment will address some of the themes that have dominated this area of interface between psychiatry and the law, and have, perhaps, obscured the real concern of the right to refuse treatment question; i.e., the issue of quality of care. Central themes include factors present in the medicolegal context and recent events, origin of the concept of the right to treatment, the separation of confinement from treatment, and the changing models of vicarious decision making. This review also addresses judicial conceptualizations of treatment, including the concept of quarantine, judicial risk-aversiveness, and judicial fantasies of drug action. Some possible directions for the future are also examined.     

Capacity to consent to or refuse treatment and/or research: theoretical considerations

This article discusses theoretical dimensions of competency to consent to or refuse treatment and/or research. We will consider a number of issues. Our first subject is the nature of assessments of competency-their empirical, normative, and conceptual aspects. We then discuss how we should divide up the components of capacity-understanding, appreciation, reasoning, and evidencing a choice; how we should understand these different components; and whether all are indeed necessary. We discuss where to draw the line between capacity and incapacity on each of the four elements of capacity. We ask whether we should have a variable competency standard, either in general or in different contexts (e.g. treatment versus research). Finally we consider the role of mental illness in competency assessments.     

Legal implications for failure to comply with advance directives: an examination of the incompetent individual's right to refuse life-sustaining medical treatment

Life-sustaining medical technology in the past century has created a growing body of case law and legislation recognizing the incompetent individual's right to make his or her own end-of-life decisions. This article focuses on California's leadership in the area of these specific end-of-life issues: specifically, exploring the right of an incompetent individual to refuse life-sustaining medical treatment. The article examines advance directives along with various judicial decision-making standards for incompetent individuals and explores the sociobehavioral and legal rationale for compliance with incompetent individual's rights to make end-of-life decisions. Finally this article concludes (i) that advance directives allow competent individuals to state the medical treatment they would prefer in the event they should later become incompetent and (ii) that when advance directives are properly executed in a detailed manner, under laws currently in effect in some jurisdictions, the preferences stated in the directive bind health care providers.     

The right to withdraw from research

The right to withdraw from participation in research is recognized in virtually all national and international guidelines for research on human subjects. It is therefore surprising that there has been little justification for that right in the literature. We argue that the right to withdraw should protect research participants from information imbalance, inability to hedge, inherent uncertainty, and untoward bodily invasion, and it serves to bolster public trust in the research enterprise. Although this argument is not radical, it provides a useful way to determine how the right should be applied in various cases.     

The right to effective behavioral treatment

WE PROPOSE THAT INDIVIDUALS WHO ARE RECIPIENTS OR POTENTIAL RECIPIENTS OF TREATMENT DESIGNED TO CHANGE THEIR BEHAVIOR HAVE THE RIGHT TO: (1) a therapeutic environment, (2) services whose overriding goal is personal welfare, (3) treatment by a competent behavior analyst, (4) programs that teach functional skills, (5) behavioral assessment and ongoing evaluation, and (6) the most effective treatment procedures available.     

Memory as discrimination: What distraction reveals

Recalling information involves the process of discriminating between relevant and irrelevant information stored in memory. Not infrequently, the relevant information needs to be selected from among a series of related possibilities. This is likely to be particularly problematic when the irrelevant possibilities not only are temporally or contextually appropriate, but also overlap semantically with the target or targets. Here, we investigate the extent to which purely perceptual features that discriminate between irrelevant and target material can be used to overcome the negative impact of contextual and semantic relatedness. Adopting a distraction paradigm, it is demonstrated that when distractors are interleaved with targets presented either visually (Experiment 1) or auditorily (Experiment 2), a within-modality semantic distraction effect occurs; semantically related distractors impact upon recall more than do unrelated distractors. In the semantically related condition, the number of intrusions in recall is reduced, while the number of correctly recalled targets is simultaneously increased by the presence of perceptual cues to relevance (color features in Experiment 1 or speaker’s gender in Experiment 2). However, as is demonstrated in Experiment 3, even presenting semantically related distractors in a language and a sensory modality (spoken Welsh) distinct from that of the targets (visual English) is insufficient to eliminate false recalls completely or to restore correct recall to levels seen with unrelated distractors . Together, the study shows how semantic and nonsemantic discriminability shape patterns of both erroneous and correct recall.     

