The evolution of law in biopreparedness

The decade following the terrorist attacks on September 11, 2001, and ensuing anthrax exposures that same fall has seen significant legal reforms designed to improve biopreparedness nationally. Over the past 10 years, a transformative series of legal changes have effectively (1) rebuilt components of federal, state, and local governments to improve response efforts; (2) created an entire new legal classification known as "public health emergencies"; and (3) overhauled existing legal norms defining the roles and responsibilities of public and private actors in emergency response efforts. The back story as to how law plays an essential role in facilitating biopreparedness, however, is pocked with controversies and conflicts between law- and policymakers, public health officials, emergency managers, civil libertarians, scholars, and others. Significant legal challenges for the next decade remain. Issues related to interjurisdictional coordination; duplicative legal declarations of emergency, disaster, and public health emergency; real-time legal decision making; and liability protections for emergency responders and entities remain unresolved. This article explores the evolving tale underlying the rise and prominence of law as a pivotal tool in national biopreparedness and response efforts in the interests of preventing excess morbidity and mortality during public health emergencies.     

Family refusal of emergency medical treatment in China: An investigation from legal,empirical and ethical perspectives

This paper is an analysis of the limits of family authority to refuse life saving treatment for a family member (in the Chinese medical context). Family consent has long been praised and practiced in many non-Western cultural settings such as China and Japan. In contrast, the controversy of family refusal remains less examined despite its prevalence in low-income and middle-income countries. In this paper, we investigate family refusal in medical emergencies through a combination of legal, empirical and ethical approaches, which is highly relevant to the ongoing discussion about the place of informed consent in non-Western cultures. We first provide an overview of the Chinese legislation concerning informed consent to show the significance of family values in the context of medical decision-making and demonstrate the lack of legal support to override family refusal. Next, we present the findings of a vignette question that investigated how 11,771 medical professionals and 2,944 patients in China responded to the family refusal of emergency treatment for an unconscious patient. In our analysis of these results, we employ ethical reasoning to question the legitimacy of family refusal of life-sustaining emergency treatment for temporarily incompetent patients. Last, we examine some practical obstacles encountered by medical professionals wishing to override family refusal to give context to the discussion.     

Evaluating and preventing illness associated with indoor air pollution.

Homicides have been on the rise in California in recent years, almost entirely as a result of increased firearm activity, resulting in one of the highest homicide rates in the country. With increasing morbidity and mortality from guns, health care professionals have called the situation an epidemic. In the past decade, attention from the health care profession has resulted in a new focus on the public health issues surrounding firearms. There is considerable confusion among policy makers regarding what should be done to stem firearm violence. I discuss morbidity and mortality trends, academic research, and legal issues surrounding firearm violence, affording insight into the seriousness and complexity of this rapidly growing problem and providing policy ideas for addressing the role of firearms. Such policy ideas include removal of the California Legislature''s preemptive authority on firearms licensing and registration; the formation of an information and advisory body within the California Department of Health; increased liability for manufacturers, distributors, dealers, and owners; and a statewide registration system.     

Medical Humanitarianism Under Atmospheric Violence: Health Professionals in the 2013 Gezi Protests in Turkey

During the 2013 Gezi protests in Turkey, volunteering health professionals provided on-site medical assistance to protesters faced with police violence characterized by the extensive use of riot control agents. This led to a government crackdown on the medical community and the criminalization of “unauthorized” first aid amidst international criticisms over violations of medical neutrality. Drawing from ethnographic observations, in-depth interviews with health care professionals, and archival research, this article ethnographically analyzes the polarized encounter between the Turkish government and medical professionals aligned with social protest. I demonstrate how the context of “atmospheric violence”—the extensive use of riot control agents like tear gas—brings about new politico-ethical spaces and dilemmas for healthcare professionals. I then analyze how Turkish health professionals framed their provision of health services to protestors in the language of medical humanitarianism, and how the state dismissed their claims to humanitarian neutrality by criminalizing emergency care. Exploring the vexed role that health workers and medical organizations played in the Gezi protests and the consequent political contestations over doctors’ ethical, professional, and political responsibilities, this article examines challenges to medical humanitarianism and neutrality at times of social protest in and beyond the Middle East.     

Not the doctor’s business: Privacy,personal responsibility and data rights in medical settings

This paper argues that assessing personal responsibility in healthcare settings for the allocation of medical resources would be too privacy-invasive to be morally justifiable. In addition to being an inappropriate and moralizing intrusion into the private lives of patients, it would put patients’ sensitive data at risk, making data subjects vulnerable to a variety of privacy-related harms. Even though we allow privacy-invasive investigations to take place in legal trials, the justice and healthcare systems are not analogous. The duty of doctors and healthcare professionals is to help patients as best they can—not to judge them. Patients should not be forced into giving up any more personal information than what is strictly necessary to receive an adequate treatment, and their medical data should only be used for appropriate purposes. Medical ethics codes should reflect these data rights. When a doctor asks personal questions that are irrelevant to diagnose or treat a patient, the appropriate response from the patient is: ‘none of your business’.     

