Amy T. Campbell

Legal and ethical considerations : Risks and benefits of postpartum depression screening at well-child visits

Pediatric professionals are being asked to provide an increasing array of services during well-child visits, including screening for psychosocial and family issues that may directly or indirectly affect their pediatric patients. One such service is routine screening for postpartum depression at pediatric visits. Postpartum depression is an example of a parental condition that can have serious negative effects for the child. Because it is a maternal condition, it raises a host of ethical and legal questions about the boundaries of pediatric care and the pediatric providers responsibility and liability. In this article we discuss the ethical and legal considerations of, and outline the risks of screening or not screening for, postpartum depression at pediatric visits. We make recommendations for pediatric provider education and for the roles of national professional organizations in guiding the process of defining the boundaries of pediatric care.

Variations in Mental Health Courts: Challenges, Opportunities, and a Call for Caution

Mental health courts have quickly proliferated in the United States and represent an attempt to expand legal leverage and enhanced treatment access to select persons with severe mental illness who are also involved in the criminal justice system. A national survey of mental health courts has begun to elucidate the procedural, clinical, and operational aspects of these courts and the defendants they adjudicate. A secondary analysis of survey data was performed to determine the similarities and differences among these courts. Results revealed large variability among existing mental health courts across multiple domains. The implications of this variability are discussed in terms benefits and limitations.ABSTRACTMental health courts have quickly proliferated in the United States and represent an attempt to expand legal leverage and enhanced treatment access to select persons with severe mental illness who are also involved in the criminal justice system. A national survey of mental health courts has begun to elucidate the procedural, clinical, and operational aspects of these courts and the defendants they adjudicate. A secondary analysis of survey data was performed to determine the similarities and differences among these courts. Results revealed large variability among existing mental health courts across multiple domains. The implications of this variability are discussed in terms benefits and limitations.

Supported Decision-Making: A Viable Alternative to Guardianship?

The law has traditionally responded to cognitive disability by authorizing surrogate decision-makers to make decisions on behalf of disabled individuals. However, supported decision-making, an alternative paradigm for addressing cognitive disability, is rapidly gaining political support. According to its proponents, supported decision-making empowers individuals with cognitive challenges by ensuring that they are the ultimate decision-maker but are provided support from one or more others, giving them the assistance they need to make decisions for themselves. This article describes supported decision-making and its normative appeal. It then provides a descriptive account of how supported decision-making works based on the empirical literature on supported decision-making as well as that on shared decision-making, a related model used in medical contexts. The article shows how employing supported decision-making in lieu of guardianship, or integrating it into the guardianship system, has the potential to promote the self-determination of persons with intellectual and cognitive disabilities consistent with international and national legal norms. However, we find that, despite much rhetoric touting its advantages, little is known about how supported decision-making processes operate or about the outcomes of those processes. Further research is necessary to design and develop effective supported decision-making systems. We therefore propose a series of research questions to help inform policy choices surrounding supported decision-making.

Addressing risks to advance mental health research.

IMPORTANCE Risk communication and management are essential to the ethical conduct of research, yet addressing risks may be time consuming for investigators and institutional review boards may reject study designs that seem too risky. This can discourage needed research, particularly in higher-risk protocols or those enrolling potentially vulnerable individuals, such as those with some level of suicidality. Improved mechanisms for addressing research risks may facilitate much needed psychiatric research. OBJECTIVE To provide mental health researchers with practical approaches to (1) identify and define various intrinsic research risks, (2) communicate these risks to others (eg, potential participants, regulatory bodies, and society), (3) manage these risks during the course of a study, and (4) justify the risks. EVIDENCE REVIEW As part of a National Institute of Mental Health-funded scientific meeting series, a public conference and a closed-session expert panel meeting were held on managing and disclosing risks in mental health clinical trials. The expert panel reviewed the literature with a focus on empirical studies and developed recommendations for best practices and further research on managing and disclosing risks in mental health clinical trials. No institutional review board-review was required because there were no human subjects. FINDINGS Challenges, current data, practical strategies, and topics for future research are addressed for each of 4 key areas pertaining to management and disclosure of risks in clinical trials: identifying and defining risks, communicating risks, managing risks during studies, and justifying research risks. CONCLUSIONS AND RELEVANCE Empirical data on risk communication, managing risks, and the benefits of research can support the ethical conduct of mental health research and may help investigators better conceptualize and confront risks and to gain institutional review board-approval.

