Treatment without consent: intervention by the court

The British Medical Journal's legal correspondent reviews two English court decisions concerning treatment or nontreatment of minors against the wishes of their parents. In the 1981 case In re P, the court sanctioned the abortion request of a 15-year-old ward of the court, whose parents objected to the procedure. In the 1976 decision In re D (A Minor), the court refused to authorize the sterilization of an 11-year-old retarded girl, despite her mother's request and a physician's recommendation. Physicians apprehensive about treating minors in sexual matters in light of the recent Gillick decision concerning contraception without parental consent are advised to contact the local juvenile authority, which can apply to the court for guidance and direction.     

Physicians and the minefield surrounding informed consent.

Most of the legal cases that follow the informed-consent standard set in recent court cases have involved surgical procedures. However, issues concerning a pregnant British Columbia mother who contracted chicken pox and whose child was subsequently born with severe medical complications demonstrate the complexity of medical decision making and the inadequacy of established legal requirements, especially when consent has dimensions beyond technical considerations usually associated with medical procedures. The problem physicians face, says lawyer Karen Capen, is to find a way to balance a range of professional responsibilities and the overriding fiduciary obligation to patients in matters associated with informed decision making and consent.     

Sterilisation of mentally handicapped girl authorised

Dyer predicts that a decision by the House of Lords authorizing the contraceptive sterilization of a severely retarded 17-year-old girl called Jeannette may bring to court many similar cases that previously would have been quietly decided by parents and physicians. The law lords rejected the Canadian Supreme Court's conclusion in a recent case, Re Eve, that sterilization of a mentally handicapped person for nontherapeutic purposes should never be authorized. Instead, the British decision found compelling reasons for the sterilization in Jeannette's developmental and behavioral characteristics and in the contraindications for other forms of contraception in her case. The lords chose not to commit themselves on whether the court would be able to act if she were no longer a minor.     

Legal abortion

The provisions of India's Medical Termination of Pregnancy Act of 1972 and some of the problems it has created are summarized. Medical, social, environmental, and eugenic grounds are considered adequate; only registered medical practitioners with experience or training in gynecology and obstetrics are authorized to do the abortions; and the pregnancy should not exceed 12 weeks. For pregnancies of 13-20 weeks opinions of 2 registered practitioners are required. The written consent of the woman is needed or, in the case of a minor or mentally incompetent person, the written consent of the parent or guardiaan. Only government-approved hospitals or clinics may be used and licenses are required. All abortions must be reported to the Director of Health Services. Although the apparent purpose of the law is to save women from the risks of criminal abortion, reduction of the birthrate also follows. Acceptance of contraception or sterilization is more frequent. The D and C method is being largely replaced by suction aspiration as an out-patient procedure. For midpregnancy abortion hysterotomy or saline amninoinfusion are used. Intraamniotic prostaglandin is being investigated. Lack of hospital facilities in India has been a handicap. As many women seeking legal abortion have been in midpregnancy, the complications have been considerable. However, present incidence of mortality from all abortions, including criminal ones, comprises 12% of maternal mortality.     

Legal consent for vasectomy of a mentally-retarded minor

The medicolegal aspects of sterilizing mentally retarded minors are discussed. In general, courts have jurisdiction over minors and have authority to issue orders for the protection or welfare of a minor. A case cited concerned an attempt to have a mentally retarded adult woman with two illegitimate children sterilized. The attempt was denied by the court because her parents had no authority to act for her since she was an adult and no guardian had been appointed who had control over her person. No cases of this nature concerning minors could be found. The consent of the parents might be sufficient reason for sterilization in the case of a minor.     

Sterilisation of incompetent mentally handicapped persons: a model for decision making.