Operation of a support service team in the emergency department of a general hospital.

We describe the development and operation of an emergency support service team in the Emergency Department of the Kingston General Hospital, Kingston, Ont. The team, composed of professionals from other departments of the hospital, provides emotional and practical support to family members or survivors in medical emergencies. We discuss the roles of the team members and their procedures for dealing with distress and grief.     

The Legal Regime Governing Sea Transport of Ultrahazardous Radioactive Materials

Although the international community has taken some steps to address the risks created by the movements of ultrahazardous radioactive cargoes, important gaps still exist in the legal regime governing these activities. An apparent consensus has been reached at the International Maritime Organization (IMO) to make the Code for the Safe Carriage of Irradiated Nuclear Fuel, Plutonium, and High-Level Radioactive Wastes in Flasks Aboard Ships (the INF Code) mandatory and to seek some clarification of the standards governing shipboard safety. But still lacking are agreements regarding salvage responsibilities, liability of shippers for damages, revision of transport cask safety standards to meet maritime accident conditions, obligations to consult regarding the best routes and to provide advance notification to concerned coastal states, the preparation of environmental assessments, and contingency planning to handle shore emergencies and salvage responsibilities. Until agreements are reached on these important matters, the shipment of these extremely dangerous or "ultrahazardous" materials will continue to violate fundamental norms of international law and comity because they place coastal nations that receive no benefit from the shipments at grave risk of environmental disaster without any legal protections. Because the shipments of ultrahazardous radioactive cargoes are increasing, it is highly advisable for concerned nations to negotiate regional protocols delineating the legal regime that applies to these maritime transports. A draft model protocol is attached at the end of this article which may provide guidance on this effort. It is also appropriate for concerned nations to consider bringing a claim against the shipping nations under the dispute resolution mechanisms established by the 1982 United Nations Law of the Sea Convention. Such a claim would be based on the failure of the shipping nations to comply with their obligations under the convention to prepare and distribute environmental impact assessments, consult with affected nations, prepare emergency contingency plans, and agree to an effective liability regime in the event of an accident. Because of the grave potential risks created by these shipments and because of the failure of the shippers to meet their obligations to protect coastal nations from these risks, coastal nations may be justified under international law to take unilateral or regional action to block future shipments.     

Artificial Respiration and Artificial Circulation: Training Experiences—Principles and Practice of Emergency Resuscitation and Post-Resuscitation Care

A training program in the newer methods of treatment of acute cardiopulmonary emergencies which was developed at the University Hospital, University of Saskatchewan, is reported. Artificial respiration by the chance rescuer, primary and secondary resuscitation, and post-resuscitation measures involving the use of special drugs and equipment by trained personnel are described. Figures and tables designed for wall-mounting and ready reference in an emergency situation are presented. Firstaid ventilatory adjuncts for use by trained personnel are classified and critically appraised, and the propriety of their use is emphasized. A plea is made to the medical profession and allied agencies to assume the responsibility of spreading knowledge of the new techniques more widely. Unless effective treatment is instituted early enough to prevent death or permanent anoxic damage to heart and brain, follow-through therapy will often be fruitless.     

BEYOND SUN,SAND, AND STITCHES: ASSIGNING RESPONSIBILITY FOR THE HARMS OF MEDICAL TOURISM

Medical tourism (MT) can be conceptualized as the intentional pursuit of non‐emergency surgical interventions by patients outside their nation of residence. Despite increasing popular interest in MT, the ethical issues associated with the practice have thus far been under‐examined. MT has been associated with a range of both positive and negative effects for medical tourists' home and host countries, and for the medical tourists themselves. Absent from previous explorations of MT is a clear argument of how responsibility for the harms of this practice should be assigned. This paper addresses this gap by describing both backward looking liability and forward looking political responsibility for stakeholders in MT. We use a political responsibility model to develop a decision‐making process for individual medical tourists and conclude that more information on the effects of MT must be developed to help patients engage in ethical MT.     

OMA's Continuing Education Program

Confronted with the inability to offer access to trained mental health personnel to their remote rural community, a private medical group practice in California recruited and integrated psychiatric social workers in their clinic. The rapid acceptance of these newer mental health professionals by community members of all economic levels and by group physicians confirms the success of this program, now in its fourth year, and rising community interest in mental health services.The group practice prototype affords a unique opportunity for innovation in community health care delivery in outlying areas with their traditional difficulties in attracting health care professionals.     

What Is So Special About a Family Physician?