Bioethics in the public square: reflections on the how

As bioethics gains more prominence in public policy debates, it is time to more fully reflect on the following: what is its role in the public square, and what limitations relate to and barriers impede its fulfilment of this role? I contend we should consider the how of bioethics (as a policy influencer) rather than simply focus on the who or what of bioethical enquiry. This is not to suggest considerations of latter categories are not important, only that too little attention has been paid to parallel or resulting policy involvement—involvement that will require specialised skills and knowledge that we can develop with a proactive (vs reactive) stance. Moreover, and equally critically, this how of public policy involvement will require more transparency regarding influences (eg, philosophical, ideological, cultural, socio-political) on what bioethicists bring to the table and what constituency base each represents—a humility as to the scope of ones role. In this vision, bioethics is not one single person or belief system for a policymaker to call to guide or give support to a position; rather, it offers tools—formed and utilised by a diverse disciplinary range of individuals—to help guide ethical analysis of biomedical endeavours, with the goal of infusion and diffusion of ethical enquiry and prioritisation in health policymaking, and greater humility among bioethicists who inform this discussion.

How Bioethics Can Enrich Medical‐Legal Collaborations

Medical-legal partnerships (MLPs) - collaborative endeavors between health care clinicians and lawyers to more effectively address issues impacting health care - have proliferated over the past decade. The goal of this interdisciplinary approach is to improve the health outcomes and quality of life of patients and families, recognizing the many non-medical influences on health care and thus the value of an interdisciplinary team to enhance health. This article examines the unique, interrelated ethical issues that confront the clinical and legal partners involved in MLPs. We contend that the ethical precepts of the clinical and legal professions should be seen as opportunities, not barriers, to further the interdisciplinary nature of MLPs. The commonalities in ethical approaches represent a potential bridge between legal and health care advocacy for patient/client well-being. Bioethics has a role to play in building and analyzing this bridge: bioethics may serve as a discourse and method to enhance collaboration by highlighting common ethical foundations and refocusing legal and clinical partners on their similar goals of service for patients/clients. This article explores this bridging role of bioethics, through a series of case studies. It concludes with recommendations to strengthen the collaborations.

Vulnerability in context: recognizing the sociopolitical influences.