Doctors are regularly confronted with requests for sterilisation of mentally handicapped people who cannot give consent for themselves. They ought to act in a medical vacuum because there doesn't exist a consensus about a model for decision making on this matter. In this article a model for decision making is proposed, based on a review of the literature and our own research data. We have attempted to select and classify certain factors which could enable us to arrive at an ethically justifiable method of making a medical decision. In doing so we distinguish two major criteria: heredity and parenting competence, and six minor criteria: conception risk, IQ, age, personality, medical aspects and prognosis and finally support and guidance for the mentally handicapped person. The major criteria give rise to a "situation of necessity". In this situation the physician is confronted with a conflict of values and interests. The minor criteria are of an entirely different ethical order. They can only be considered once the major criteria have created a "situation of necessity". Ultimately it comes down to deciding whether the benefits of sterilisation outweigh the drawbacks and whether the means are appropriate to the end, where efficient contraception is the end and irreversible sterilisation is the means.     

Eugenic sterilization: a discussion of certain legal,medical, and moral aspects of present practices in our public mental institutions

Eugenic sterilization is defined as sterilization of a person who is either mentally ill or mentally defective and will either severely handicap any future offspring through heredity or is unable to properly care for a child. When an institutionalized mentally disordered person of reproductive age reaches a stage when he is able to return to the community, 3 possibilities arise: 1) eugenic surgical sterilization; 2) eugenic institutional sterilization, where the patient is effectively sterilized by being kept in the institution; and 3) discharge without eugenic sterilization. 3 cases of patients discharged without sterilization are presented. A review of the law of eugenic surgical sterilization reveals that 22 states have laws that permit compulsory eugenic sterilization without patient consent. Even though a state does not specifically authorize eugenic sterilization, it does not mean that such a procedure cannot be done legally. However, fewer and fewer eugenic sterilizations are being performed. Decisions relating to sterilization more often are made by medical men than by judges. Medically, the Committee of the American Neurological Association for the Investigation of Eugenical Sterilization, in a report made 25 years ago, condemned on both medical and philosophical grounds widespread eugenic surgical sterilizations except in certain cases. Morally, the author believes that patients and physicians are incapable of acting as moral beings in dealing with the question of eugenic sterilization because of 1) lack of proper facilities to allow freedom of choice, and 2) lack of knowledge of available relevant facts. With respect to the 3 alternatives for dealing with mental patients who are capable of reproducing, the author asks: Is it morally just to sterilize a person without first offering adequate treatment, rehabilitation, and follow-up that a well-equipped institution could offer? Is it just to incarcerate a patient without offering the personnel and facilities for proper custodial and therapeutic care? Is it proper to discharge a person without sterilization without offering rehabilitation and follow-up that might lead to a better life? A study comparing the way the problem of sterilization is being handled in states with different approaches to the subject is proposed.     

Legal issues affecting confidentiality and informed consent in reproductive health

The law governing confidentiality and informed consent has acquired unique characteristics in the area of reproductive health, as a consequence of both the establishment of a constitutional right to privacy in reproductive health matters and the reaction of those politically and morally opposed to the exercise of that right. The primary issues have involved: 1) the right of minors to receive reproductive health services without parental consent, which remains a political battleground; 2) laws requiring physicians to provide information to pregnant patients that is intended, not to inform them of the risks and benefits of the procedure, but to discourage them from obtaining abortions; 3) coerced and prohibited sterilizations; 4) court-ordered contraception and procedures to protect the fetus; and 5) restrictions on counseling about abortion, contraception, sterilization, and other reproductive health services authorized by state conscience or noncompliance clauses that shield such restrictions from the usual ethical, medical, and legal rules governing informed consent. The last area is of profound significance to the ability of women to make informed decisions about their reproductive health options. In the current economic environment, which fuels mergers and acquisitions involving sectarian and nonsectarian institutions, women are increasingly being put at risk as a result of such restrictions.     

Spouse's consent to sterilization

If a medical procedure will secondarily result in the sterilization of the patient, is the consent of the patient's spouse required? Is the consent of the patient's spouse required if the procedure is not medically necessary, but is intended primarily for sterilization? If a procedure is medically necessary, the consent of the patient's spouse in not required. The consent of the spouse is not required even if it incidentally will result in the sterilization of the patient. Statutes in Georgia, North Carolina, and Virginia requie the written consent of the patient's spouse to voluntary sterilizations. In the absence of such a statute, no definitive answer can be given. Every individual does have the right to consent to any lawful Medical treatment or procedure. However, an individual also has an interest in the procreative ability of his or her spouse. While it appears that the right to consent to lawful medical procedures would be paramount to the interest of the patient's spouse, this matter has not yet been judicially resolved.     

