File Name: the law of life and the law of death.zip
Interdisciplinary Perspectives on Mortality and its Timings pp Cite as.
Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. The principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment may be inferred from our prior decisions. Cruzan v. A seriously ill or dying patient whose wishes are not honored may feel a captive of the machinery required for life-sustaining measures or other medical interventions.
The roles of judges, legislators, and administrative officials in influencing care at the end of life vary from the dramatic to the commonplace. On the dramatic end of the continuum are the court cases about the legality of physician-assisted suicide, which were argued before the U. Supreme Court as this report was being drafted. In contrast, the right of people to refuse unwanted life-sustaining and other treatments—once the subject of highly charged court cases—is now commonly accepted and enforced if not always perfectly.
Documenting the impact of statutes, regulations, case law, and administrative actions on clinicians, patients, families, and others can be difficult.
In addition, the applicability of various statutes and judicial precedents to specific patient circumstances is quite often a matter of dispute and speculation rather than straightforward matching of law to facts. Nonetheless, in the committee's view, the legal issues discussed here raise concerns either about their possible effects on compassionate and effective care for those approaching death or about the unrealistic expectations they may create or both.
This chapter considers laws relating to prescription of opioids, informed consent and advance directives, and assisted suicide. Among those with clinical, administrative, or similar involvement in end-of-life care, much of the debate about issues such as prescription regulation or informed consent is practical.
For example, how can prescription laws be modified so that they do not discourage effective pain management but still respond to legitimate concerns about misuse of controlled substances? For some issues, most notably assisted suicide and euthanasia, ethical concerns may dominate legal discussions, but practical issues also arise as described later in this chapter. The focus here is primarily on how laws may affect the quality of care for dying patients.
Although the impact of malpractice litigation on medical practice is a complex and disputed question, it is discussed only briefly because the committee did not view the prospect of malpractice litigation as likely to have a significant impact on end-of-life care specifically. The committee, however, recognized concerns that physicians may engage in defensive medicine e.
Similarly, decisions might sometimes be influenced by the fear of being sued for not following a family's wishes, even if those wishes were contrary to the doctor's clinical judgment and the patient's own wishes. The committee did not find evidence that physicians were concerned about liability for failure to intervene to relieve pain or other symptoms. In any case, many of the steps proposed in this report would tackle problems of undertreatment, overtreatment, or mistreatment of dying patients in ways that should reduce the potential for litigation and physician uncertainties and fears about being sued.
At the practitioner level, these steps include changing clinicians' attitudes, knowledge, and practices so that they communicate more effectively with patients and families, engage patients and families in a process of goal setting and decisionmaking that increases trust and minimizes misunderstanding, and properly assess and treat pain and other symptoms.
At the system level, they include strategies for measuring, monitoring, and improving care that seek to identify and respond to the preferences, experiences, and feelings of patients and families.
If, however, these strategies fail to correct the deficits identified in Chapter 3 and if patients come to understand that the standards of care e. The primary injured plaintiff would, in the case of a dying patient, likely have died, and although a family could claim injury and testify about the decedent's suffering, damages would be hard to establish.
In addition, the status of practice guidelines in the courts. Overall, the committee was doubtful that malpractice litigation could be relied upon as an instrument to improve care at the end of life.
All patients who suffer pain—not just the dying—deserve relief through treatments that are known to be effective for most pain. Indeed, early treatment of pain as a part of a continuum of good care for those who are seriously ill may be the best approach to minimizing pain at the end of life. Other parts of this report document deficiencies in pain management and gaps in scientific knowledge. This section examines how effective pain management may be compromised by prescription drug laws that are intended to minimize drug addiction and diversion of drugs from legal to illegal sources.
Relief of dyspnea may also be affected by these laws, although this has not been the subject of much attention. Because these laws both arise from and interact with the misperceptions and attitudes of physicians, medical boards, lawmakers, patients, and the public, reform needs to go beyond revisions in written policies to affect knowledge and values.
Diversion occurs when persons with legal access to controlled substances distribute them or use them for illegal purposes or when people fraudulently obtain drugs from legal sources Cooper et al. Alternatively, people might forge prescriptions or misrepresent their symptoms to secure prescriptions. Newspaper articles and television news reports periodically expose the problems of diverted opioids and clinician addiction.
No reliable studies document the extent of opioid diversion specifically or compare it to other illegal sources e. A household survey estimated that 4 percent of the population over the age of 12 had used prescription analgesics, stimulants, tranquilizers, or sedatives at least once for nonmedical reasons in the preceding year, and almost 1.
A California estimate puts the. Theft and other forms of illegal access are also problems but are less susceptible to control through anti-diversion regulations.
Legal and regulatory policies intended to prevent diversion include triplicate prescriptions and limits on the number of medication dosages that may be prescribed at any one time. These policies are burdensome and appear to deter legitimate prescribing of opioids see, e.
