Medico-Legal Examination of Sexual Assaulted Victims Unable to Consent in Portugal: Ethical Decision-Making.

Medical decision-making is a complex task in any field. In the medico-legal examination of victims that have (allegedly) been sexually assaulted there are many specific variables and features influencing the decision. It is essential to complement the clinical intervention with a forensic approach. Clinical parameters such as the victim's physical and cognitive state along with circumstantial information such as the elapsed time from the event and the type of abuse (described or suspected) grant different levels of priority to the forensic medical assessment. In such cases, forensic medical doctors or other medical doctors responsible for attending to the victim may have to decide whether to perform the examination prior to a judicial analysis of the case if consent cannot be obtained. This implies the need to deliberate about performing the examination and/or reporting the case to legal authorities. This article discusses the forensic medical decision-making process in cases of alleged recent sexual assault of victims who are legally unable to consent or unable to consent for other reasons. We aimed to identify possible ethical problems that can arise in this context and discuss which elements should be considered by medical doctors when making decisions about such cases. The Portuguese legal framework of medico-legal examinations is analyzed. The authors also make considerations about reporting these cases from a legal point of view. The discussion turns to an ethical perspective where possible ethical problems arising from medical deliberation are identified. Issues about legally incompetent victims and incompetent victims due to other reasons are addressed. A decision-making tree, based on the problems identified, is proposed.

Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry.

BACKGROUND: Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment (COT) in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. MAIN BODY: The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002-2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. CONCLUSION: Ross Upshur's principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice.

Overtreatment in elderly care: ethical considerations.

letter to editor.

Resource Allocation During the COVID-19 Pandemic: Contributions to an Ethical Approach.

The COVID-19 pandemic has brought dramatic worldwide consequences affecting social, economic and healthcare systems. Considering that the number of infected patients requiring admission to intensive care units far exceeded the available resources, healthcare professionals have had to face challenging decisions concerning who should benefit from the limited resources and who should not. In this context, after a careful ethical reflection, we propose some principles to be adopted when dealing with allocation resource decisions, based on core ethical values. Ideally, these strategies should be established and integrated into institutional policies before a crisis scenario, in order to anticipate a potential new public health emergency and prevent possible tragic consequences.

A pandemia por COVID-19 associa-se a consequências dramáticas a nível social, económico e dos sistemas de saúde. Tendo em conta que o número de pacientes críticos ultrapassa consideravelmente o número de recursos hospitalares disponíveis, os profissionais de saúde depararam-se com decisões difíceis, nomeadamente determinar quais os pacientes que deveriam beneficiar destes recursos escassos. Neste contexto, após uma cuidadosa reflexão ética, propomos alguns princípios a considerar aquando das decisões de alocação de recursos em saúde, baseados em valores éticos fundamentais. Idealmente, estas decisões devem ser estabelecidas e integradas nas políticas institucionais antes de um cenário de crise, de forma a antecipar uma potencial nova emergência de saúde pública e mitigar possíveis consequências trágicas com ela relacionadas.

[Respecting minors' autonomy in child custody cases]. / O Respeito pela Autonomia da Criança na Regulação das Responsabilidades Parentais.

Child custody decisions are among the most difficult for judges to make. The possibility of child abuse allegations or parents' deviant/ psychopathologic behaviours within this context, make the decision further complicated. Based on jurisprudence the listening of children opinion is a way to protect their best interest. In fact children have the right to express an opinion in all matters affecting their life. It should be given proper consideration to children opinion according with his/her age and maturity. Nonetheless custody disputes are emotionally draining issues. Asking the child to express an opinion during a public hearing, most likely in the presence of both parents, its not recommended because this is a potential stressful experience. Child interviews should take place in a proper environment and be set to their age. Medicine and Psychology have an important role in assessing children cognitive, emotional and volitional abilities, which is essential to properly account their opinions according to autonomy degree. This essay analyses the contribution of medico-legal and/or psychological exams to respect the autonomy of the child in cases of regulation of parental responsibilities. The conclusion is the need to establish a symbiotic relationship between the medical and legal perspectives of the (open) concept of child's best interests.

As decisões de custódia parental estão entre as mais difíceis de ser tomadas pelos tribunais. A possível coexistência de alegações de abuso da criança ou comportamentos desviantes/psicopatológicos dos progenitores aumenta a complexidade da tomada de decisão. Decorre da jurisprudência que a audição da criança se consagra como a forma mais lídima de auscultar o seu superior interesse. De facto, a menor tem direito a ser ouvido em todas as decisões que lhe digam respeito, devendo a sua vontade ser considerada de acordo com a sua idade, discernimento e maturidade. No entanto, as disputas de custódia configuram uma importante fonte de angústia para a criança, pelo que pedir-lhe que expresse a sua preferência em audiência pública, porventura na presença de ambos os progenitores, não é aconselhável, por razões que se prendem com a necessidade de a proteger de uma experiência potencialmente stressante. Há que privilegiar entrevistas em ambiente adequado, acessíveis e ajustadas à idade do menor. À Medicina e à Psicologia cabe o importante papel de avaliar as capacidades cognitivas, volitivas e emocionais do menor, facto essencial à adequada consideração da sua opinião de acordo com o seu grau de autonomia. Este ensaio analisa o contributo da perícia médico-legal e/ou psicológica para que o respeito pela autonomia do menor seja verdadeiramente contemplado, nos casos de regulação das responsabilidades parentais. Conclui-se a necessidade de estabelecer uma relação de simbiose entre as perspetivas médica e judicial do conceito (aberto) do superior interesse da criança.