The Impact of Immigration Policy Changes on Preterm Birth Rates in Texas: An Examination of Border and Nonborder Regions.

BACKGROUND: Our study examined the acute and sustained impact of immigration policy changes announced in January 2017 on preterm birth (PTB) rates among Hispanic and non-Hispanic white women in Texas's border and nonborder regions. METHODS: Using Texas birth certificate data for years 2008 through 2020, we used a multiple group interrupted time series approach to explore changes in PTB rates. RESULTS: In the nonborder region, the PTB rate among Hispanic women of any race was 8.64% in 2008 and was stable each year before 2017 but increased by .29% (95% CI [.12, .46]) annually between 2017 and 2020. This effect remained statistically significant even when compared with that of non-Hispanic white women (p = .014). In the border areas, the PTB rate among Hispanic women of any race was 11.67% in 2008 and remained stable each year before and after 2017. No significant changes were observed when compared with that of non-Hispanic white women (p = .897). In Texas as a whole, the PTB rate among Hispanic women of any race was 10.16% in 2008 and declined by .07% (95% CI [-.16, -.03]) per year before 2017, but increased by .16% (95% CI [.05, .27]) annually between 2017 and 2020. The observed increase was not statistically significant when compared with that of non-Hispanic white women (p = .326). CONCLUSIONS: The January 2017 immigration policies were associated with a sustained increase in PTB among Hispanic women in Texas's nonborder region, suggesting that geography plays an important role in perceptions of immigration enforcement. Future research should examine the impact of immigration policies on maternal and child health, considering geography and sociodemographic factors.

The Boundaries of "Good Behavior" and Judicial Competence: Exploring Responsibilities and Authority Limitations of Cognitive Specialists in the Regulation of Incapacitated Judges.

Both law and medicine rely on self-regulation and codes of professionalism to ensure duties are performed in a competent, ethical manner. Unlike physicians, however, judges are lawyers themselves, so judicial oversight is also self-regulation. As previous literature has highlighted, the hesitation to report a cognitively-compromised judge has resulted in an "opensecret" amongst lawyers who face numerous conflicts of interest. Through a case study involving a senior judge with severe cognitive impairment, this article considers the unique ethical dilemmas that cognitive specialists may encounter when navigating duties to patient, society, and the medical profession, without clear legal guidance. Systemic self-regulatory inadequacies in the legal profession are addressed, as well as challenges that arise when trying to preserve the trust and dignity of an incapacitated patient who must fulfill special duties to society. Ultimately, because of their unique neurological expertise and impartial assessments, we submit that allowing cognitive specialists to submit their assessments to an internal judiciary board may act as an additional check and balance to ensure the fair and competent administration of justice.

Capacity Evaluation Requests in the Medical Setting: A Retrospective Analysis of Underlying Psychosocial and Ethical Factors.

BACKGROUND: Psychosocial and ethical variables influence physicians in requesting decision-making capacity (DMC) evaluations. Previous authors have classified certain DMC evaluation requests as "unwarranted" when there is no explicit suspicion or evidence that the patient might lack DMC. OBJECTIVE: To explore psychosocial and ethical reasons motivating both "warranted" and "unwarranted" DMC evaluation requests by physicians in the medical setting. METHODS: A retrospective electronic health record review was approved by the institutional review board. All psychiatric consultation requests identified as DMC evaluation requests between January 1, 2012 and December 31, 2012 were assessed independently by 2 reviewers. Each reviewer identified each DMC evaluation request as "warranted" vs "unwarranted." Unwarranted DMC evaluation requests were defined as those lacking explicit suspicion that the patient might lack DMC or those with explicit evidence of a patient with blatantly impaired DMC. We hypothesized that most (over half) DMC evaluation requests would be deemed unwarranted. Descriptive statistics, chi-square/Fisher exact tests, and t-test/ANOVA were used. RESULTS: A total of 146 DMC evaluations were reviewed, and 83 (56.8%) of these were deemed unwarranted. Of these, most were likely driven by a previous neuropsychiatric disturbance (p < 0.001). Various other psychosocial and ethical patterns were identified (i.e., the practice of defensive medicine and guardianship concerns). CONCLUSION: Over half of DMC evaluation requests in a general medical setting were unwarranted. Many such requests were motivated by unarticulated psychosocial and ethical factors. DMC evaluation requests appear to serve as a means for indirectly resolving various psychosocial and ethical dilemmas beyond assessing DMC itself. Implications and future directions are discussed.

In My Best Interest.

BACKGROUND: Advance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration's Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed. OBJECTIVE: To describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs. DESIGN/SETTING: A descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014. MEASUREMENTS: Responses to VA AD with emphasis on health care agents (HCAs) and LW responses. RESULTS: Veterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA. CONCLUSION: Most of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.

Setting a Minimum Standard of Care in Clinical Trials: Human Rights and Bioethics as Complementary Frameworks.

For the past few decades, there has been intense debate in bioethics about the standard of care that should be provided in clinical trials conducted in developing countries. Some interpret the Declaration of Helsinki to mean that control groups should receive the best intervention available worldwide, while others interpret this and other international guidelines to mean the best local standard of care. Questions of justice are particularly relevant where limited resources mean that the local standard of care is no care at all. Introducing human rights law into this complex and longstanding debate adds a new and important perspective. Through non-derogable rights, including the core obligations of the right to health, human rights law can help set a minimum standard of care.

"She Just Doesn't Know Him Like We Do": Illuminating Complexities in Surrogate Decision Making.

When patients are not able to speak for themselves, surrogate decision makers are asked to guide treatment decisions and formulate a plan of care in accordance with what the patients would have wanted. This necessitates an exploration into the patients' views about life and how it should be lived, how the patients constructed their identity or life story, and their attitudes towards sickness and suffering. When an individual appoints a surrogate, such as a healthcare power of attorney, a common presumption is that this designation evinces merit. This obscures the possibility of multiple other considerations that influence individual choice. This article presents a clinical case in which the claim to know someone best created a controversy that brought treatment decisions to a standstill. Further, it illuminates how the question, "Given the current medical condition, what would this person want?" risks presuming that a singular, unambiguous preference exists and that one person can provide the answer. Clinical ethicists can play a vital role in situations when there is a dispute among a designated surrogate and family members over a patient's preference. By embracing the complexity of the desire to synthesize seemingly irreconcilable perspectives about identity, uncovering the reasons that underlie disagreement, and guiding inquiry in such a way that allows stakeholders to move beyond the conflict, clinical ethicists can facilitate decision making that honors the patient and may mitigate moral distress.