Triplicate prescription programs require the prescribing physician to complete detailed, multiple-copy prescription forms. The forms themselves are often difficult to obtain and, if incorrectly filled out, must be completed again by the physician. The triplicate forms also become available to the state medical board, which may choose to pursue disciplinary measures on the basis of such information.
Electronic forms and monitoring systems would ease the burden on physicians as well as allow easier monitoring but such systems have not been widely adopted or rigorously evaluated nor have appropriate norms to guide such oversight been developed and tested. Some states have laws limiting the dosages a physician may prescribe to one patient at any given time. These laws force patients who suffer pain that requires frequent medication to request and renew prescriptions repeatedly.
This not only inconveniences both patients and physicians but may subject patients to possible interruptions in pain management if something disrupts the timely requests and responses. Such problems are a special concern for patients who are not in a medical facility but are at home or in a care facility without an on-site physician. The committee recognizes the problems created by illegal drug use and drug diversion and the need for law enforcement responses.
It, however, knows of no evidence, anecdote, or other reason to believe that the prescription of opioids in the care of dying patients contributes in any meaningful way to drug diversion problems.
The effect of anti-diversion policies on their intended targets is unclear. They do, however, appear to affect the rate of prescriptions and perhaps increase the use of less effective or even harmful medications Cooper et al. One study reported that when Texas introduced a multiple-copy prescription program, prescriptions for opioids to control pain were halved Sigler et al.
It is not known whether this dramatic drop resulted from declines in inappropriate prescribing and diversion or whether physicians and pharmacists became reluctant to prescribe appropriate medications. Nonetheless, the magnitude of the change makes it reasonable to expect that the regulation had some impact on patient care Von Roenn et al.
Bishop, Surveys of physicians—discussed further below—suggest that anti-diversion and anti-addiction policies combined with social antipathy toward real or imagined addiction discourages effective, appropriate, and legal pain prevention and management. How can laws be constructed and interpreted in ways that minimize drug diversion without obstructing effective medical management of pain? Options include 1 replacing triplicate forms with electronic reporting of prescriptions and 2 allowing standing prescriptions for outpatients to be monitored by home health care professionals or pharmacists.
In addition to reducing regulatory barriers to effective pain prescribing practices, states could require that pain experts or palliative care specialists be represented on state medical boards to help inform board policies and interpretations. Information collected from triplicate or electronic prescriptions might also be analyzed to identify questionable prescribing practices, which could be used to guide education of physicians and pharmacists about effective and appropriate use of opioids.
Another IOM committee has already recommended additional research on the effects of controlled substance regulations on patient care and scientific research IOM, d. The creation of new addictions is a separate issue from the diversion of drugs to the black market. A collection of social forces joins with legal restrictions to create a general antipathy toward drug use that flows into the area of medical practice and undermines effective pain management. Even the terminology muddies the waters when chronic use of opioids, which produces physical dependence, is sometimes equated with addiction.
For example, California law defines addicts as "habitual users," which might include patients with chronic pain who regularly and appropriately take opioids necessary to manage their pain Marcus, States have addressed the perceived problem of medically induced drug addiction through varied combinations of laws, regulations, and medical board disciplinary policies.
Because the committee concluded that policies often reflect inadequate understanding of the mechanisms of pain and addiction, these mechanisms will be described before the policies are considered. Research indicates that addiction in patients appropriately receiving opioids for pain is very small, ranging from roughly 1 in 1, to less than 1 in 10, Porter and Jick, ; Angell, ; Jaffe, ; Rinaldi et al.
The committee concluded that drug tolerance and physical dependence should be more uniformly and clearly distinguished from addiction. Tolerance occurs when a constant dose of a drug produces declining effects or when a higher dose is needed to maintain an effect. Physical dependence on opioids is characterized by a withdrawal effect following discontinuation of a drug. Such dependence is a common effect in chronic pain management, but it is not restricted to opioids. Other agents such as beta-blockers, caffeine, and corticosteroids also produce physical dependence.
Further, clinical evidence suggests that patients receiving opioids can be easily withdrawn from them in favor of an alternative, effective pain control mechanism if that is clinically indicated. Typical practice is to reduce the dose by fractions, stopping administration of opioids altogether after a week or so Doyle et al. This practice may not be relevant, however, for dying patients.
Neither physical dependence nor tolerance should be equated with addiction or substance abuse. Portenoy and Kanner proposed that "addiction is a psychological and behavioral syndrome characterized by 1 the loss of control over drug use, 2 compulsive drug use, and 3 continued use despite harm" p.
