Physician-assisted suicide: reflections on Oregon's first case

The authors analyze Oregon's first reported assisted suicide of Mrs. A as a real life application of the Oregon Death with Dignity Act. They critique the effectiveness of the Act's safeguards as illustrated by the case of Mrs. A. They point out that the Act does not require that physicians be adequately trained in palliative care in order to participate in assisted suicide. Most physicians do not have such training. Without it, they are not able to effectively present alternatives to patients requesting assisted suicide. Most physicians also lack the expertise to assess patients' decision-making capacity. Nor does the Act ensure that physicians will be in a position to assess coercion of patients' decisions. The Act requires physicians to report only minimal information about their cases, and there are no enforcement provisions to see that even this is done. Under the Act, a good faith standard rather than the more usual negligence standard immunizes physicians from civil or criminal liability even when they act negligently. The authors demonstrate that the Act protects physicians more than patients, and encourages secrecy. The authors conclude that secrecy will need to be replaced by openness to permit the kind of examination the practice of assisted suicide warrants.     

Potential for non-shivering thermogenesis in perfused chicken (Gallus domesticus) muscle

The state of Oregon decided to cover all potentially eligible Medicaid citizens to 100% of poverty. Previously, Oregon had covered persons up to 67% of poverty. In order to keep overall program costs in check. Oregon decided to limit the number of services that its Medicaid program would cover. Oregon's normative choice was to contain program costs by covering all eligible persons up to 100% of poverty, while at the same time uniformly limiting access to certain services for everyone in the overall group of eligible persons. The state developed a prioritization list of medical services and priced the components on the list. The amount of money ultimately available for the Medicaid program was a political decision informed by data about the cost of different services and influenced by the priorities set through an independent process of priority-setting. Physicians were asked to determine what works medically, how well it works, and what benefits accrue to patients. Recognizing that physician perspectives on efficacy might vary from patients' perspectives on valuation of benefits, Oregon's planners developed a method for valuing medical outcomes that stemmed from particular medical interventions. This blend of medical fact and value to patients allowed for comparing valuations by introducing cost considerations. Condition-treatment (CT) pairs linked a medical condition with one or more courses of treatment. The goal was to determine the likely incremental medical benefit from a given treatment. In addition, Oregon developed a Quality-of-Well-Being scale to determine the net patient benefit from medical intervention and used a telephone survey to value that net benefit. A cost-benefit ratio was derived, and a prioritization of CT pairs was developed. The article analyzes and evaluates Oregon's use of cost-benefit calculations in the allocation of Medicaid funds, noting that Oregon itself backed away from many of the implications of its cost-benefit analysis and that the Americans with Disabilities Act has constrained use of quality-of-life judgments in Medicaid resource allocation decision-making.     

What happens now? Oregon and physician-assisted suicide

With assisted suicide now legally sanctioned, health care professionals in Oregon face the challenge of implementing Oregon's Death with Dignity Act. Physicians, hospice professionals, pharmacists, and other caregivers may find their relationships with patients, families, and fellow professionals changing in unanticipated ways as all learn what it means to make aid in dying openly and compassionately available to patients at the end of life.     

Oregon's first year: The medicalization of control.

The results of Oregon's first year with physician-assisted suicide raise two questions. First, how will it be possible to evaluate what is actually going on in Oregon if there is no public access to the records and if physicians are shielded by patient confidentiality rules? The second question is whether the public understood that many, not most, of those who want physician-assisted suicide want it not to relieve suffering as ordinarily understood but to maintain control over their dying, something that may not correlate at all with suffering from illness and disease. This commentary reviews the existing evidence from the Netherlands and suggests that abuse of the vulnerable will likely occur in Oregon over time. It also reviews the insufficiency of the data emerging from Oregon. Finally, it addresses the various issues raised by the other commentators to the main article. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Causal knowledge and categories: The effects of causal beliefs on categorization, induction, and similarity.

Despite the recent interest in the theoretical knowledge embedded in human representations of categories, little research has systematically manipulated the structure of such knowledge. Across four experiments this study assessed the effects of interattribute causal laws on a number of category-based judgments. The authors found that (a) any attribute occupying a central position in a network of causal relationships comes to dominate category membership, (b) combinations of attribute values are important to category membership to the extent they jointly confirm or violate the causal laws, and (c) the presence of causal knowledge affects the induction of new properties to the category. These effects were a result of the causal laws, rather than the empirical correlations produced by those laws. Implications for the doctrine of psychological essentialism, similarity-based models of categorization, and the representation of causal knowledge are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preferential benefit of implementation of a statewide trauma system in one of two adjacent states