知情同意书质量分析与改进对策

目的 检查了解手术与有创操作知情同意书签署缺陷,分析原因,寻找对策.方法 随机抽取某院2013年1月-2014年3月手术及有创检查6369份归档病案,根据卫生部颁布的《病历书写基本规范》与总部病案检查评分标准,就知情同意书填写格式、项目、内容签署缺陷进行质控检查并做统计.结果 在手术与有创检查的6369份病案中检出各类知情同意书缺陷病案631份（达9.91％）.631份病案中各类知情同意书均有一项至多项缺陷,其中手术知情同意书缺陷580频次;麻醉知情同意书缺陷236频次;输血知情同意书缺陷173频次;有创治疗检查操作同意书缺陷213频次;其它缺陷167频次.结论 病案中知情同意书规范性、完整性尚存在不足,须采取有效措施加以提高.保障知情同意书作为法律依据的完整性、有效性,是有效规避医疗纠纷的有力措施.     

Enforcing patient preferences. Linking payment for medical care to informed consent

The legal and ethical doctrine of informed consent is well accepted in modern medicine. Nonetheless, medical interventions sometimes take place in the absence of informed consent, particularly in the case of life-sustaining medical procedures. These procedures ordinarily are reimbursed by third-party payers. This article proposes as a strategy to ensure greater attention to patient preferences in medical decision making that financial reimbursement for each medical service be linked to a requirement of valid patient (or surrogate) consent to the service involved. Utilization review bodies could monitor informed consent in the same way that other aspects of necessity, appropriateness, and quality are now monitored.     

第三方调处是化解医患纠纷的创新之举——以济宁市医患维权协会为例

医患纠纷是我国社会长期存在而又难以化解的社会矛盾之一。近年来,国内不少地方相继探索第三方调处医患纠纷的新途径。实践证明,第三方调处医患纠纷不失为化解医患纠纷的创新举措。     

On the Ottoman consent documents for medical interventions and the modern concept of informed consent

Information for patients prior to medical intervention is one of the principles of modern medical practice. In this study, we looked at an earlier practice of this principle. Ottoman judges had record books called sicil. One of the categories in sicils was the consent documents called riza senedi, which was a patient-physician contract approved by the courts. These contracts were especially for the protection of physicians from punishment if the patient dies. It is not clear whether patients were informed properly or not. Consent for minors was obtained from parents. However, a situation where an adult does not have the capacity to consent, was not clear in these documents. Any sign of free withdrawal of consent was not found in these records. Due to the legal system of Ottoman State, these contracts were related to Islamic law rather than modern civil law. We aim, in this paper, to present a legal practice, which is possible to consider as an early example of the informed consent practice.     

谈患者的知情同意权

患者的知情同意权是医患沟通的重要组成部分,是人权在医疗系统的重要体现。本文概括了知情同意权的由来,从权利、义务的主体及内容明确了知情同意权的法律概念,探讨了知情同意权在医学实践中的表现形式和实现程序,提出了医务人员的告知是基础、患方知情是核心、患者签字是最终体现的理念,为医务人员准确理解并落实患者知情同意权提供了新思路。     

Concern at Gillick judgment

A meeting of the British Medical Association's Central Committee for Community Medicine and Community Health found most members concerned about the likely effects of an appellate court judgment that it is now unlawful for doctors to give advice or treatment on contraception or abortion to individuals under 16 years of age without parental consent. A brief report is provided of the committee's deliberations.     