This is consistent with a definition proposed by the American Medical Association: "the compulsive use of a substance resulting in physical, psychological, or social harm to the user and continued use despite that harm" Rinaldi et al. The federal Controlled Substances Act defines an addict as someone who habitually uses an opioid in ways that endanger public health or safety AHCPR, a.
Unfortunately, the general term substance dependence is often used as a synonym for addiction, perhaps because the latter is more stigmatizing. For example, the American Psychiatric Association sets out criteria for dependence rather than addiction in its Diagnostic and Statistical Manual of Mental Disorders 4th ed. Despite a disclaimer that the scheme focuses on "maladaptive" substance use, the discussion of substance dependence may nonetheless mislead p.
A later disclaimer about distinguishing legitimate medical purposes from opioid dependence is not specific, given that, as described below, many seem to be confused about what is legitimate. The committee is particularly concerned about misinterpreta-.
Tolerance and withdrawal are, in general, clinically acceptable although not necessarily invariable or desirable consequences of effective use of opioids to manage pain, and "overuse" as defined above may be difficult to distinguish from increasing use due to uncontrolled pain, which may result from increasing pathology, tolerance, or other sources Weissman and Haddox, Similarly, some behaviors suggestive of addiction may be confused with those resulting from inadequately managed pain or anxiety about the reliability of pain management.
Responses to the problem of addiction take several forms including some of those already identified in the discussion of drug diversion. Federal and state laws and regulations attempt to control the prescribing behavior of physicians, nurses, and pharmacists by criminalizing certain activities. In addition to legislatures and courts, state medical boards set policies that, although not having the official force of law, may be just as powerful in their effect.
These policies dictate the standards by which physicians may be professionally disciplined. Laws and medical board policies are also intertwined, in that legislatures may place legal limitations on the extent of a medical board's powers. Medical Board Policies. State medical boards may establish guidelines on pain-prescribing practices that constitute official statements of board policy. Such guidelines describe acceptable medical practice and notify health care practitioners of professional boundaries.
Patient-directed care at the end of life. This bill enacts the Maine Death with Dignity Act authorizing a person who is 18 years of age or older, who meets certain qualifications and who has been determined by the person's attending physician to be suffering from a terminal disease, as defined in the Act, to make a request for medication prescribed for the purpose of ending the person's life. The bill establishes the procedures for making these requests, including 2 waiting periods and one written and 2 oral requests and requires a 2nd opinion by a consulting physician. The bill requires specified information to be documented in the person's medical record, including all oral and written requests for a medication to hasten death. The bill requires the attending and consulting physicians to assess the patient for depression or other mental health condition that impairs judgment. If the attending or consulting physician, in the physician's professional opinion, believes such a condition exists, the patient must be evaluated and treated by a state-licensed psychiatrist, psychologist, clinical social worker or clinical professional counselor.
The right to die is a concept based on the opinion that human beings are entitled to end their life or undergo voluntary euthanasia. Possession of this right is often understood that a person with a terminal illness , incurable pain, or without the will to continue living, should be allowed to end their own life, use assisted suicide , or to decline life-prolonging treatment. The question of who, if anyone, may be empowered to make this decision is often subject of debate. Some academics and philosophers , such as David Benatar , consider humans to be overly optimistic in their view of the quality of their lives, and their view of the balance between the positive and the negative aspects of living. Proponents typically associate the right to die with the idea that one's body and one's life are one's own , to dispose of as one sees fit.
Death in Jack London's 'The Law of Life' - American Studies / Literature - Term Paper Format: PDF, ePUB and MOBI – for PC, Kindle, tablet, mobile.
In , the Task Force released Allocation of Ventilators in an Influenza Pandemic: Planning Document — Draft for Public Comment March 15, , which addressed how ventilators should be allocated to adults in the event of a shortage due to a pandemic outbreak of influenza. Though scientists do not know with certainty whether or when a pandemic will occur, the better prepared New York State is, the greater its chances of reducing morbidity, mortality and economic consequences. If the most severe forecast becomes a reality, New York State and the rest of the country will confront the allocation of a limited number of ventilators. These innovative Guidelines were amongst the first of their kind to be released in the United States and have been widely cited and followed by other states. In November , the Task Force released its updated Guidelines.
Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. The principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment may be inferred from our prior decisions. Cruzan v. A seriously ill or dying patient whose wishes are not honored may feel a captive of the machinery required for life-sustaining measures or other medical interventions. The roles of judges, legislators, and administrative officials in influencing care at the end of life vary from the dramatic to the commonplace. On the dramatic end of the continuum are the court cases about the legality of physician-assisted suicide, which were argued before the U.
Code of Hammurabi. Much can be learned both about Mesopotamian life and ideals through these laws. It should be kept in mind that we cannot be sure how well enforced these laws were, but it is safe to say that a powerful king in ancient Mesopotamia thought these were the laws that would guide a just society. This code was not was not an entirely new set of laws, but a compilation and revision of earlier law codes of the Sumerians and Akkadians.
