In re Edna MF: Case Law Confusion in Surrogate Decision Making

I review the recent case of Edna Folz, a 73 year-old woman who was suffering through the end stages of very advanced Alzheimer's dementia when her case was adjudicated by the Wisconsin Supreme Court. I consider this case as an example of how courts are increasingly misinterpreting the ethical and legal decision-making standards known as substituted judgment and best interests and thereby threatening individuals' treatment decision-making rights as developed by other courts over the past two decades and creating serious roadblocks to health-care providers' ability to render appropriate patient care. The Wisconsin Supreme Court held that Edna's legal guardian could not authorize withdrawal of Edna's treatment, ruling that as a matter of law, if an incompetent person is not in a persistent vegetative state, it is not in his or her best interests for life-sustaining treatment to be withdrawn unless (s)he has executed an advance directive or other statement clearly indicating his or her desires.     

Surrogate safety indicator for unsignalised pedestrian crossings

ProblemAlthough the road safety situation in Poland is generally improving, the number of accidents at pedestrian crossings has not decreased in the last four years. This paper presents the results of the MOBIS research project, the aim of which was to develop surrogate safety indicators, based on detection of pedestrian-vehicle conflicts using video analysis.MethodPedestrian and vehicle traffic was filmed at two unsignalised pedestrian zebra crossings in Warsaw and Wrocław for over 40 days. Motion trajectories of vehicles and pedestrians were determined based on video processing. Several variables describing pedestrian-vehicle interactions were calculated, such as speed, post-encroachment time, distance between the participants, decelerations, etc. Classification of encounters was based on interactions of pedestrians and vehicles i.e. drivers yielding to pedestrians, vehicles passing just in front of, or behind pedestrians.Results and discussionCriteria for identification of dangerous encounters were selected with the assumption that it should be possible to automate the assessment process. The selected variables were: pedestrian-vehicle passing distance and the vehicle speed at that moment. Other criteria were used in cases of abrupt braking – deceleration exceeding 4 m/s² and vehicle speed. A Dangerous Encounter Index is proposed as a surrogate safety indicator for pedestrian crossings. It relates the occurrence of dangerous events to exposure, defined as the number of pedestrian-vehicle encounters.Practical applicationsThe proposed index shows that crossing two lanes involves more risk than crossing one lane, given similar traffic flow. Some improvement of safety at both types of crossing was observed after active signage involving blinking lights had been introduced. The proposed method is a step towards automation of safety assessment.     

Affaire Vincent L. : les maux de la fin

As called back it June 24th, Council of State in its press release, the Vincent L.’s case “raise scientific, ethical and human questions”. At first, to decide on the fate of this 38-year-old man, the administrative jurisdiction recovered from it in expert opinions asked to establish the existence or not of an unreasonable stubbornness. But the objectivity of the medical science cannot solve only this litigation where the outcome is the life or the death of a patient. That is why the court opened its doors to the ethical speech too. If in this case, the science could not exist without consciousness, if the legal word could not exist without the ethical word, it's because of the human dimension which fills this media and legal affair. So behind this patient's case, called now “the Vincent L.’s affair”, it's a question about the death, that of a young man in the incapacity to express its will. It's also a question of a family disagreement on the future of their son, brother, or husband. In this context, “politically and mediatically charged”, the administrative jurisdiction pronounced four times on the decision of the stop of Vincent L.’s treatment. The educational position of the French judges allowed to clear up statutory provisions of the Leonetti's act.     

Turning failures into successes: a methodological shortcoming in empirical research on surrogate accuracy

Decision making for incompetent patients is a much-discussed topic in bioethics. According to one influential decision making standard, the substituted judgment standard, a surrogate decision maker ought to make the decision that the incompetent patient would have made, had he or she been competent. Empirical research has been conducted in order to find out whether surrogate decision makers are sufficiently good at doing their job, as this is defined by the substituted judgment standard. This research investigates to what extent surrogates are able to predict what the patient would have preferred in the relevant circumstances. In this paper we address a methodological shortcoming evident in a significant number of studies. The mistake consists in categorizing responses that only express uncertainty as predictions that the patient would be positive to treatment, on the grounds that the clinical default is to provide treatment unless it is refused. We argue that this practice is based on confusion and that it risks damaging the research on surrogate accuracy.