BACKGROUND: Implementation of Oregon's trauma system was associated with a reduction in the risk of death for hospitalized injured patients. An alternative explanation for improved outcome, however, is favorable concurrent temporal trends, e.g., new technologies and treatments. PATIENTS AND METHODS: To control for temporal trends, seriously injured hospitalized patients in Oregon and Washington were compared before either state had a trauma system (1985-1988) and when only the Oregon trauma system had been implemented (1990-1993). The study group consisted of hospitalized injured patients aged 16 to 79 years with one or more index injuries in six body regions, i.e., head, chest, spleen/liver, femur or pelvis fracture, and burns. Hospital discharge claims data were analyzed, converting International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis codes to Abbreviated Injury Scale scores and Injury Severity Scores using a conversion algorithm. Multivariate logistic regression models were used to estimate the differential risk-adjusted odds of death in Oregon compared with Washington after adjustment for demographics, injury type, and injury severity. RESULTS: Findings indicated no difference in the risk-adjusted odds of death between Oregon and Washington while both states functioned under an ad hoc trauma system (1985-1988). A significant reduction in the risk of death, however, was noted in Oregon for patients with an index injury and an Injury Severity Score > 15 compared with Washington (adjusted odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.70-0.91) after trauma system implementation in Oregon (1990-1993). Specifically, reductions in the risk of death were demonstrated for patients with head injuries (adjusted OR = 0.70, 95% CI = 0.59-0.82) or liver/spleen injuries (adjusted OR = 0.73, 95% CI = 0.54-0.99). CONCLUSION: Assuming that the two states demonstrated similar concurrent temporal trends, the findings support the conclusion that improved outcomes among injured patients in Oregon may be attributed to the institution of a statewide trauma system.     

When laws and values conflict: Comment on Pope and Bajt.

Of 100 psychologists surveyed by K. S. Pope and T. Bajt (1988), 21% acknowledged having violated child abuse reporting laws, presumably in the interest of the therapeutic alliance with the abuser. However, experience in a program for survivors of torture shows that failure to report abuse may be antitherapeutic. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pessimism, age, and cancer mortality.

Cancer patients (N?=?238) receiving palliative radiation treatment were followed for 8 months; 70 patients had died by the 8-month follow-up. Controlling for site of cancer and level of symptomatology at baseline, the authors studied the independent effects on mortality of pessimism, optimism, and depression. The findings show that the endorsement of a pessimistic life orientation is an important risk factor for mortality, but only among younger patients (ages 30–59). Attempts to replicate this finding with conceptually related constructs such as depression or optimism did not yield significant associations for either younger or older patients, suggesting that negative expectations about the future may contribute to mortality in unique ways. The authors conclude that attempts to link psychosocial factors to mortality should focus on specific psychological constructs instead of diffuse, global measures that cover many psychological phenomena and that the role of psychological processes in mortality may vary dramatically depending on age. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pain prevalence and pain treatments for residents in Oregon nursing homes

The Client Care Monitoring Unit of Oregon's Senior and Disabled Services Division developed and conducted a study with survey-generated information to describe the prevalence of pain and the effectiveness of pain interventions for residents of Oregon nursing home facilities. Forty-four percent of sampled residents who were identified as having pain management needs were found to have problematic treatment regimens. Reports of surveyors' experiences during information collection and review of the Medicare/Medicaid recertification reports of the sampled facilities revealed that lack of assessment, and reevaluation of the effectiveness of treatment for pain were the chief contributing factors that led to these findings.     

Bridging psychology and biology: the analysis of individuals in groups.

Biological systems are particularly prone to variation, and the authors argue that such variation must be regarded as important data in its own right. The authors describe a method in which individual differences are studied within the framework of a general theory of the population as a whole and illustrate how this method can be used to address three types of issues: the nature of the mechanisms that give rise to a specific ability, such as mental imagery; the role of psychological or biological mediators of environmental challenges, such as the biological bases for differences in dispositional mood; and the existence of processes that have nonadditive effects with behavioral and physiological variables, such as factors that modulate the response to stress and its effects on the immune response. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Misconceived sources of opposition to physician-assisted suicide.

This article addresses 2 prominent sources of opposition to physician-assisted suicide (PAS): first, the fear of abuse and, second, common moral distinctions drawn between PAS and other forms of end-of-life decisions and care. Each is grounded in a false assumption that PAS is radically different from other forms of widely accepted end-of-life decisions and care. The experience to date in Oregon gives some reassurance that the practice there permitting PAS has not been significantly abused. Moreover, the author argues that abuse, understood as decisions not in accord with what the patient wants, or would have wanted, is greatest when someone, other than the patient is the decision maker. On this ground, PAS should be less subject to abuse than other surrogate decisions about life support. Moreover, Oregon's law, like virtually all proposals to legalize PAS, contains numerous safeguards that are not present in decisions about life support generally. Second, it is argued that some prominent conceptualizations of accepted end-of-life decisions and care thought to distinguish them morally from PAS fail on closer analysis to do so. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cortical DC potential shifts accompanying the central processing of visually presented analogue and digital time displays