Though his sight had long since faded, his hearing was still acute,and the slightest sound penetrated to the glimmering intelligence which yet abode behind thewithered forehead, but which no longer gazed forth upon the things of the world. Sit-cumto-hawas his daughter's daughter, but she was too busy to waste a thought upon her brokengrandfather, sitting alone there in the snow, forlorn and helpless. Camp must be broken. The longtrail waited while the short day refused to linger. Life called her, and the duties of life, not death. Andhe was very close to death now.
Within the UK, the law adopts brain-stem death (BSD) as the point at which life ends. Some commentators argue for the introduction of a legal concept of higher-.
Jack London really John Griffith was born in San Fransisco and is believed to have been the illegitimate son of William Henry Chaney, an astrologer. Flora Wellman, his mother, married John London soon after Jack's birth. He grew up on the waterfront of Oakland and his schooling was intermittent. Much of his youth was spent on the wrong side of the law. Among other things he was an oyster pirate, and he also spent a month in prison for vagrancy. At the age of 17 he signed on a sailing ship which took him to the Arctic and Japan.
In , Oregon enacted the Death With Dignity Act, allowing terminally ill Oregonians to end their lives through the voluntary self-administration of a lethal dose of medication, expressly prescribed by a physician for that purpose. Our position is a neutral one, and we believe these data are important to parties on both sides of the issue. While it is not our role to interpret the DWDA, we routinely receive inquiries about the law. Below are answers to some frequently asked questions. Please browse the list of questions below or download FAQs pdf. A: The Death with Dignity Act DWDA is a permissive law that allows terminally ill Oregonians to end their lives through the voluntary self-administration of a lethal dose of medication, expressly prescribed by a physician for that purpose.
This means that terminally-ill Californians who meet specific requirements can once again legally obtain life-ending medications while the case works its way through the courts. This could be a long process of uncertainty for everyone involved. The original case on which Ottolia ruled, Ahn v. Hestrin, has two parts. One part argues it is invalid because it was passed during a special legislative session called for a different purpose, which is unconstitutional.
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ГЛАВА 124 - Атаке подвергся последний щит. На ВР отчетливо было видно, как уничтожалось окно программной авторизации. Черные всепроникающие линии окружили последний предохранительный щит и начали прорываться к сердцевине банка данных. Алчущие хакеры прорывались со всех уголков мира.
Она в столовой. Консьерж снова покачал головой: - Ресторан закрылся полчаса. Полагаю, Росио и ее гость ушли на вечернюю прогулку.
Хватка на горле Сьюзан слегка ослабла. Стратмор выключил телефон и сунул его за пояс.
Глаза его расширились от ужаса. - Нет! - Он схватился за голову. - Нет. Шестиэтажная ракета содрогалась.
Стресс - это убийца, Сью. Что тебя тревожит. Сьюзан заставила себя сесть. Она полагала, что Стратмор уже закончил телефонный разговор и сейчас придет и выслушает ее, но он все не появлялся.
- Взмахом руки Клушар величественно отверг вопрос Беккера. - Они не преступницы - глупо было бы искать их, как обычных жуликов. Беккер все еще не мог прийти в себя от всего, что услышал.
Помнишь, что случилось в прошлом году, когда Стратмор занимался антисемитской террористической группой в Калифорнии? - напомнила. Бринкерхофф кивнул. Это было одним из крупнейших достижений Стратмора. С помощью ТРАНСТЕКСТА, взломавшего шифр, ему удалось узнать о заговоре и бомбе, подложенной в школе иврита в Лос-Анджелесе. Послание террористов удалось расшифровать всего за двадцать минут до готовившегося взрыва и, быстро связавшись по телефону с кем нужно, спасти триста школьников.
Вроде. - У Соши был голос провинившегося ребенка. - Помните, я сказала, что на Нагасаки сбросили плутониевую бомбу.
Я не собираюсь оплачивать твое пристрастие к наркотикам, если речь идет об. - Я хочу вернуться домой, - сказала блондинка. - Не поможете. - Опоздала на самолет. Она кивнула.
Наверное, он сейчас у. - Понимаю. - В голосе звонившего по-прежнему чувствовалась нерешительность. - Ну, тогда… надеюсь, хлопот не .
Life called her, and the duties of life, not death. And he was very close to death now. The thought frightened the old man for the moment. He stretched forth a.Hada A. 30.05.2021 at 08:00
Life called her, and the duties of life, not death. And he was very close to death now. The thought made the old man panicky for the moment, and he stretched forth.Gamaliel B. 31.05.2021 at 01:18
Or perhaps the definition of life should be more intellectual, such as “I think, therefore I am”? If asked, Read Online · Download PDF. Save. Cite this Item.