Family connectedness and women's sexual risk behaviors: implications for the prevention/intervention of STD/HIV infection.

The present study explores the relationship between connectedness with the intergenerational family and women's sexual risk-taking as a guide to the development of family-focused prevention and intervention. Cross-sectional interview data from a pilot study were analyzed for correlations between a number of self-reported, risky sexual practices, the range of extended family members with whom the respondent was in contact, and awareness of stories pertaining to intergenerational family history. Structured interviews were administered by female interviewers to 56 women from two contexts: a STD (sexually transmitted disease) Clinic (N = 26), and an inner-city, Hispanic Community Organization (N = 30). Knowledge of stories about grandparents or great-grandparents was a robust predictor of lower sexual risk-taking in the STD Clinic sample. This relationship persisted, but only at the trend level in the Community Organization sample. In both the total sample and the STD subsample, the number of categories of extended family members with whom a respondent was in at least monthly contact was correlated with less sexual risk-taking. Given the fundamental importance of the family system as the primary social unit, these findings argue for further family theory-based research and for its potential application in the development of health prevention and intervention. Implications for practice and future research are discussed.

Medication refusal and judicial activism: a reexamination of the effects of the Rivers decision.

OBJECTIVE: In 1986 New York State courts in Rivers v. Katz mandated judicial review of cases in which involuntarily hospitalized psychiatric patients formally refuse medications; previously only a clinical-administrative review was required. In an earlier study the authors found that formal refusals of medications declined significantly in the year after the Rivers decision and that length of time between refusal and its resolution increased. To determine whether these effects were maintained over time, data for the second year after the Rivers decision were examined. METHODS: Chi square analysis and analysis of variance were used to compare data from both a private and a state-operated hospital for the year before the Rivers decision with data from the first and second years after. RESULTS: The significant declines in the number of patients formally refusing medications were maintained in the second year after Rivers at both hospitals, as were the significant increases in the length of time to resolution. In the second year, judges continued to uphold the treating psychiatrists' recommendations. The decline in the refusal rates was not found to be part of a broader trend that had been manifest before the Rivers decision. CONCLUSIONS: The sharp decline in refusals resulted in fewer patients having their medications reviewed by others not directly involved in their care. Increased time to resolution has diminished quality of care and has resulted in increased patient decompensation and staff injuries.

Systems ethics and the history of medical ethics.

This paper reviews the current conclusions in medical ethics which have followed the 1969-1970 Medical Ethics Discontinuity, a break that challenged the Hippocratic way of thinking about ethics. The resulting dislocations in quality of care and the medical value system are discussed, and an alternative medical ethics is offered: Systems Ethics. A methodology for a Systems Ethics analysis of cases is presented and illustrated by the case of a physician-assisted suicide. The advantages, both theoretical and clinical, of a Systems Ethics approach to medicine, which is an expansion of the Hippocratic tradition in medical ethics, are developed. Using Systems Ethics, it is possible to avoid the dangers of legalism, bureaucratic ethics, utilitarian cost cutting, and "political correctness" in medical ethics.

Right to refuse treatment: impact of Rivers v. Katz.

This article examines the impact of the New York court decision, Rivers v. Katz, which in June 1986 dramatically changed the state procedure for responding to involuntarily committed psychiatric patients who formally refused psychopharmacologic treatment. The court rejected the medically administered review process that had been used to respond to involuntarily committed psychiatric patients who formally refused medication, and replaced it with a judicial determination of competent and "substituted judgment" provided by the court. Post-Rivers, the rate of patients consistently refusing treatment decreased, and the time from refusal to resolution increased. The clinical, legal, and economic implications of the Rivers procedure are discussed.

Assessment of suicide risk in patients with personality disorder and major affective diagnosis.

Mortality reviews conducted by the quality assurance committee in the Department of Psychiatry at the University of Rochester Medical Center during 1982-1984 disclosed a pattern of suicides by patients with a combination of major depression and either mixed or borderline personality disorder. This finding coincides with earlier published research on suicide risk for such patients. Data from the reviews led to the establishment of a suicide prevention task force and to changes in policies regarding patient transfers, family therapy, discharge planning, and suicide risk assessment. The data also suggest several hypotheses for further research on suicide risk assessment and case management for this patient population.

Patients' ethical obligation for their health.

In contemporary medical ethics health is rarely acknowledged to be an ethical obligation. This oversight is due to the preoccupation of most bioethicists with a rationalist, contract model for ethics in which moral obligation is limited to truth-telling and promise-keeping. Such an ethics is poorly suited to medicine because it fails to appreciate that medicine's basis as a moral enterprise is oriented towards health values. A naturalistic model for medical ethics is proposed which builds upon biological and medical values. This perspective clarifies ethical obligations to ourselves and to others for life and health. It provides a normative framework for the doctor-patient relationship within which to formulate medical advice and by which to evaluate patient choice.

KIE: The authors believe that too little attention has been paid to the proposition that individuals have an ethical obligation for their health, and to how best to characterize the nature and moral force of this obligation. While Samuel Gorovitz and others argue against a primary obligation to oneself for health, Sider and Clements defend the view that such an obligation is a fundamental constituent of human morality. They claim that health is a responsibility owed to oneself and to others, particularly family members, and one that determines the nature of the physician patient relationship. Acknowledging that their position runs counter to most of contemporary medical ethics and its preoccupation with patients' rights, truth telling, and contracts, the authors argue that health is a basic human good, and that maintaining health is a moral duty.

Medical ethics' assault upon medical values.

KIE: The authors argue that current theories of medical ethics, based on a philosophical patient-oriented autonomy model, have subverted values that are essential to medicine. They analyze the concept of autonomy, then outline attempts to apply the autonomy ethic to medicine by establishing its primacy over principles such as paternalism or patient good. Critics of autonomy ethics have proposed alternatives that are equally at odds with traditional medical values. After tracing the decline of traditional medical norms, Clements and Sider call for a new clinical ethic concerned with the adaptation, function, and best interest of the patient.^ieng

Suicide: bad act or good intervention.

This article develops a different perspective on the ethics of suicide, based on theoretical and clinical grounds. In terms of value theory, applying "good" or "bad" to the suicide act makes no sense. We need to shift our focus from a search for an ethical statement about suicide (e.g., "rational suicide") to the ethical justification for intervention based on the needs and interests of an affirming therapeutic profession. We choose to intervene because of values we hold about well-functioning, existence, potential for human life; and because as emphatic, social beings, we feel for others and are motivated by that feeling. This justification leads us to suggest a situational case-centered ethics for suicide intervention.