Moving from cognition to behavior: What the research says

In 1994, R. G. Lord and P. E. Levy proposed a variant of control theory that incorporated human information processing principles. The current article evaluates the empirical evidence for their propositions and updates the theory by considering contemporary research on information processing. Considerable support drawing from diverse literatures was found for propositions concerning the activation of goal-relevant information, the inhibition of goal-irrelevant information, and the consequences of goal completion. These effects were verified by meta-analytic analyses, which also supported the meaningfulness of such effects on the basis of their unstandardized magnitudes. The authors conclude by proposing new directions for this version of control theory by invoking recent theorizing on goal emergence and the importance of velocity and acceleration information for goal striving and by reviewing research in cognitive neuroscience.     

Two-year-old twins refuse to eat: A multidisciplinary approach to diagnosis and treatment

This round table addresses the diagnosis and treatment of feeding disorders and failure to thrive. It describes a family-centered approach by a multidisciplinary feeding disorders team, beginning with the screening evaluation by the team coordinator at intake, through the evaluations by various team members, the team meeting with the parents, the development of a treatment plan, to a 1-year follow-up after treatment. Both twins refused to eat textured food and were found to have a posttraumatic feeding disorder secondary to repeated gagging and choking on cereal and lumpy baby food. However, only one twin was engaged in a battle with the parents over eating and developed infantile anorexia associated with failure to thrive. The differential diagnosis and the specific treatment plans of these two feeding disorders characterized by food refusal are discussed.     

Biobank research and the right to privacy

What is privacy? What does privacy mean in relation to biobanking, in what way do the participants have an interest in privacy, (why) is there a right to privacy, and how should the privacy issue be regulated when it comes to biobank research? A relational view of privacy is argued for in this article, which takes as its basis a general discussion of several concepts of privacy and attempts at grounding privacy rights. In promoting and protecting the rights that participants in biobank research might have to privacy, it is argued that their interests should be related to the specific context of the provision and reception of health care that participation in biobank research is connected with. Rather than just granting participants an exclusive right to or ownership of their health information, which must be waived in order to make biobank research possible, the privacy aspect of health information should be viewed in light of the moral rights and duties that accompany any involvement in a research based system of health services.     

Stories for therapy: The right story to the right person at the right time

In the postmodern information era with its increasing complexity and demands on my time, I find storytelling increasingly attractive. The right story told to the right person(s) at the right time in the right way can powerfully define and shape both individuals and the systems into which they organize themselves. As interventions go, I find stories to be relatively high impact, low-risk, parsimonious, and user-friendly. This paper contains some of my favorite teaching stories and describes why and how I use them as both a family therapist and teacher of family therapy.     

Right of active duty military personnel to refuse psychiatric treatment

Under Federal Court precedents, mentally ill patients have a qualified right to refuse treatment. The amount of due process that may be required to override treatment refusals by active duty military patients is discussed. Due process for these individuals need not be judicial, since medical review satisfies federal requirements. Involuntary administration of medication to active duty military personnel is justified in some circumstances. Specific criteria for overriding treatment refusals are suggested. A sample protocol for overriding the treatment refusals of active duty personnel is offered.     

The organization of thinking: What functional brain imaging reveals about the neuroarchitecture of complex cognition

Recent findings in brain imaging, particularly in fMRI, are beginning to reveal some of the fundamental properties of the organization of the cortical systems that underpin complex cognition. We propose an emerging set of operating principles that govern this organization, characterizing the system as a set of collaborating cortical centers that operate as a large-scale cortical network. Two of the network’s critical features are that it is resource constrained and dynamically configured, with resource constraints and demands dynamically shaping the network topology. The operating principles are embodied in a cognitive neuroarchitecture, 4CAPS, consisting of a number of interacting computational centers that correspond to activating cortical areas. Each 4CAPS center is a hybrid production system, possessing both symbolic and connectionist attributes. We describe 4CAPS models of sentence comprehension, spatial problem solving, and complex multitasking and compare the accounts of these models with brain activation and behavioral results. Finally, we compare 4CAPS with other proposed neuroarchitectures.     

The framing heuristic influences judgements about younger and older adults' decision to refuse medical treatment

Three-hundred and one young adults evaluated medical dilemmas in which a patient (1) was portrayed as either 40 or 70 years old, (2) decided to either refuse or consent to a risky treatment for a serious medical disorder, and (3) received either positively or negatively framed information about the potential effectiveness of a proposed medical treatment. Participants' evaluations of the patients' decisions reflected the implementation of a framing heuristic and an age heuristic. The framing heuristic influenced participants' judgements of patients who refused the proposed treatment. Specifically, information which was positively framed resulted in risk-avoiding judgements, while information which was negatively framed resulted in risk-taking judgements. The age heuristic predisposed participants to recommend that 40 year old patients, more so than 70-year-old patients, opt for high-risk medical treatments that could potentially add a large number of years to their lives.