This article examines treatment refusal in a large group of hospitalized civilly committed patients. Comparison is made between those subjects whose refusal was reviewed by Oregon's administrative procedures for treatment refusal (override group) and those committed patients who more readily accepted treatment and were not evaluated by this procedure. The objective was to examine the override process and to explore potential differences between these groups in their utilization of hospital and community mental health services before and after the index hospitalization. We reviewed hospital charts on all subjects who went through the administrative override procedure and collected state hospital and community mental health services information from the statewide computerized information system on all subjects in the study. Several key differences were found between the groups. The override sample had significantly more women, and these patients spent significantly more time in the index hospitalization and had had more past hospitalizations. There were no differences between the groups in their utilization of community services before or after the index hospitalization and no difference in hospitalization rates after the index hospitalization. The conclusion is that the Oregon override procedure is functioning consistently, without undue delay in decision making. More investigation is necessary to determine whether override subjects represent a distinct subpopulation within the larger group of chronically mentally ill patients.     

Some Comments on "After Legislation".

Comments on Deutsch's article "After Legislation: What Price Psychology?" (see record 1960-00289-001). The current authors suggest that Deutsch places disproportionate emphasis on legislation as a mechanism for enhancing the position of the psychological profession. While coincidental benefits like these are not to be slighted, the primary purpose of such legislation is necessarily the promotion of the public good. Therefore, Deutsch's criticism that certification laws do not really improve the lot of clinical psychologists vis-a-vis the medical profession is, in addition to being debatable, quite beside the major point. Deutsch properly states that it is necessary to balance the debits against the credits in evaluating legislation. The current authors believe that, as far as can now be ascertained, the credits heavily outweigh the debits--provided that the scale employed is one calibrated in terms of the common weal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Examining conflict between components of attitudes: Ambivalence and inconsistency are distinct constructs.

Past research has indicated that attitudes can be based on different types of psychological information or components, such as emotions and beliefs. It has also been suggested that the amount of ambivalence and inconsistency between and within these components are important aspects of attitude structure. In this paper, the authors discuss the relation between ambivalence and inconsistency, and their effects on message processing. Based on past theorizing and research, and on the reanalyses of previous data (G. R. Maio et al, 1996), the authors conclude that ambivalence and inconsistency are distinct constructs, which are empirically unrelated and produce different effects on message processing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Judicial Application of Daubert to Psychological Syndrome and Profile Evidence: A Research Note.

The authors present previously unreported results from a nationwide survey (N=325) of state trial judges (S. I. Gatowski et al., 2001) that was conducted pre-Kumho. The authors report how the 1993 Daubert guidelines were applied to psychological syndrome and profile evidence, and the impact of the decision on the admissibility of such evidence. They found that judges' views of and experience with psychological testimony varied widely and that most judges neither understood nor applied the more technical Daubert guidelines, such as falsifiability and error rate, when assessing psychological evidence. Overall, the findings suggest that Daubert's impact on the admissibility of psychological syndrome and profile testimony is negligible and that most judges are more comfortable with pre-Daubert standards when this type of testimony is proffered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Elevating the status of psychologists: A simple solution is neither simple nor a solution.

Discusses the article by B. D. Forman and S. A. Shackar (1981) in which they discuss how psychologists can improve their status so as to be viewed as "real doctors." The current authors point out that a major difficulty with achieving this status lies in state legislative processes. An example is used of how state laws regulate who can receive cadavers for experimental use and how the cadavers can be used. Some states refuse to recognize psychologists as permissible recipients of cadavers and prohibit the inclusion of psychological techniques as permissible procedures that can be performed on cadavers. (1 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interpersonal effects of suffering in older adult caregiving relationships.

Examining the interpersonal effects of suffering in the context of family caregiving is an important step to a broader understanding of how exposure to suffering affects humans. In this review article, the authors first describe existing evidence that being exposed to the suffering of a care recipient (conceptualized as psychological distress, physical symptoms, and existential/spiritual distress) directly influences caregivers’ emotional experiences. Drawing from past theory and research, the authors propose that caregivers experience similar, complementary, and/or defensive emotions in response to care recipient suffering through mechanisms such as cognitive empathy, mimicry, and conditioned learning, placing caregivers at risk for psychological and physical morbidity. The authors then describe how gender, relationship closeness, caregiving efficacy, and individual differences in emotion regulation moderate these processes. Finally, the authors provide directions for future research to deepen understanding of interpersonal phenomena among older adults, and they discuss implications for clinical interventions to alleviate the suffering of both caregivers and care recipients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)