The implications of situation and route familiarity for driver-pedestrian interaction at uncontrolled mid-block crosswalks

Most routine daily trips take place along the same route, a fact that previous studies have not investigated together with the repeated situation of conflicting with other road users. Consequently, our study addresses driver behaviour by separating the driving experience into three categories: (i) drivers unfamiliar with the route, (ii) those route-familiar, and (iii) situation-familiar drivers. The specific case of driver-pedestrian interaction at uncontrolled mid-block crosswalks is investigated. A multi-level factorial experiment including (i) crosswalk design (linear sidewalk and curb extension), (ii) driver familiarity, and (iii) pedestrian time gap acceptance (4, 6, and 8 s) was conducted using a driving simulator. Fifty-two participants were divided into four groups and stratified by age, gender, and driving experience. The minimum instantaneous time to collision, post-encroachment time, maximum car deceleration, and maximum car speed were all used as surrogate safety measures (SSM).Route-familiarity led to higher speed, while situation-familiarity positively affected driving behaviour making drivers more inclined to decrease their speed at circa 100 m before a crosswalk. The curb extension layout enhanced pedestrian safety and mitigated any adverse effects due to familiarity, with a particularly relevant impact on SSM at low accepted time gaps for pedestrians. Situation- and route-familiarity treatment protocols lead to different behaviours among drivers, indicating a clear need to account for these two familiarity levels in experiments on safety-related countermeasures.     

Evasive action characteristics of motorcycle riders towards occluded-surprise and expected pedestrians: A pedestrian mock-up study

Evasive action performance of motorcycle riders plays a vital role in the prevention of road crashes. In possible conflicting scenarios, motorcycle riders need to respond quickly and perform evasive actions successfully to prevent collisions with other vulnerable road users such as crossing pedestrians. To study the motorcycle rider behavior in conflicts with occluded and visible pedestrians, we designed four mock-up pedestrian scenarios, which includes, two surprise scenarios, one stationary scenario, and one expected scenario. Riders’ responses to the conflicts were measured using instrumented vehicle’s trajectory. Most riders preferred deceleration over swerving at the beginning of the interaction, followed by swerving at manageable speeds. Further, the analysis of riders’ deceleration rates revealed that a linear relationship existed between the deceleration rates and time to collisions (TTC). The study also analyzed the riders’ responses using repeated-measures analysis of variance (RM-ANOVA) to check for the effect of scenario type on deceleration rates. Results indicated that scenario type significantly affected the mean deceleration rates. Further, RM-ANOVA analysis carried out on the jerk behavior of motorcycle riders indicated that there was a significant effect of scenario type on the jerk behavior. Motorcycle riders’ jerks varied linearly with TTC and motorcyclists employ relatively higher decelerations and jerks when faced with pedestrians emerging suddenly from occluded locations such as from the blind spots formed due to parked vehicles. This study helps in understanding motorcycle rider behavior in critical situations and shows the need for assistive evasive systems for motorcycle riders to mitigate collisions with other vulnerable road users.     

Yielding behavior and traffic conflicts at cyclist crossing facilities on channelized right-turn lanes

Channelized right-turn lanes (CRTLs) improve traffic flow efficiency, enabling right-turning drivers to bypass traffic lights at signalised intersections (for right-hand drive countries). Many CRTLs provide crossing facilities for pedestrians and cyclists. Previous studies examining the safety performance of CRTLs indicate that they increase overall safety levels but hint that safety issues regarding vulnerable road users exist. This study investigated these issues through site-based observations of yielding behavior and evaluated the effect of the priority rule on cyclists’ safety in two CRTL designs. Four locations in Belgium were selected for video observations: two where the priority rule favoured cyclists and two where motorists had priority.With regard to yielding, four types of crossing behavior were identified and defined. Independent of the priority rule, cyclists crossed the conflict zone first in most interactions without taking the initiative to cross first. Underlying reasons for motorists willingly giving away their right-of-way could not be determined, but possible courtesy or fear of inflicting injuries at vulnerable road users might be at hand. A safety evaluation was performed using two traffic conflict indicators (TTC_min and the TA value). High correlations between the two indicators were found (r² > 0.83), but no conclusions about the safest priority rule for cyclists could be drawn. The results hinted, however, that locations with motorist priority and cyclists crossings from right to left (from the driver’s point of view) yields the highest proportion of safety critical events.     

