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PubMedDate not supplied

Nationwide practices for screening and reporting prenatal cocaine abuse: a survey of teaching programs.

Questionnaires surveying policies and opinions about prenatal cocaine abuse were sent to training programs nationwide. Eighty-one pediatric and 81 obstetric programs from 42 states responded. Although respondents favored routinely screening all patients by maternal history (81%) and by urine toxicology (36%), only 64% and 8%, respectively, reported these as established policy. Physicians reporting higher regional prenatal cocaine abuse rates more commonly favored universal perinatal screening (p = .009), but established policies were similar regardless of local prevalence (p = .19). Fifty-two percent of respondents were unaware of their state's requirements for reporting prenatal cocaine abuse. While most physicians favored interventions such as voluntary drug rehabilitation (64%) and family support services (64%), some physicians favored foster care placement for the infants (28%) and involuntary drug rehabilitation (31%). Only 3% felt that criminal prosecution of the mother was appropriate. Policies for managing prenatal cocaine abuse often did not reflect physicians' opinions. A multidisciplinary medical, social, and legal approach is needed to develop effective management policies.

Cocaine↗
PubMed1990

Baby Doe regulations and medical judgment.

The potential for conflict between social policy and medical judgment can be examined in relation to the 'Baby Doe' regulations issued by the U.S. Federal Government in 1984. These regulations identify the circumstances in which medical treatment may be withheld from handicapped infants. This article reports on a national survey of perinatal social workers which compared their responses to the answers of physicians to similar questions published earlier. These social workers failed to express a conflict between sound medical judgment and the federal regulations when confronted with three hypothetical cases. The same was true in the published study of physicians but that data was erroneously interpreted as providing evidence of a conflict between medical judgment and federal regulations. On some general opinion statements, the social workers were similar to physicians in their criticism of these regulations but on others they were equivocal. While the majority of responses of social workers to other questions about these regulations was rather similar to the responses of physicians, the social workers were found to be more inclined than physicians to express the view that these regulations were needed to protect the rights of handicapped infants and the view that the physician's practice had been changed as a result of these regulations.

Ethics, Medical↗
PubMed1978

Physician responsibility for the cost of unnecessary medical services.

Most diagnostic and therapeutic services are ordered by physicians, but physicians practicing under fee-for-service conditions have few incentives to contain the costs of medical care. Without such incentives, effective cost control through mechanisms such as Professional Standards Review Organizations have been disappointing. Several legal approaches might be used to increase physicians' responsibility for the cost of unnecessary services--expansion of tort law, implied contact, redesign of insurance mechanisms, equitable estoppel and informed consent. However, increasing physician responsibility will require uniform but flexible definitions of medical necessity, reliable means for predeterming the need for services and effective penalties or incentives. We propose a peer-review system that would incorporate the sharing of financial risk among physician, hospital, insurer and patient in the fee-for-service sector.

Costs and Cost Analysis↗
PubMed1985

Parental discretion and children's rights: background and implications for medical decision-making.

This paper argues that liberal tenets that justify intervention to promote the welfare of an incompetent do not suffice as a basis for analyzing parent-child relationships, and that this inadequacy is the basis for many of the problems that arise when thinking about the state's role in resolving family conflicts, particularly when monitoring parental discretion in medical decision-making on behalf of a child. The state may be limited by the best interest criterion when dealing with children, but parents are not. The state's relation with the child is formal while the parental relation is intimate, having its own goals and purposes. While the liberal canons insist on the incompetent one's best interest, parents are permitted to compromise the child's interest for ends related to these familial goals and purposes. Parents decisions should be supervened, in general, only if it can be shown that no responsible mode of thinking warrants such treatment of a child.

Adult↗
PubMed1991

Refusal of tube feeding as seen from a patient advocacy organization: a comparison with landmark court cases.

OBJECTIVE: To determine how closely high court decisions regarding tube feeding are a reflection of the situations that occur in the general population. DESIGN: A retrospective review was conducted of memos recording inquiries made to the Society for the Right to Die (SRD), a patient advocacy organization. Characteristics of clients were compared to characteristics of individuals considered in landmark "right-to-die tube feeding cases during the same period of time. RESULTS: Information from 116 memos of inquiries made from 1985 through mid-1990 was compared to 20 court cases, and significant differences were identified. The average age of the SRD clients was 77.6 (+/- 18.4) years compared to 55.1 (+/- 22.8) years for the court cases (P less than 0.001). Of the clients, 79% were 70 years of age or older and 28% were 90 or older; in contrast, 7 (35%) of subjects in the court cases were 70 years of age or older, and none was over 90 (P less than 0.001). In addition, whereas 14 (70%) of the court cases dealt with individuals in a persistent vegetative state, only 17 (15%) of SRD clients carried that diagnosis (P less than 0.001), with the remainder suffering from dementia, various stages of coma, or a variety of other debilitating disorders. The sex distribution, year of inquiry or year of court decision, and geographic distribution were similar. Some states were overrepresented in both groups. CONCLUSION: High court cases may inadequately reflect the majority of situations that arise on a day-to-day basis. Elderly individuals, in particular those who are not in a persistent vegetative state, are significantly underrepresented.

Aged↗
PubMed1991

The dilemma of civil rights versus the right to treatment: questionable involuntary admissions to a mental hospital.

Admission to a close ward was analyzed at the Department of Psychiatry, University of Oulu using 888 patients and their 1861 assessment and treatment episodes. Of all referrals for involuntary assessment (n = 237, 12.7% of all episodes) a total of 44 (2.4%) used "questionable" juridical criteria: the final diagnosis was not psychosis. In the follow-up, the admission of the questionable patients was mainly considered a clinical necessity, and at least one third of them were diagnosed as being psychotic and 2 committed suicide. An elevated probability of belonging to the questionable group was seen among patients in their first treatment episode, with minimal professional education, female sex, short treatment time, or residence in a rural area. The result suggests that some inequality existed between women and men, less and more educated and residents of urban and rural areas. The results also reflect conflict between the ethics and clinical practice of involuntary commitment, and the phrasing of the law, especially its diagnostic limitation to psychotic states only.

Adult↗