Legal briefing: The unbefriended: making healthcare decisions for patients without surrogates (Part 1)

This issue's "Legal Briefing" column covers recent legal developments involving medical decision making for unbefriended patients. These patients have neither decision-making capacity nor a reasonably available surrogate to make healthcare decisions on their behalf. This topic has been the subject of recent articles in JCE. It has been the subject of major policy reports. Indeed, caring for the unbefriended has even been described as the "single greatest category of problems" encountered in bioethics consultation. Moreover, the scope of the problem continues to expand, especially with rapid growth in the elderly population and with an increased prevalence of dementia. Unfortunately, most U.S. jurisdictions have failed to adopt effective healthcare decision-making systems or procedures for the unbefriended. "Existing mechanisms to address the issue of decision making for the unbefriended are scant and not uniform". Most providers are "muddling through on an ad hoc basis". Still, over the past several months, a number of state legislatures have finally addressed the issue. These developments and a survey of the current landscape are grouped into the following 14 categories. The first two define the problem of medical decision making for the unbefriended. The remaining 12 categories describe different solutions to the problem. The first six of these solutions are discussed in this article (Part 1). The last eight solutions will be covered in the Summer 2012 issue of JCE (Part 2). 1. Who are the unbefriended? 2. Risks and problems of the unbefriended. 3. Prevention: advance care planning, diligent searching, and careful capacity assessment. 4. Decision-making mechanisms and standards. 5. Emergency exception to informed consent. 6. Expanded default surrogate lists: close friends. 7. Private guardians. 8. Volunteer guardians. 9. Public guardians. 10. Temporary and emergency guardians. 11. Attending physicians. 12. Other clinicians, individuals, and entities. 13. Institutional committees. 14. External committees.     

A Test of the Central Factor in Visual Adaptation

Bull, Nina. The Attitude Theory of Emotion. New York: Nervous and Mental Disease Monographs, 1951. Pp. 159. Reviewed by William E. Galt.     

CRM in Sales-Intensive Organizations: A Review and Future Directions

With the advent of technology enabling greater customer tracking, more robust knowledge management, and direct customer communication, the implementation of customer relationship management (CRM) strategies has grown in importance with many implications for sales-intensive organizations. Implications of CRM strategy, analytical CRM, and operational CRM are discussed, particularly in terms of research opportunities. Although there are, no doubt, many other interesting and worthwhile research opportunities available, the nexus of technology, CRM, and sales-intensive go-tomarket strategies provide myriad opportunities for exciting research.     

The Asceticism Dimension of the Protestant Work Ethic: Shedding Its Status of Invisibility

Asceticism seems an “invisible” Protestant work ethic (PWE) dimension that has largely been ignored in research. This study, building directly on existing knowledge, investigated the possibility that deference to authority was central to asceticism and the possible ethical implications of this. In 3 samples of employed persons, results demonstrated that highly ascetic individuals were highly authoritarian, were low in advanced moral reasoning, and regarded ethically questionable activities benefiting organizations (but not individuals) as relatively acceptable. However, “hard workers,” another PWE dimension, regarded all ethically questionable activities as inappropriate, regardless of the beneficiary, and were less clearly authoritarian. Significant relationships involving the PWE may sometimes be undetectable when combining distinct dimensions, and asceticism merits attention as a distinct PWE component.     

Decision making and testosterone: When the ends justify the means

Behavioral endocrinology research suggests that testosterone may play a role in moral decision making. Studies involving human and nonhuman animals indicate that high basal testosterone is associated with decreased aversion to risk and an increased threshold for conflict, fear, stress, and threat. We tested the role of testosterone in moral decision making. We predicted and found that individuals high in testosterone are more likely to make utilitarian decisions—specifically when doing so involves acts of aggression and social cost.     

Legal briefing: Crisis standards of care and legal protections during disasters and emergencies

This article outlines current safe harbors in the law for healthcare practitioners who work in a disaster setting. It reviews available legal protection in crisis situations with respect to the Emergency Medical Treatment and Labor Act (EMTALA), criminal liability, and licensure.     

Deliberate Microbial Infection Research Reveals Limitations to Current Safety Protections of Healthy Human Subjects

Here we identify approximately 40,000 healthy human volunteers who were intentionally exposed to infectious pathogens in clinical research studies dating from late World War II to the early 2000s. Microbial challenge experiments continue today under contemporary human subject research requirements. In fact, we estimated 4,000 additional volunteers who were experimentally infected between 2010 and the present day. We examine the risks and benefits of these experiments and present areas for improvement in protections of participants with respect to safety. These are the absence of maximum limits to risk and the potential for institutional review boards to include questionable benefits to subjects and society when weighing the risks and benefits of research protocols. The lack of a duty of medical care by physician–investigators to research subjects is likewise of concern. The transparency of microbial challenge experiments and the safety concerns raised in this work may stimulate further dialogue on the risks to participants of human experimentation.