Sex offenders, sentencing laws and pharmaceutical treatment: a prescription for failure.

The phenomenon of adults who have sexual interests involving children as partners, or pedophiles, is considered among the most sociopathological of human conditions. Considerable literature is devoted to issues and problems associated with or related to pedophilia, including prevalence, etiology, treatment, and outcome studies. The sexual victimization of children, based upon data gathered from a number of sources, suggests an intractable problem that is national in scope. Recent manifestations of society's efforts to deal with the sexual victimization of children include the enactment of criminal sentencing laws that mandate the treatment of offenders with certain pharmaceutical agents, such as medroxy-progesterone acetate ("MPA"). Because sentencing laws as a rule vary widely from state to state, there is considerable variation as to who is subject to MPA treatment laws, and how such laws-including specific provisions, such as clinical criteria, if any, required for treatment; type and period of treatment plans; informed consent; etc-are implemented. Most important, these sentencing laws may have remarkably little relation to what is widely considered effective treatment for pedophilia disorders. We examine in detail the most recent sentencing laws pertaining to treatment of persons who have been convicted of sex offenses involving children as victims. Our critique may offer insight and suggestions as to how such sentencing laws can be more suitably tailored to the treatment needs of persons with pedophilia disorders.

Goals and strategies for teaching death and dying in medical schools.

Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should be identified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meet the needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Education on Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools. They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medical schools could miss their mark in fostering the student's ability to care for the dying.

Protecting subjects and fostering research. Striking the proper balance.

Bonnie reminds us of the heritage and limitations of human subjects research. He points out that over the years, the protection of human subjects in research has enjoyed progress, experienced false starts, and endured inflated expectations. Both he and Elliott call attention to the fact that IRB review rarely probes how researchers propose to deal with impairments to subjects' decision-making capacities. We agree to IRBs should be encouraged to rethink their roles. But, as Bonnie argues, this requires a systematic review of the roles and functions of IRB rather than ad hoc adjustments by individual institutional IRBs. His proposal that IRBs should be encouraged to be more vigilant and through in their monitoring of research is sound, especially if the subjects are vulnerable or the research is risky. A strength of Bonnie's review is that it suggests both specific ways to test competency and a range of options for IRBs to ensure that vulnerable subjects are protected from overzealous or overreaching researchers. His historical review and normative proposals are objective, balanced, and thoughtful. Elliott's critique seems to single out psychiatric research with depressed patients as a special problem area. Although his title emphasizes severely depressed patients, he sometimes appears to neglect the fact that depression ranges across a spectrum from mild to severe. Elliott's point is well taken that severely depressed patients who are clearly incompetent should not, unless proper safeguards are provided, be enrolled in research. But his analysis falters because his position does not in the end respect personal autonomy.

Educating medical students about law and the legal system.

The study of jurisprudence--law, legal reasoning, and the legal system--has become progressively more common in medical school curricula. Familiarity with jurisprudence helps physicians practice medicine well, collaborate productively with lawyers, and be more effective in public discourse about health care delivery. Moreover, the study of jurisprudence can help physicians polish the methods and clarify the purposes common to law and medicine. Empirical studies over the last 30 years demonstrate patterns of change in the frequency and focus of jurisprudence teaching in medical school curricula that can guide contemporary efforts to devise or refine curricula in medical jurisprudence. The general goal of such curricula should be to enhance physicians' clinical, institutional, and public effectiveness. These curricula should adhere to principles of sound pedagogy and be based on informed answers to the central questions of what should be taught, when, how, and by whom, and how the curriculum should be evaluated. Developing skills and changing attitudes are more important than imparting information about particular doctrines and laws. Curriculum planners should take into account the intellectual styles of the learners; integrate, not just coordinate, the new courses with the rest of the curriculum; build on features that medicine and law share and where they collaborate; and ensure intra- and inter-curricular coherence and continuity. Even though limitations of time, people, and money and differences in educational goals will influence what, when, and how medical jurisprudence is taught, the effort should be made if physicians are to be better empowered to use the law and their law colleagues to serve patients and promote public welfare.

Eavesdropping on the 50-minute hour: managed mental health care and confidentiality.

This article discusses managed care, recent case law developments, and the legal basis of confidentiality in the patient-therapist relationship. It discusses how managed care intrudes into the confidential treatment relationship with prospective and retrospective utilization reviews. Some of the areas adversely impacted include public policy, the patient-therapist relationship, and informed consent. In order to be a program in the interest of patients and not simply cost containment, managed care must accommodate patients' reasonable expectations of confidentiality. Suggestions are delineated for the protection of confidentiality by managed care, including expanding the duty of confidentiality to managed care, obligating managed care to secure patients' informational privacy, obtaining informed consent to disclose as little information as necessary, and involving the patient in the cost containment and quality assurance process.

Privacy, confidentiality, and privilege in psychotherapeutic relationships.

The dilemma faced by mental health professionals in guaranteeing clients' privacy and confidentiality while complying with the legitimate requests of third parties for confidential information is addressed. How that dilemma is played out in relation to child-abuse reporting laws is examined in terms of the legal and ethical aspects of privacy, confidentiality, and privilege in mental health practice.

Legal regulation of terminal care: options and obstacles.

The law regulates some aspects of medical practice and facilitates other aspects. Two laws in Texas that both facilitate and regulate medical care are the Texas Natural Death Act (TNDA) and the Durable Power of Attorney for Health Care (DPOAHC). The TNDA implements the treatment wishes of the patient who is terminally ill. The DPOAHC designates a proxy to make medical decisions for patients when they become incompetent. Because these laws can provide considerable help in caring for terminally ill or incompetent patients, physicians in Texas should understand these laws and use them in their practices.

Suicide of AIDS patients in Texas: a preliminary report.

The incidence of suicide in patients with the diagnosis of acquired immunodeficiency syndrome (AIDS) in the state of Texas during the period between January 1986 and August 1987 was determined. AIDS patients were found to have a rate of suicide higher than expected when compared to the general population. The results of this study document this trend which has important implications in the care of the growing number of patients with AIDS.

Rights, roles, and relationships in radiology.

Traditionally, radiologists report their findings to the referring physician. When a patient who understands the reason for the diagnostic examination asks the radiologist to disclose the results, in most cases the radiologist should not decline but should answer truthfully.