Organ donation after cardiac death: legal and ethical justifications for antemortem interventions

Organ donation after cardiac death increases organ availability, but raises several legal and ethical issues, including consent. Medical interventions for people who are unconscious usually require guardian consent and must meet patients' best-interests standards. Antemortem procedures can improve the success of organ transplant after cardiac death, but do not serve the patient's medical interests, and it is contentious whether consent for antemortem interventions is legal under current Australian guardianship legislation. We argue that consent decisions should take patients' wishes as well as their medical interests into account. Antemortem interventions are ethically and legally justified if the interventions are not harmful and the person concerned wished to be an organ donor.     

Child sterilization

We are greatly indebted to the BBC and to certain contributors to the recent programme on child sterilization, televised from the Royal Institution, London, on 16 August under the title of `Controversy', for their permission to reproduce in this issue the opening remarks of the Chairman, Professor Sir George Porter, and those of the opening speakers - Mr Michael Brudenell, Dr Jack Bavin and Mr Ian Kennedy. Of the other participants, we thank Professor Peter Huntingford, Dr Brian Kirman, Professor Philip Graham, Dr Hugh Jolly, Mr Stanley Segal and Mr Frank Hooley, MP, whose contributions are also included.

A great deal of interest and controversy was aroused in Britain by the recent case of an II-year-old girl whom it was proposed to sterilize at the request of the mother because the child was the victim of a rare mental disorder. In the part of the televised programme which we reproduce below the case is argued for and against sterilization of minors in similar situations to that of the child under discussion. (That child was at the time the subject of a court order action.) The three experts who opened the discussion - a gynaecologist, a psychiatrist, and a barrister - on the whole were not in favour of sterilization although the gynaecologist said that if requested he would perform the operation on certain patients. The general discussion which followed supported the congentions of those who opposed the sterilization of minors who were mentally abnormal, arguing that there were other, less final methods of birth control. (Some of the audience, however, disagreed very forcefully.) The general conclusion was that to deprive any human being of essential rights without being able to foresee that person's future development could not be in the best interests of the child or of society. The full consent of society as well as of parents or guardians would have to be obtained. In short, the problem was more than a personal problem in the accepted sense.

     

The right to die

2 acts of the United Kingdom Parliament, the Suicide Act of 1961 and the Abortion Act of 1967, have drastically altered doctor/patient relations as outlined in the Hippocratic oath. The major advantage of the Suicide Act is that the physician would be under no obligation to prevent a crime. However, 2 dilemmas involved with this aspect of the Suicide Act are: dealing with the relative slow death of the patient; and/or the possibility of the patient requesting the means to end his or her life. The latter of these 2 choices involves both a moral and a legal issue dealing with the patient's competent intentions. Concerning legislation dealing with abortion, several controversial issues have been raised over the reasons for abortions. Mental and physical defects are reasons which have been cited for abortions and neonate euthanasia. However, bills being currently debated in Parliament feel that it is not the decision of the courts to decide on behalf of a mentally or physically handicapped child whether or not they have the right to die.     

Current practice for obtaining consent in UK neonatal units

Working practice in neonatal units, like other medical and surgical specialties, is undergoing drastic changes to incorporate current legal and ethical requirements. We surveyed the current working practices of 60 neonatal units in this country. Consent appeared to be implied for routine procedures. Variable rates of consent were reported for specialised interventions and the surgical team was consistently involved in obtaining consent for all surgical procedures. There is great variation in practices for seeking consent in neonatal units in this country.     

Increase in obstacles to abortion: the American perspective in 2004

This paper summarizes the barriers to abortion in the United States, including the determination of viability, cost and insurance coverage, waiting periods and parental consent laws, restrictions on medical abortion, provider unavailability, harassment, targeted regulation of abortion providers laws, refusal clauses, anti choice laws, and the fetal legal rights movement. Federally subsidized abstinence-only sex education, which has not been shown to decrease the rate of unintended pregnancy (and may increase it), has expanded and access to a full range of contraceptive options has been limited. The policies of the current and past administrations have strengthened barriers to abortion both at home and abroad. Preserving women's right to choose will require improved public and professional education, legislative and legal efforts, and advocacy by physicians and other health care professionals.