Five Things Clinicians Should Know When Caring for Unrepresented Patients.

Increasingly, clinicians confront patients who are incapacitated and have no available surrogate. Such unrepresented patients cannot consent to proposed health care, and nobody else is available who is authorized to consent on their behalf. Despite the challenge of decision making for unrepresented patients, few laws or professional organization policy statements offer a solution. This article helps fill this void by describing the top 5 things clinicians should know when they are caring for unrepresented patients: (1) realize that these patients are highly vulnerable; (2) confirm that the patient is incapacitated; (3) confirm that the patient is unrepresented; (4) appreciate variability among state law decision-making processes for unrepresented patients; (5) use guardianship only as a last resort.

Legal Briefing: Medicare Coverage of Advance Care Planning.

This issue's "Legal Briefing" column covers the recent decision by the Centers for Medicare and Medicaid Services (CMS) to expand Medicare coverage of advance care planning, beginning 1 January 2016. Since 2009, most "Legal Briefings" in this journal have covered a wide gamut of judicial, legislative, and regulatory developments concerning a particular topic in clinical ethics. In contrast, this "Legal Briefing" is more narrowly focused on one single legal development. This concentration on Medicare coverage of advance care planning seems warranted. Advance care planning is a frequent subject of articles in JCE. After all, it has long been seen as an important, albeit only partial, solution to a significant range of big problems in clinical ethics. These problems range from medical futility disputes to decision making for incapacitated patients who have no available legally authorized surrogate. Consequently, expanded Medicare coverage of advance care planning is a potentially seismic development. It may materially reduce both the frequency and severity of key problems in clinical ethics. Since the sociological, medical, and ethical literature on advance care planning is voluminous, I will not even summarize it here. Instead, I focus on Medicare coverage. I proceed, chronologically, in six stages: 1. Prior Medicare Coverage of Advance Care Planning 2. Proposed Expanded Medicare Coverage in 2015 3. Proposed Expanded Medicare Coverage in 2016 4. The Final Rule Expanding Medicare Coverage in 2016 5. Remaining Issues for CMS to Address in 2017 6. Pending Federal Legislation.

Legal briefing: home birth and midwifery.

This issue's "Legal Briefing" column covers recent legal developments involving home birth and midwifery in the United States. Specifically, we focus on new legislative, regulatory, and judicial acts that impact women's' access to direct entry (non-nurse) midwives. We categorize these legal developments into the following 12 categories. 1. Background and History 2. Certified Nurse-Midwives 3. Direct Entry Midwives 4. Prohibition of Direct Entry Midwives 5. Enforcement of Prohibition 6. Challenges to Prohibition 7. Forbearance without License 8. Voluntary Licensure 9. Unclear and Uncertain Status 10. Growth of DEM Licensure 11. Licensure Restrictions 12. Medicaid Coverage

Legal briefing: Healthcare ethics committees.

This issue's "Legal Briefing" column covers recent legal developments involving institutional healthcare ethics committees. This topic has been the subject of recent articles in JCE. Healthcare ethics committees have also recently been the subject of significant public policy attention. Disturbingly, Bobby Schindler and others have described ethics committees as "death panels." But most of the recent attention has been positive. Over the past several months, legislatures and courts have expanded the use of ethics committees and clarified their roles concerning both end-of-life treatment and other issues. These developments are usefully grouped into the following eight categories: 1. Existence and availability. 2. Membership and composition. 3. Operating procedures. 4. Advisory roles. 5. Decision-making and gate-keeping roles. 6. Confidentiality. 7. Immunity. 8. Litigation and court cases.

Legal briefing: organ donation and allocation.

This issue's "Legal Briefing" column covers legal developments pertaining to organ donation and allocation. This topic has been the subject of recent articles in JCE. Organ donation and allocation have also recently been the subjects of significant public policy attention. In the past several months, legislatures and regulatory agencies across the United States and across the world have changed, or considered changing, the methods for procuring and distributing human organs for transplantation. Currently, in the U.S., more than 100,000 persons are waiting for organ transplantation. In China, more than 1.5 million people are waiting. Given the chronic shortage of available organs (especially kidneys and livers) relative to demand, the primary focus of most legal developments has been on increasing the rate of donation. These and related developments are usefully divided into the following 12 topical categories: 1. Revised Uniform Anatomical Gift Act. 2. Presumed Consent and Opt-Out. 3. Mandated Choice. 4. Donation after Cardiac Death. 5. Payment and Compensation. 6. Donation by Prisoners. 7. Donor Registries. 8. Public Education. 9. Other Procurement Initiatives. 10. Lawsuits and Liability. 11. Trafficking and Tourism. 12. Allocation and Distribution.

Legal briefing: conscience clauses and conscientious refusal.

This issue's "Legal Briefing" column covers legal developments pertaining to conscience clauses and conscientious refusal. Not only has this topic been the subject of recent articles in this journal, but it has also been the subject of numerous public and professional discussions. Over the past several months, conscientious refusal disputes have had an unusually high profile not only in courthouses, but also in legislative and regulatory halls across the United States. Healthcare providers' own moral beliefs have been obstructing and are expected to increasingly obstruct patients' access to medical services. For example, some providers, on ethical or moral grounds, have denied: (1) sterilization procedures to pregnant patients, (2) pain medications in end-of-life situations, and (3) information about emergency contraception to rape victims. On the other hand, many healthcare providers have been forced to provide medical treatment that is inconsistent with their moral beliefs. There are two fundamental types of conscientious objection laws. First, there are laws that permit healthcare workers to refuse providing - on ethical, moral, or religious grounds healthcare services that they might otherwise have a legal or employer-mandated obligation to provide. Second, there are laws directed at forcing healthcare workers to provide services to which they might have ethical, moral, or religious objections. Both types of laws are rarely comprehensive, but instead target: (1) certain types of healthcare providers, (2) specific categories of healthcare services, (3) specific patient circumstances, and (4) certain conditions under which a right or obligation is triggered. For the sake of clarity, I have grouped recent legal developments concerning conscientious refusal into eight categories: 1. Abortion: right to refuse 2. Abortion: duty to provide 3. Contraception: right to refuse 4. Contraception: duty to provide 5. Sterilization: right to refuse 6. Fertility, HIV, vaccines, counseling 7. End-of-life measures: right to refuse 8. Comprehensive laws: right to refuse.

Legal briefing: Informed consent.

This issue's "Legal Briefing" column covers legal developments pertaining to informed consent. Not only has this topic been the subject of recent articles in this journal, but it also been the subject of numerous public and professional discussions over the past several months. Legal developments concerning informed consent can be usefully grouped into nine categories: 1. General disclosure standards in the clinical context; 2. Shared decision making; 3. Staturorily mandated abortion disclosures; 4. Staturorily mandated end-of-life counseling; 5. Other staturorily mandated subject-specific disclosures; 6. U.S. Food and Drug Administration (FDA) labeling and federal pre-emption of state informed consent law; 7. Relaxed informed consent for HIV testing; 8. General disclosure standards in the research context; 9. Issues on the horizon.