H. Richard Beresford

Metastasis of intracranial germinoma through a ventriculoperitoneal shunt.

A young man developed a tumor in the pineal region that grew along ventricular surfaces and caused obstructive hydrocephalus. Cytologic examination of cerebrospinal fluid demonstrated malignant cells consistent with germinoma. Following a ventriculoperitoneal shunt and radiotherapy, the tumor and the hydrocephalus regressed. Three years later, an intraperitoneal tumor appeared that was diagnosed by transcutaneous biopsy specimen as a germinoma. The abdominal germinoma also regressed after radiotherapy. While extracranial metastases of intracranial germinomas via shunts are probably rare, their occurrence, as exemplified by this case, argues for including protective filters in the shunts.

The Quinlan decision: problems and legislative alternatives.

In the Quinlan decision, a state supreme court authorized remval of a respirator from a person in a chronic vegetative state provided that the attending physicians and an “ethics committee” agreed there was no reasonable possibility of her regaining cognition or sapience. While the decision involves an unusual factual situation and poses some troublesome technical and doctrinal problems, it underscores the need for formal legal standards to guide physicians and families of severely brain‐damaged patients.

Invited Article: Professionalism in neurology: The role of law

Professionalism may be defined as the obligation of the physician to uphold the primacy of patients’ interests, to achieve and maintain medical competency, and to abide by high ethical standards. Recent commentary has suggested that medical professionalism is being threatened by commercialism and the legal system. Consideration of judicial rulings centered on primacy of patients’ interests (informed consent, end-of-life care, and conflicts of interest), medical competence (standard of care in medical malpractice cases, medical futility cases, and confidentiality of peer review), and enforcement of ethical standards (peer review by professional organizations) demonstrates that the law generally defers to standards set by the medical profession, but competing views over what health care model is operative may generate non-deferential outcomes.

COGNITIVE DEATH: DIFFERENTIAL PROBLEMS AND LEGAL OVERTONES

The Quinlan case raised the issue of when physicians may lawfully terminate care for severely brain-damaged adults. The question was not whether Karen Quinlan was dead, for the medical testimony clearly indicated that she did not meet existing criteria for brain death. Instead, the question was whether her physicians and family could take steps that the court thought would lead to her death. The New Jersey court made “cognition” the touchstone of decisionmaking. It formulated a procedure to permit withdrawal of a presumptively life-supporting respirator following a medical determination that cognition was irretrievably lost. The court thus established a legal precedent for terminating care of those adults who, while retaining vegetative neurologic functions, lack the capacity to interact with the external environment. But, although many seem to have applauded the decision, it has some disturbing features which bear mention. To support its judgment, the court stated some conclusions that had limited evidentiary support.2 For example, it flatly assumed that Miss Quinlan herself would have wished the respirator removed if only she could have perceived that there was almost no hope of recovery.* It concluded that she was suffering, despite extensive medical testimony that she lacked the capacity for conscious emotional experience. It suggested that her attending physicians would willingly turn off the respirator if it weren’t for the fear or civil or criminal liability, despite testimony by them that this was not the basis of their reluctance. It concluded that she would not survive withdrawal of the respirator, despite medical testimony that she might survive for an indefinite period after it was removed. It assumed that the capacity of physicians to predict outcome for persons such as Miss Quinlan was well-enough developed to permit the drastic step of withdrawing life-support measures, despite the lack of systematic, statistically validated studies of prognosis in chronic vegetative states. If this seems to be ungracious quibbling that has lost sight of the “good” the court was trying to achieve, let me move the dialogue to another level. Recall that the court was being asked to appoint Miss Quinlan’s father as her guardian for the express purpose of authorizing removal of life support. To

Legal Implications of Epilepsy

Summary: Physicians who care for patients with epilepsy may function as agents or targets of social control. As agents, they may assist in the identification and control of epileptic drivers, may provide information that enables fair and appropriate job placements for epileptic persons, and give testimony that helps the legal system resolve issues relating to the liability of epileptic persons for harm attributed to seizures or interictal behavioral disturbances. As targets, they may be charged with negligent failure to diagnose, treat, or inform about epilepsy or its associated problems, with failure to exercise due care in protecting persons harmed by their patients, or with failure to preserve confidentiality of medical information. Although legislation and judicial decisions have defined some of the physicians legal duties with reasonable clarity, areas of uncertainty remain, particularly regarding the issue of violating medical confidentiality for the benefit of persons other than the patient.