The legal consensus about foregoing life-sustaining treatment: its status and its prospects

The legal consensus that has evolved through adjudication and legislation since the Karen Quinlan case in 1976 is founded on the premise that there is a bright line between passive euthanasia and active euthanasia. Indeed, the term passive euthanasia is often eschewed in favor of less emotionally-laden terminology such as "forgoing life-sustaining treatment" or "terminating life support" so as to further sever any possible connection with active euthanasia. Legal approval has been bestowed upon passive euthanasia under certain circumstances while active euthanasia is routinely condemned. This consensus was put to a test in 1990 when the United States Supreme Court ruled on the Cruzan case. However, the Court's narrow decision did not upset the consensus, and in the most significant appellate decisions handed down by state courts since Cruzan, there has been a reaffirmation--and possibly even an extension--of the consensus. Two other threats to the legal consensus about forgoing life-sustaining treatment have begun to manifest themselves: the increasing pressure for mercy killing and "futility" cases. Both of these challenge the fundamental premises on which the consensus is grounded.     

The influence of affect on self-focused attention: Conceptual and methodological issues

A number of investigators have suggested that affective states influence the focus of attention. One recent proposal is that negative moods increase self-focus. This review considers the evidence that bears on this hypothesis. Conceptual issues pertaining to the construct of self-focus are discussed first. Next, the various parameters that influence attentional focus are presented in order to provide a way of organizing the mood/selffocus literature. Studies that have used state measures of mood and self-focus are considered in this context. Methodological limitations of existing studies are discussed and directions for future work provided.     

Work,leisure, and psychological well-being in a sample of young adults

This study of 20 ‘white-collar’ workers aged 20–30 measured motivation, enjoyment and access to various categories of experience in both work and leisure, and examined their relationship with psychological well-being on a number of dimensions. The method used a short questionnaire, psychological scales and the innovatory ‘experience sampling methodology’ (ESM) where respondents answer questions in a diary on the receipt of a signal from a pre-programmed watch or radio pager eight times a day for 1 week. The results show, in line with other studies, that intrinsic motivation in daily life is correlated with happiness but that, not previously reported, when motivation at work is examined both extrinsic motivation and instances where a person had to do the activity but did not wish to be doing something else, i.e. ‘positive motivational change’, are correlated with positive aspects of psychological well-being, while instances where a person wanted to do the activity but wished to be doing something else, i.e. ‘negative motivational change’, correlated with negative aspects. The results also show that enjoyment in both work and leisure correlates with aspects of psychological wellbeing; and that macro ‘flow’ experiences, where high skills and high challenges are perceived as equal, are enjoyable and interesting and come primarily from work. The study also shows that categories of experience considered important for psychological well-being and deemed to come primarily from work can be obtained in leisure. The results are discussed in the context of person—situation interactions and processes, and it is advocated that these should be studied in a variety of samples.     

Comparison of simultaneous prompting and constant time delay procedures in teaching sight words to elementary students with moderate mental retardation

Simultaneous prompting (a type of antecedent prompt and test procedure) and constant time delay were compared with four students with moderate mental retardation learning expressive sight words. A parallel treatments design across word sets and replicated across students was used. For acquisition, the simultaneous prompting procedures required fewer trials, sessions, and training time to criterion and resulted in fewer student errors during daily probe and training sessions. However, maintenance data indicated mixed results across the two procedures. Reliability data (both dependent and independent variables) revealed no differences between the two procedures in terms of the teacher's accuracy in recording student responses and implementing each procedure. Future research issues are discussed.     

Delayed constructed-response identity matching improves the spelling performance of students with mental retardation

We assessed the effects of a computerized matching-to-sample procedure on the spelling performances of three students with mental retardation. Initially, the students could 1) match pictures and printed words to one another, and 2) match pictures and printed words to spoken words. However, they could not construct words to either pictures or spoken words (e.g., touch, in order, the letters s->h->o->e given the spoken-word sample Shoe). Word constructions then improved markedly after exposure to delayed constructed-response identity matching (e.g., touch the letters s->h->o->e given the printed-word sample shoe). One subject's oral and written spelling also improved. The results extend previous research by showing multiple positive effects of a computerized spelling intervention. These effects may have occurred in part because of the formation of stimulus classes among pictures, printed words, and spoken words.     

Applied behavior analysis and the movement to restructure schools: Compatibilities and opportunities for collaboration

The field of applied behavior analysis has devoted considerable effort to the problem of educating America's youth. In addition to developing a wide range of procedures to improve children's academic and classroom survival skills, behavioral researchers have discussed a wide range of technological characteristics that are likely to facilitate the adoption of their procedures by educational decision-makers and practitioners. A movement to restructure American schools has become highly popularized within educational, political, and public media forums over the past several years. One general characteristic of this movement is its failure to recommend the more frequent implementation of applied behavior analysis techniques to educate America's youth. A close inspection of three global models for school reform, however, reveals notable compatibilities with the focus and goals of applied behavior analysis. Applied behavior analysts can collaborate with and contribute to the school restructuring movement by pursuing the more formal and systematic analyses of characteristics essential to the adoption process.     

Case vignette: premature surrender

Three commentaries are offered on the following case: George, age 57, is a previously healthy man who recently underwent surgery for removal of a low-grade malignant thymoma. At the time of admission to the hospital, George stressed to the staff that he had long ago signed a "living will," which he renewed immediately after he learned of his cancer diagnosis. At the time of surgery, the tumor was found to extend into his mediastinum; although it was removable, this required revision of part of the sternum and grafting of the vessels feeding the heart chambers. Because of the resultant tissue damage and neuronal hyperactivity, George experienced postoperative episodes of cardiac arrhythmia and bronchospasm. Unanimous medical opinion was that this situation was a temporary problem that would resolve itself as the tissues healed. Until that time, however, it will be difficult to wean him from ventilatory support. When his stay in the intensive care unit became prolonged, George and his family began to insist that his status be changed to "do not resuscitate" and reminded the staff about his longstanding living will. All of this is happening despite the fact that the patient and family seemingly comprehend that although the short-term interventions are invasive, there is a high probability of a successful outcome. George's cancer prognosis is excellent, and, although he may well have an episode of life-threatening arrhythmia, he is likely to respond to resuscitation interventions. Once the immediate postoperative period is over, his potential for a long and productive life with full capacities is excellent. Consider the following questions: (a) Should George's expressed wishes be respected, or should the staff take additional steps to help him survive the postoperative period, even if that means violating his stated wishes? and (b) What steps might the staff follow in sorting through this problem?     

Justice and care: The implications of the Kohlberg-Gilligan debate for medical ethics

Carol Gilligan has identified two orientations to moral understanding; the dominant ‘justice orientation’ and the under-valued ‘care orientation’. Based on her discernment of a ‘voice of care’, Gilligan challenges the adequacy of a deontological liberal framework for moral development and moral theory. This paper examines how the orientations of justice and care are played out in medical ethical theory. Specifically, I question whether the medical moral domain is adequately described by the norms of impartiality, universality, and equality that characterize the liberal ideal. My analysis of justice-oriented medical ethics, focuses on the libertarian theory of H.T. Engelhardt and the contractarian theory of R.M. Veatch. I suggest that in the work of E.D. Pellegrino and D.C. Thomasma we find not only a more authentic representation of medical morality but also a project that is compatible with the care orientation's emphasis on human need and responsiveness to particular others.