Economic influences on end-of-life care: empirical evidence and ethical speculation.

Although very little actual evidence on the issue is available, much ethical speculation has been voiced about the probable impact of the current cost containment-oriented economic climate in the United States on decisions that are being made and implemented in the context of end-of-life medical care. This article, after noting that numerous factors besides money drive the behavior of various actors in the health care system, turns to the economic influences on care for dying patients. These influences, both real and imagined, may be manifested in the amount of de facto health care rationing by age that occurs, the prevalent fears of older persons regarding both overtreatment and undertreament, the financial expectations as well as disappointments emanating from the practice of advance medical planning, and the paucity of options from which many impoverished individuals must choose at the end of their lives. It is too early to judge specifically the impact of managed care on end-of-life decisions, but positive opportunities as well as perils may materialize.

Legal interventions for persons with dementia in the USA: ethical, policy and practical aspects.

The US legal system has developed a number of methods by which the state or private parties may intervene to protect persons, including those with dementia, who lack sufficient cognitive or emotional capacity to make and express autonomous choices about various aspects of their lives. These interventions may be planned and voluntary or unplanned and involuntary. This article explores the ethical and cultural values underlying legal alternatives in the United States and their strengths and weaknesses when measured against those values. The article poses issues about which US policy makers, health and human service practitioners, and attorneys might seek wisdom from the various strategies that other countries have devised to deal with the challenge of protecting, but not overprotecting, their own citizens with dementia.

Professional development in law, health care, and aging: a model fellowship program.

There is a growing need for a strong core of professionals with the knowledge, skills, and sensitivities necessary to integrate the fields of law, health care, and gerontology. This article describes a unique professional development program that attempted to address this need by making it possible for a small number of recently graduated attorneys to observe, experience, and question on a firsthand level the provision of various forms of health care to older patients.

The legal status of clinical practice parameters: an updated annotated bibliography.

In response to extensive speculation about the probable liability implications for health care providers of the formal creation and dissemination of explicit practice parameters of guidelines, I prepared several years ago an annotated bibliography of emerging literature on that topic (1). Since preparation of that catalogue, little meaningful clarification of these issues has emerged from the courts, legislatures, or regulatory agencies.

Treatment and refusal rights in mental health: therapeutic justice and clinical accommodation.

The impact of recognition by courts and legislatures in the 1970s and early 1980s of patients' rights to receive or to refuse mental health treatment is evaluated. The implementation of these rights in practice does not appear to have exerted an unduly disruptive or destructive effect on mental health services or their clienteles. At the same time, their recognition has not led to the salutary therapeutic jurisprudence envisioned by their proponents.