Guidelines for the ethical use of neuroimages in medical testimony: report of a multidisciplinary consensus conference.

SUMMARY: With rapid advances in neuroimaging technology, there is growing concern over potential misuse of neuroradiologic imaging data in legal matters. On December 7 and 8, 2012, a multidisciplinary consensus conference, Use and Abuse of Neuroimaging in the Courtroom, was held at Emory University in Atlanta, Georgia. Through this interactive forum, a highly select group of experts-including neuroradiologists, neurologists, forensic psychiatrists, neuropsychologists, neuroscientists, legal scholars, imaging statisticians, judges, practicing attorneys, and neuroethicists-discussed the complex issues involved in the use of neuroimaging data entered into legal evidence and for associated expert testimony. The specific contexts of criminal cases, child abuse, and head trauma were especially considered. The purpose of the conference was to inform the development of guidelines on expert testimony for the American Society of Neuroradiology and to provide principles for courts on the ethical use of neuroimaging data as evidence. This report summarizes the conference and resulting recommendations.

When the payer says "no!": ethical considerations in patient advocacy.

Spinal cord injury is a relatively infrequent but often catastrophic injury. As such, it presents special challenges for the individuals affected and the clinicians who care for them. Claims for reimbursement of acute care, rehabilitation, and long-term care are often denied, requiring patients and clinicians to exhaust every effort to ensure coverage for therapeutic interventions, preventive care, and durable medical equipment. Ethical dilemmas are presented within the framework of the US healthcare system, and practical strategies are discussed.

The improbable future of employment-based insurance.

Voluntary, employment-based insurance is afflicted by a variety of internal imbalances: inequities in the way health insurance is paid for, a conflict of interest in the selection of health insurance, the concentration of the healthy and the sick into separate plans, and free-ridership. But while all these imbalances generate severe problems, those seeking to reform health insurance in the United States should concentrate on the last two.

The rehabilitation marketplace: economics, values, and proposals for reform.

This article examines whether the ideals, goals, and values of medical rehabilitation can be realized in a market-based health care system. The article observes that rehabilitation is greatly disadvantaged in today's health care marketplace, which violates virtually all the assumptions of a perfectly competitive one. Nevertheless, the authors argue that rehabilitation goals and market economics are not inherently incompatible and call for several market reforms that are congruent with both rehabilitation goals and market theory. These reforms will clarify and facilitate providers' fiduciary responsibilities to patients as well as their accountability to payers. The authors conclude that while the marketplace is an inevitable medium for realizing rehabilitation goals, the vision and value of rehabilitation will not derive from the internal workings of the marketplace but ultimately from committed individuals and socially responsible institutions outside the marketplace.

Ethics, values, and world culture: the impact on rehabilitation.

Cultural beliefs affect how health-care professionals and consumers interpret health, illness and disability. This discussion focuses on the therapeutic relevance of cultural beliefs; the implications of cultural practices and cultural values for rehabilitation theory; and the implications of cultural beliefs for social justice. Cultural beliefs cause people to learn 'approved' ways of being ill, influence their attribution of the aetiology of illness or disability, and determine what they expect from treatment and their physicians. Medical professionals need to be aware of cultural differences that can affect the outcome of treatment. Rehabilitation can also be culturally diverse. A universal, transcultural understanding of rehabilitation is possible, however, if it is understood that disabilities are concerned with integrated activities expected of the person or the body as a whole. If culture distinguishes how we engage the world, rehabilitation universally addresses the form of that engagement in its physical, behavioural, and/or cognitive manifestations.

Assessing client competence to participate in rehabilitation decision making.

Numerous persons receiving rehabilitation services demonstrate compromised judgmental or cognitive ability which occasionally casts doubt on the validity of their consent to, or refusal of, rehabilitation treatment. A 14-member panel of nationally recognized forensic and neurorehabilitation experts (recruited from physiatry, law and mental health) viewed 21 videotaped competency interviews of cognitively impaired inpatients in an acute care rehabilitation hospital. Each rater offered an opinion on whether the interviewee was competent or not based on background history and the interview format presented here. Their ratings are compared with those of the interviewees' treating professionals, who based their competency assessments on their day-to-day clinical interactions with the patients. Results showed similar judgments among the three groups of videotape raters but statistically significant differences between the ratings of the panel members and the patients' treatment team. Reasons for these discrepancies are explored with additional comments on the conceptual obstacles presented by competency assessments in general. This article also describes a brief evaluation of competence to consent to treatment developed during the research program with input from the panel of experts. Qualified rehabilitation providers might employ such techniques to assess competence to participate in medical decision making.