Around a core of common, acute and chronic, recurrent health problems, a family physician must marshall the traditional episodic management for both inpatient and outpatient illness. He must also be especially adept at recently emerging routines of prevention and early detection. He provides individual and familial psychologic support and counselling, for both its therapeutic and preventive values. In addition, he must relate the individual care of his patient and the patient''s family to the community as a whole. In doing this he will use not only his own skills but those of lay health volunteers, trained allied health care professionals and skilled subspecialists in the limited medical disciplines.The proper preparation of family physicians for this complicated role has far-reaching implications for change in both medical education and medical practice.     

Moral courage in medicine--disclosing medical error

Medical error is an inevitable occurrence that stresses the relationship between healthcare professionals and their patients. The number of errors is shocking; so too, is the revelation that few medical errors are routinely disclosed. When healthcare providers fail to inform patients of harm-causing medical error, then trust in the patient/provider relationship is broken and many ethical challenges surface. To successfully restore trust and perhaps lower liability costs, healthcare providers must avoid pointing fingers and adopt a policy of honesty and full disclosure.     

Health professionals' overestimation of knowledge on snakebite management,a threat to the survival of snakebite victims—A cross-sectional study in Ghana

BackgroundAccording to the World Health Organization, snakebites, a common occupational hazard in developing countries accounts for an annual loss of between 81,000 and 138, 000 lives following 5 million bites of which 2.7 million results in envenomation. Since snakebite-associated morbidity and mortality are more prevalent in agricultural economies such as Ghana, health professionals should be optimally knowledgeable on how to manage the incidence of snakebites. Lack of knowledge or overestimation of a professional''s knowledge can affect heath delivery especially for emergencies such as snakebites. The three rurally situated Tongu districts in South-Eastern Ghana with agriculture as the major source of livelihood for their inhabitants, are prone to snakebites. This study, therefore, brings up the need to assess whether the health professionals in these districts are well-equipped knowledge-wise to handle such emergencies and whether they can rightly estimate their knowledge with regards to snakebite management.Methodology/Principal findingsData was collected using a de novo semi-structured questionnaire administered through google form whose link was sent via WhatsApp to 186 health workers made up of nurses, midwives, physician assistants, medical doctors, pharmacists, and pharmacy technicians. This data was analyzed using Statistical Package for the Social Sciences (SPSS) Version 25. Association between variables was determined using the appropriate tools where necessary, using a confidence interval of 95% and significance assumed when p ≤ 0.05. This study found male health workers significantly more knowledgeable about snakebite management (11.53±5.67 vs 9.64±5.46; p = 0.022) but it was the females who overestimated their knowledge level (27.9% vs 24.1%). The medical doctors exhibited the best knowledge on snakebite management with the registered general nurses least knowledgeable. Although most professionals overestimated their knowledge, the registered general nurses were the worst at that (53.7%). Overall knowledge of health care professionals on snakebite management was below average [10.60±5.62/22 (48.2%)] but previous in-service training and involvement in the management of snakebite were associated with better knowledge. Respondents who had no previous training overestimated their knowledge level compared to those who had some post-qualification training on snakebite management (38.1% vs 7.5%). The greatest knowledge deficit of respondents was on the management of ASV associated adverse reactions.ConclusionHealth workers in rural Ghana overestimated their knowledge about snakebite management although their knowledge was low. Training schools, therefore, need to incorporate snakebite management in their curriculum and health authorities should also expose health workers to more in-service training on this neglected tropical disease.     

Should living wills be legalized?

Living wills allow patients to state their wish to die and not be kept alive through the use of medications, artificial means or "heroic" measures. They have been made legal documents in 38 states in the United States. Living wills permit advance expression of a patient''s wishes, promote effective communication and demonstrate respect for the patient as a person. Problems with legal recognition of such wills include the need for agreement on fundamental terms, possible restriction of patients'' rights, limitation of options in decision-making and possible negative effects on the physician-patient relationship. Before legislation is enacted, public and professional attitudes toward the care of terminally ill patients should be assessed. All health care professionals should receive better education in this area, and palliative care services should be made more widely available. Only if these measures fail should living wills be made legal documents in Canada.     

Influenza vaccine scarcity 2004-05: implications for biosecurity and public health preparedness

In the event of a bioterrorist event or a pandemic flu outbreak, it might be necessary to ration vaccine or other treatments. In this article, researchers examine how medical and public health decision makers negotiated the unanticipated 2004-05 influenza vaccine shortage, using the regional hospital system headquartered in Pittsburgh, Pennsylvania, as the focal study site. This account of that case study describes the circumstances that contributed to the national and local vaccine shortage; the improvisation by health policymakers, hospital administrators, physicians, and nurses to prevent influenza cases despite the shortfall; and some of the legal, fiscal, logistical, social, and political pressures that local health professionals faced in deciding who should receive the limited supply of influenza vaccine. This instance of an acute vaccine shortage provided an opportunity to examine the practical and ethical dilemmas of managing medical resources during a public health emergency.     