Levine et al. (2004) ably discuss the importance, yet complexity, of the concept of vulnerability in research and are right to suggest that changing times in research, as well as changing understandings of vulnerability, demand that we revisit the basis and context for protections. However, I would argue that one cannot do justice to such an endeavor without considering the concept of vulnerability in its broader sociopolitical context. “Vulnerability” cannot be removed from this larger context if we hope to understand how our current research review process works (or not) and how this, in turn, affects calls to revise our current approach. Other commentators to the Levine et al. (2004) article illuminate the complexity of the concept of vulnerability, but also offer up reasonable cautions against abandoning it in favor of “special scrutiny” targeted at research risks versus research subjects. However, suggested alternatives are restrained by the institutional review board (IRB) review system. Perhaps the problem is not simply that of our terminology, and the bounds that such implies (or could imply), but also the very review structure we created so many years ago. Localized review has its merits, especially in attentiveness to local community concerns. Recommendations by Justo (2004) and Jotkowitz (2004) build upon these strengths by offering an enriched vision of community participation in research review. Yet, once again, the focus is on fitting the community into the existing review model. I would argue that, to fully address “vulnerability”—to include the myriad of situations and relationships in which vulnerability arise (within and beyond the research setting)—the research review model must also adapt to this broadened perspective. That is, not only should the community be brought more fully into the review process, but the review process should also expand into the community. Such bi-directionality is endorsed by a relational perspective of vulnerability as set forth by Henderson, Davis, and King (2004). Most importantly, this shift in scope requires that we reach beyond the research milieu to the broader community, recognizing that vulnerability cannot be narrowly considered in the context of a research protocol. It requires an understanding of history, politics, social environment, and the myriad of other “relationships” at issue beyond that of “subject” and “investigator.” Moreover, these are not decisions to leave to IRBs, whether in the context of regulations, relationships, “special scrutiny,” or a history of past abuses (Silvers 2004). The issue is not simply that certain groups have a history of being “exploited for the sake of science” (Moreno 2004, x). Rather, the issue is a much larger one, which goes beyond science to the social sanctioning of separate classes—based on and perpetuated by “vulnerability”—in all facets of life, which spill over into science. The discussion therefore must occur long before research protocols are conceived and drafted, even before research itself enters the picture. The full community should begin to discuss vulnerability as it plays out in social settings (e.g., employment, housing, education), political life (local, state, national, global), environment, and health (e.g., insurance, access, treatment decisions, research participation). Perhaps not surprisingly, a model for such discussion may be found outside the medical literature, namely in the environmental policy literature. Grinnell (2004) persuasively draws upon the latter in advancing a precautionary principle that calls for “more democratic standards” to “involve the potentially impacted public in the decisionmaking process” (Grinnell 2004, x). And yet, his “solution” is also limited by the status quo, albeit in this instance a status quo of democracy-in-practice versus the status quo of the research review structure. While certainly headed in the right direction, I would caution by asking, What do we do when “democracy,” as applied and experienced in the real world, perpetuates stigma through its own expressed and implied classifications, including that of vulnerability? Consider, by way of example, the tendency in our society to label persons, including in our laws, with mental disorders as being “vulnerable,” which carries over into, and in turn influences, our treatment and research settings. (This “vulnerable” population is one of many that could be singled out; however, it is particularly emblematic of the larger discussion entertained by Levine et al. (2004) and by arguments against overreliance on class-based categories driven by often idiosyncratic capacity/cognition factors (Carpenter 1999).) Research regulatory bodies, culminating in the National Bioethics Advisory Committee (NBAC) in the late 1990s, clump mental disorders into a “class” and thus seek to restrict individual choice in treatment and research decision making broadly to persons with mental disorders (NBAC 1998). This approach might be considered a “protected class” notion of categorical protection. Contrast this categorical approach with the emerging emphasis in mental health law and bioethics on fostering individual freedom over medical decision making, in recognition of

Building a Public Health Law and Policy Curriculum to Promote Skills and Community Engagement

This article describes implementation of a longitudinal curriculum in public health law, building on doctrinal coursework with skills-based coursework and opportunities for interdisciplinary, community-based engagement and service learning. It specifically describes development of a Policy Practicum, giving an example of how law students can learn policy skills and skills of effective community coalition work through a healthy homes partnership, highlighting areas where the curriculum can incorporate interdisciplinary education. It offers lessons learned during the curriculum-building process, and concludes with a more intensive service-learning strategy through the development of a Policy Lab.

A case study for applying therapeutic jurisprudence to policymaking: Assembling a policy toolbox to achieve a trauma-informed early care and learning system

E-mail address: a.t.campbell@memphis.edu. 1 The author wishes to thank participants at the Ther Workshop, convened by Professor Carol Zeiner at St. Tho in February 2018, for invaluable feedback on the initial d for help with editing and references and James Andrew Ro ting references, and the two peer reviewers for helpful edit Professor DavidWexler for his commitment to thedevelop of therapeutic jurisprudence (TJ), and his continued effort generation of TJ scholars, including herself. The seeds of th sentation at the 35th Congress of the International Academ Prague in July of 2017. 2 Families U.S.A., 2017.

Is There a Therapeutic Way to Balance Community Sentiment, Student Mental Health, and Student Safety to Address Campus-Related Violence?

This chapter addresses the interrelated dynamics among mental health, public safety, media attention, and community sentiment, and specifically, the law’s response to (and at times impact on) this interplay of issues. For purposes of this discussion, law itself is seen as an intervention that has consequences on behaviors, attitudes, perceptions, and outcomes—positive or less so, intended or not. To ground discussion of law’s role within this context, case examples drawing on recent episodes of campus-based or campus-connected “mass killings” are featured, and reference is made to related developments in the law. Current legal mechanisms for addressing (often) community-fueled requests for action are juxtaposed with a potential alternative framing mechanism—therapeutic jurisprudence. The chapter concludes that teasing out the therapeutic and anti-therapeutic drivers and consequences of our legal mechanisms offers a more effective response to campus safety concerns and community emotions and is consistent with an evidence-based approach.