Safety of bicyclists in roundabouts with mixed traffic: Video analyses of behavioural and surrogate safety indicators

Although converting an intersection into a roundabout has been shown to result in fewer injury accidents for both motor vehicle drivers and pedestrians, the effect on bicyclists’ safety is unclear or even negative. This study focuses on roundabouts without bicycle facilities (i.e., mixed traffic conditions) and makes use of semi-automated video observation software with the aim of analysing bicyclists’ behaviour and safety on roundabouts with different diameter. Four urban roundabouts in Belgium are observed. Interactions between bicyclists and other vehicles are analysed using speed, lateral position and five indicators to describe the closeness of interactions (TTC_min, PET, T_{2 min}, lateral overtaking proximity and minimum distance headway). Additionally, the lateral position and riding speed of bicyclists that are in interaction with other vehicles is compared with the behaviour of bicyclists that are not in interaction with other vehicles.The behavioural analysis revealed that regardless of the type of condition (free-flow bicyclists or different interactions bicyclist-car), bicyclists always ride faster on roundabouts with big diameter and slower on roundabouts with small diameter. Moreover, bicyclists ride closer to the central island on roundabouts with big diameter compared to roundabouts with small diameter for all the conditions analysed.The analysis of surrogate safety indicators (TTC_min, PET, T_{2 min}) revealed that close interactions between bicyclists and cars are relatively frequent at both small and big roundabouts. The percentages of close interactions are more or less equal for roundabouts with big diameter (7.86% of observed interactions) and roundabouts with small diameter (8.24%). The analysis of the indicators to describe the closeness of interactions also showed that the closest interactions at roundabouts are all situations where the bicyclist has a leading role. The analysis of the most common types of close interactions revealed indeed that the most common close interactions are interactions where the bicyclist is entering the roundabout. The analysis of lateral overtaking proximity showed that bicyclists who overtake a car take smaller lateral overtaking proximities compared to cars overtaking a bicyclist. The analysis of minimum distance headway finally revealed that bicyclists who ride behind a car take smaller distance headways compared to cars driving behind a bicyclist.     

Crash risk evaluation of aggressive driving on motorways: Microscopic traffic simulation approach

This paper provides quantitative evaluation of safety implications of aggressive driving (speeding, following closely and weaving through traffic) by using microscopic traffic simulation approach. Combination of VISSIM and Surrogate Safety Assessment Model (SSAM) were used to model motorway and assess safety of the simulated vehicle. The use of vehicle conflicts was validated by correlating it to historic crashes. Crash risk, severity levels and the magnitude of the perceived benefits of aggressive driving were quantified relative to normal drivers under two scenarios: (1) congested, and (2) non-congested traffic conditions. Involvement in vehicle conflicts is used to determine crash-risk while reductions in Post Encroachment Time (PET) and travel time were used to determine the severity levels of the expected crashes and the magnitude of the perceived benefits. The results indicated that the crash risk of aggressive drivers was found to be in the range 3.10–5.8 depending on traffic conditions and type of road aggression. PET of the conflicts involving aggressive drivers reduced by 7–61% indicating high severity levels of the expected crashes. Moreover, the magnitude of the perceived benefit in terms of reduction in travel time was found to be as little as 1–2%. The study concluded that aggressive driving is entailed with a massive risk while its benefits are actually very little.     

Marginally Represented Patients and the Moral Authority of Surrogates

Abstract

Incapacitated adult patients are commonly divided into two groups for purposes of decision making; those with a surrogate and those without. Respectively, these groups are often referred to as represented and unrepresented, and the relative ethics of decision making between them raises two particular issues. The first issue involves the differential application of the best interests standard between groups. Second is the prevailing notion that representedness and unrepresentedness are categorical phenomena, though it is more aptly understood as a multidimensional and continuous variable based on relational moral authority. This paper examines the nature of representedness as it relates to ethical norms of surrogate decision making.