Planificación anticipada de los cuidados y del uso de recursos hospitalarios en pacientes con COVID-19 en un programa de atención integrada para adultos mayores frágiles en residencias

ObjectivesTo estimate the magnitude and importance of a process of stratification and advance care planning and the use of health resources, among patients in an integrated health care program for frail elderls in nursing homes,that were referred to the hospital with COVID-19.Material and methodsProspective cohort study of patients > 64 years old with COVID-19 infection, in a health care program in nursing homes (from 3/15/2020 to 9/15/2020). The identification of patients with palliative needs, the performing and visible registration in electronic health records of the advance care planning and the use of intensive care were assessed.ResultsWe included 374 COVID-19 patients. 88% were women, the median age was 88 years old. The 79% were patients with palliative needs, of which 68% had the advance care planning (P<.001) registered in the electronic health record. Only 1% of patients with palliative needs and severity criteria were admitted to the intensive care unit. Overall mortality was 25%. Of those who died, 74% had severity criteria (P<.001) and 90% had palliative needs (P<.001).ConclusionsCarrying out a care process based on identification of patients with palliative needs and advance care planning and a central and visible registration of advance care planning in health records, could improve the quality and safety of care and optimize the use of intensive care health resources at all times and especially in public health emergencies.     

Incidental findings in data-intensive postgenomics science and legal liability of clinician-researchers: ready for vaccinomics?

Vaccinomics encompasses a host of multiomics approaches to characterize variability in host-environment (including pathogens) interactions, with a view to a more directed or personalized use of vaccine-based health interventions. Although vaccinomics has the potential to reduce adverse effects and increase efficacy of vaccines, the use of high-throughput, data-intensive technologies may also lead to unanticipated discoveries beyond the initial aims of a vaccinomics study--discoveries that could be highly significant to the health of the research participants. How do clinician-researchers faced with such information have to act? What are the attendant legal duties in such circumstances and how do they differ from the duties of non-clinician researchers? Together with a critical analysis of the international laws and policies framing researchers' duties with regard to incidental findings, this article also draws from Quebec's civil law--with its rich jurisprudence on clinician and researcher liability--as a case study to evaluate the potential legal implications associated with vaccinomics investigations. Given previous lessons learned from other data-intensive sciences, the education of clinician-researchers with regard to their roles, limitations, and legal obligations remains an important strategy to prevent potential legal complications and civil liability in vaccinomics research in the postgenomics era.     

Current Management of Surgical Oncologic Emergencies

ObjectivesFor some oncologic emergencies, surgical interventions are necessary for dissolution or temporary relieve. In the absence of guidelines, the most optimal method for decision making would be in a multidisciplinary cancer conference (MCC). In an acute setting, the opportunity for multidisciplinary discussion is often not available. In this study, the management and short term outcome of patients after surgical oncologic emergency consultation was analyzed.MethodA prospective registration and follow up of adult patients with surgical oncologic emergencies between 01-11-2013 and 30-04-2014. The follow up period was 30 days.ResultsIn total, 207 patients with surgical oncologic emergencies were included. Postoperative wound infections, malignant obstruction, and clinical deterioration due to progressive disease were the most frequent conditions for surgical oncologic emergency consultation. During the follow up period, 40% of patients underwent surgery. The median number of involved medical specialties was two. Only 30% of all patients were discussed in a MCC within 30 days after emergency consultation, and only 41% of the patients who underwent surgery were discussed in a MCC. For 79% of these patients, the surgical procedure was performed before the MCC. Mortality within 30 days was 13%.ConclusionIn most cases, surgery occurred without discussing the patient in a MCC, regardless of the fact that multiple medical specialties were involved in the treatment process. There is a need for prognostic aids and acute oncology pathways with structural multidisciplinary management. These will provide in faster institution of the most appropriate personalized cancer care, and prevent unnecessary investigations or invasive therapy.     

Disruptive medical patients. Forensically informed decision making.

Patients who disrupt medical care create problems for physicians. The risks are not entirely clinical. Although these patients may compromise sound clinical judgment, some are also litigious and express their dissatisfaction in legal or other forums. It then becomes necessary for treating physicians to be aware of the legal and ethical boundaries of their patient care responsibilities. Some disruptive patients are treated by setting limits, which is usually affirmed by health care agreements. A hospital review board may advise clinicians on these agreements and on the management of disruptive patients. If termination of the physician-patient relationship is considered, physicians must follow proper protocol. We examine these forensic considerations and place them in the context of malpractice. Communication, consultation, and documentation are the key elements in reducing liability.