Physicians, firearm counseling, and legal liability.

To explore the potential legal consequences to physicians of counseling their patients about gun violence, I consider the question: If a patient divests herself of a firearm upon the advice of her physician and is subsequently the victim of a rape, robbery, aggravated assault, or homicide, could she or her survivors argue convincingly that her physician was negligent? In attempting to answer this question, the four elements that a patient must establish to prevail in a malpractice action against a physician are discussed, and possible strategies for establishing them in the hypothetical case are explored. I conclude that plausible arguments can be made against the hypothetical physician engaged in firearm counseling as described. Conversely, physicians not engaging in discussions of gun safety face substantially lower liability risks.

Deactivating the implantable cardioverter-defibrillator: a biofixture analysis.

Automatic implantable cardioverter-defibrillators (ICDs) are becoming increasingly common, as is refusal of resuscitative efforts at the end of life, both by patients and surrogate decision-makers. While it is clear that a terminally ill patient who lacks decisional capacity may, through a surrogate, refuse cardiopulmonary resuscitation (CPR), is it appropriate for physicians to infer from such a refusal that the patient's ICD should be deactivated? A proper answer to this question requires consideration of the nature of consent to a do-not-resuscitate (DNR) order, the context in which permission is given for the writing of the DNR order, and the ontologic status of implantable devices in general and ICDs in particular. We introduce the concept of "biofixtures" and suggest that a biofixture analysis is a novel way of approaching the difficult ethical issues that may confound the care of patients with implantable devices.

How dead is the federal constitutional right to assisted suicide?

The US Supreme Court recently upheld state laws in New York and Washington that prohibit assisted suicide. In both cases, the judgment of the Court was unanimous. Closer scrutiny of the opinions in the cases, however, suggests that we may not have seen the last of a federal constitutional right to assisted suicide.

Poison pen letters, due process, and medical schools' policies toward anonymous correspondence that disparages medical school faculty.

PURPOSE: To learn more about the frequency of and response to poison pen letters (anonymous correspondence that disparages faculty members) in academic medicine. METHOD: The authors surveyed all 143 deans of medical schools that are members of the AAMC about their practices and policies regarding the handling of poison pen letters. RESULTS: Of the deans surveyed, 119 (83%) responded. Sixty-seven deans (56%) reported having received poison pen letters during their tenure. Of those, 16 (24%) reported that they had discarded the letters based solely on the anonymity of the authors. The remaining 51 deans (76%) reported that they had either sequestered, investigated, or placed the letters into the faculty members' files, or that they had based their decisions to discard the letters on factors other than the authors' anonymity. Only one dean reported having a written policy for handling such correspondence. CONCLUSION: This survey of AAMC schools indicates that poison pen letters are not uncommon. The authors recommend a policy by which anonymous letters that disparage current or prospective faculty members would be categorically discarded.

Bioethics in the medical subspecialty literature.

We have previously reported that a smaller percentage of the surgical literature than the medical literature is devoted to bioethics, and that this difference is statistically significant. In order to determine: 1) whether the medical subspecialty literature is more akin, in terms of its quantitative bioethics content, to the surgical or to the medical literature, and 2) whether differences exist between the "invasive" and the "noninvasive" medical subspecialties in terms of their quantitative bioethics content, we conducted a computerized search of the MEDLINE database. The journals searched were selected from the "Medicine", "Surgery", and "Cardiovascular System" sections of the "Brandon-Hill List", and the search was limited to the 1994 issues of these journals. From the 15 medical journals searched, 331 out of a total of 10,578 bibliographic records indexed dealt with bioethics, while from the 12 surgical journals searched only 14 out of a total of 3990 bibliographic records indexed dealt with bioethics. From the 26 medical subspecialty journals searched (14 "invasive" and 12 "noninvasive"), 38 (20 "invasive", 18 "noninvasive") out of a total of 12,733 bibliographic records indexed (5745 in the "invasive" literature, 6988 in the "non-invasive" literature) dealt with bioethics. We conclude that there is a statistically significant difference (p < 0.001) between the general medical literature and the medical subspecialty literature in terms of their quantitative bioethics content, that there is no such difference between the surgical literature and the medical subspecialty literature, and that no statistically significant difference exists between the "invasive" and the "noninvasive" medical subspecialties in terms of their quantitative bioethics content.