Deception in advertising and marketing: ethical applications in rehabilitation.

A much discussed issue in contemporary discussions of health care reform is the considerable competition that is anticipated to occur among providers. An inevitable aspect of this competition will be the ways health care services are presented in the marketplace through advertising and other forms of promotional literature. Considerable concern has already emerged among certain rehabilitation professionals, however, that advertising and marketing practices in rehabilitation must cohere with ethical standards. This article will discuss certain aspects of those standards, particularly as they have evolved from the Federal Trade Commission's definition of and rulings on deceptive practices in advertising. Salient aspects of the Commission's 1983 definition of deception will be related to rehabilitation by way of examining instances of rehabilitation advertising and marketing that might satisfy the Commission's definition of deception. The article will conclude with certain recommendations, principally drawn from various Federal Trade Commission rulings, that might be useful to individuals or corporate entities who advertise or market rehabilitation services.

Discussing cardiopulmonary resuscitation with elderly rehabilitation patients. Ethical and clinical considerations toward the formation of policy.

Studies have demonstrated that most elderly persons who undergo cardiopulmonary resuscitation do not survive to hospital discharge. Because resuscitation efforts among elderly patients may fail either to restore hemodynamic stability or the patient's prearrest functional levels, ethical arguments as well as regulatory standards have urged the involvement of patients and their families in deciding about the advisedness of cardiopulmonary resuscitation. This article examines various ethical dimensions of conducting do-not-resuscitate discussions with competent, elderly persons in acute rehabilitation environments. Viewpoints that seek to excuse or resist do not resuscitate discussions among elderly rehabilitation consumers will be discussed as well as programmatic or psychological factors that appear to bolster such positions. These arguments, however, will be shown to be inferior to others that urge rehabilitation providers to engage their patients in frank and sincere discussions regarding their resuscitation status in the event of arrest.

Ethical issues in treating pediatric rehabilitation patients.

Ethical issues pertaining to treating pediatric rehabilitation patients stem from at least three sources: the fact that children are not morally autonomous persons and must depend on the values and moral beliefs of others in ethically complex decision-making situations; the extent of parental authority in asserting problematic beliefs or imposing questionable demands affecting treatment decisions; and the way clinical uncertainty affects moral uncertainty in determining treatment approaches or alternatives. Although these problems are pervasive among all age groups of children with disabilities, this article will primarily examine their impact on the rehabilitation of children and adolescents. Principles and strategies for managing value-laden conflicts will be discussed along with how various ethical, social, and clinical constraints may nevertheless compromise a straightforward resolution of an ethically vexing situation.

Outcomes following cardiopulmonary resuscitation in an acute rehabilitation hospital. Clinical and ethical implications.

This retrospective study examines cases of cardiac arrest requiring cardiopulmonary resuscitation (CPR) in an acute rehabilitation hospital. All admissions to the Center for Rehabilitation Medicine at Emory University, a 56-bed facility, are reviewed. Seventeen cases of true cardiac arrest are identified for analysis of ultimate disposition over a 10-yr period. Only one patient (5.9%) survived CPR to discharge from the rehabilitation hospital, but he died subsequent to his transfer to the acute hospital. Though the sample size is small, it reflects the total population of patients eligible for CPR who suffered a cardiac arrest. We conclude that CPR is generally not successful in the elderly inpatient rehabilitation population. The growing clinical complexity of the rehabilitation patient demands that health-care providers and their patients more regularly address decision-making issues pertinent to CPR.

Malpractice litigation for uninformed consent. Implications for physical therapists.

Although physicians generally are expected to secure their patients' informed consent to medical treatment, an emerging body of legal opinion holds that in certain situations nurses and allied health care professionals may be found similarly responsible. Failure of a health care provider to protect a patient's right of informed consent might result in a lawsuit alleging that serious harm was sustained needlessly because the patient plaintiff was not informed of certain significant risks of or consequences that resulted from treatment. As a professional group that puts patients at risk of harm during treatment, physical therapists need to know about their legal duty to facilitate a patient's awareness of and consent to treatment. This article discusses the nature of that duty and how a patient plaintiff might try to prove negligence against a physical therapist who allegedly fails to secure a valid statement of informed consent. The article also provides recommendations so that physical therapists might protect themselves from malpractice suits alleging "uninformed" consent.