William J. Winslade

Severe brain injury: Recognizing the limits of treatment and exploring the frontiers of research

Persons who experience severe brain injury often suffer significant disorders of consciousness. Anoxic injuries from cardiac arrest or strokes and traumatic injuries from falls, vehicular crashes, or assaults can result in several conditions in which patients lose or have diminished consciousness for an extended period of time. Two such conditions that create considerable public confusion and controversy are the vegetative state (VS) and the minimally conscious state (MCS). Although these conditions have generated significant medical and academic research, the general public and policymakers are often confused about the nature of VS and MCS. The most recent evidence for this confusion is the acrimonious public debate, the extensive media coverage, the prolonged litigation, and the attempts of various governmental officials to intervene in dealing with the plight of Terri Schiavo. I thank my legal researcher, Tejal Banker, J.D., LL.M., for her assistance.

Psychotherapeutic Discretion and Judicial Decision: A Case of Enigmatic Justice

On October 27, 1969, Prosenjit Poddar, a 25-year old graduate student from India, fatally shot and stabbed Tatiana Tarasoff, a young junior college student. One might suppose that this was a crime of passion with a familiar pattern: a spurned suitor’s desire for revenge erupts into an uncontrollable (or perhaps only uncontrolled) impulse to destroy the rejecting woman. Not unexpectedly, the jury convicted Poddar of second-degree murder, despite a plea of insanity and diminished capacity that was considerably buttressed by psychiatric and lay testimony as to Poddar’s bizarre behavior. Poddar’s criminal trial might have ended with his conviction and sentencing, followed by his serving about five years (the average time served for second-degree murder1) and, if his prison behavior was acceptable, his release on parole.

An overview of the scientist's responsibilities: comments by an attorney.

Scientific research which utilizes human tissue produces valuable scientific knowledge and contributes to the development of medical therapy. But human tissue research, however valuable it may be, is and should be subject to regulations to prevent fraud, deception or other forms of overreaching to the acquisition of human tissue to protect potential contributors. (My discussion deals primarily with problems in connection with the acquisition rather than the utilization of human tissue. The latter topic, which also deserves careful study, lies beyond the scope of this paper.) Such regulations also help to define and limit the scope of liability of scientists or others who acquire and utilize human tissue. In addition, when one deals with human subjects, it is particularly important to prevent not only actual abuses, but also to avoid the appearance of impropriety. Because many contributors of human tissue for research are persons who are patients in medical centers or other institutions, they are more vulnerable to exploitation than healthy or noninstitutionalized persons. Accordingly, it is necessary to obtain informed consent of contributing human subjects, to regulate the procedures for acquiring human tissue and to critically examine the goals sought through the utilization of human tissue. It is necessary to be alert to potential conflicts among the needs of scientists, the legal doctrines relevant to protecting persons, and the moral values, emotions and religious sentiments connected with persons and their bodies. In what follows I attempt to identify some of the legal, moral and psychological issues which are germane to scientific research on human tissue and to suggest, in a preliminary way, some of the further steps that must be taken by scientists to maintain high standards of professional responsibility and sensitivity to human subjects.

Ethical Issues in Psychiatric Research

The primary goal of psychiatric research is to increase scientific knowledge about human psychology and behavior. Other chapters in this book treat the methodologies for achieving this goal as well as special topics and areas about which knowledge is sought. In this chapter, we consider ethical issues that arise in the course of formulating and conducting psychiatric research.

Surgical castration, Texas law and the case of Mr T

Persons who commit crimes involving sexual abuse of children exploit their victims in several ways. