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.     

Assessment of Socio-Economic Characteristics and Quality of Life Expectations of Rural Communities in Enugu State,Nigeria

This study examined the social, infrastructural and economic conditions prevalent in some rural communities of Enugu State, Nigeria, where recent oil and gas prospecting activities have generated concerns for the environment and quality of rural life. Mixed but complimentary methods of data collection employed include consultations with key stakeholders, focus group discussions, questionnaire survey, field observations, key-informant interviews and secondary sources. Existing socio-economic and infrastructural conditions, citizens’ perceptions of oil and gas activities, and quality of life (QoL) expectations of study communities were documented. Six major units of analysis (or levels of aggregations) with the aid of qualitative and quantitative methodologies were used to describe both empirical and /or secondary data. The study revealed large population sizes and even higher population densities, with the economic base in the study area being agriculture. Findings of the study indicate that despite some negative socio-environmental perceptions, citizens’ receptiveness and attitude towards the projects were patently positive. QoL expectations of the communities were embedded in environmentally responsible, culturally sensitive and socially responsive operation of oil companies. Agents and institutions of social control and well- being were also appraised to highlight their QoL contributions in the area.     

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.     

‘The snake and the seraph’ – sexual addiction and religious behaviour

The purpose of this article is to explore the relationship between sexual misconduct and religious vocation. Drawing on clinical and ministerial experience the article suggests that most sexual misconduct among religious officials is a combination of sexual addiction and religious behaviour acting as interconnected responses to narcissistic damage. It goes on to outline a reciprocal inter-locking cyclical pattern of behaviour and suggests a treatment strategy that prioritizes four tasks: psycho-education, group work, family of origin exploration, and facilitating access to the components of a good quality of life.     

Are most precontemplators contemplating smoking cessation? Assessing the validity of the stages of change.

OBJECTIVE: To assess the validity of the stages of change (SOC) algorithm for current smokers. DESIGN: This study was a mail-based, cross-sectional survey study of 242 adult smokers. MAIN OUTCOME MEASURES: The main outcome measures were the SOC algorithm and a variety of alternative questionnaire items measuring motivation to quit smoking. RESULTS AND CONCLUSION: The results revealed that the SOC algorithm systematically underestimated motivation to quit smoking relative to a variety of other measures. Further, the stages of change do not appear to be qualitatively distinct categories. More than half the precontemplators were contemplating cessation, and many precontemplators intended to quit. Most contemplators were not merely contemplating cessation but rather were trying to quit currently. In summary, there is a divergence between the concepts underlying the SOC - precontemplation, contemplation, and preparation - and the operational definitions of these concepts.     

Young adult e-cigarette users’ reasons for liking and not liking e-cigarettes: A qualitative study

Objective: To gain an in-depth understanding of what young adult electronic- or e-cigarette users like or dislike about e-cigarettes. We aimed to determine the reasons that may encourage young adults to use e-cigarettes or discourage them from using e-cigarettes.

Design: Twelve focus group discussions were conducted with 62 current daily e-cigarette users (63% men) of mean age = 25.1 years (standard deviation = 5.5). Data were analysed following principles of inductive content analysis.

Results: Results indicated 12 categories of reasons for liking e-cigarettes (e.g. recreation, smoking cessation) and 6 categories of reasons for not liking e-cigarettes (e.g. poor product quality, poor smoking experience).

Conclusions: Young adults’ motives for using or not using e-cigarettes appear to be varied and their relative importance in terms of predicting e-cigarette use initiation, dependence, and cigarette/e-cigarette dual use needs to be carefully studied in population-based, empirical studies. The current findings suggest that e-cigarettes may serve social, recreational, and sensory expectancies that are unique relative to cigarettes and not dependent on nicotine. Further, successful use of e-cigarettes in smoking cessation will likely need higher standards of product quality control, better nicotine delivery efficiency and a counselling component that would teach smokers how to manage e-cigarette devices while trying to quit smoking cigarettes.     

Legal briefing: organ donation and allocation

This issue's "Legal Briefing" column covers legal developments pertaining to organ donation and allocation. This topic has been the subject of recent articles in JCE. Organ donation and allocation have also recently been the subjects of significant public policy attention. In the past several months, legislatures and regulatory agencies across the United States and across the world have changed, or considered changing, the methods for procuring and distributing human organs for transplantation. Currently, in the U.S., more than 100,000 persons are waiting for organ transplantation. In China, more than 1.5 million people are waiting. Given the chronic shortage of available organs (especially kidneys and livers) relative to demand, the primary focus of most legal developments has been on increasing the rate of donation. These and related developments are usefully divided into the following 12 topical categories: 1. Revised Uniform Anatomical Gift Act. 2. Presumed Consent and Opt-Out. 3. Mandated Choice. 4. Donation after Cardiac Death. 5. Payment and Compensation. 6. Donation by Prisoners. 7. Donor Registries. 8. Public Education. 9. Other Procurement Initiatives. 10. Lawsuits and Liability. 11. Trafficking and Tourism. 12. Allocation and Distribution.     

Book Review

Abstract

In this article, I respond to questions about, and criticisms of, my article “Toward an African Moral Theory” that have been put forth by Allen Wood, Mogobe Ramose, Douglas Farland and Jason van Niekerk. The major topics I address include: what bearing the objectivity of moral value should have on cross-cultural moral differences between Africans and Westerners; whether a harmonious relationship is a good candidate for having final moral value; whether consequentialism exhausts the proper way to respond to the value of a hannonious relationship; what makes a moral theory count as “African”; how the existing literature on African ethics relates to the aim of analytically developing and defending a single foundational moral principle; whether the intuitions I appeal to ground an African moral theory are pro tanto right-makers or general moral truths; whether the moral theory I defend can capture pro tanto rightness; and whether the best interpretation of African ethics is self-regarding (deeming the only basic moral reason for action to be that it would develop one’s own valuable human nature) or other-regarding (holding that a certain kind of harmonious relationship between individuals could ground a basic moral reason for action).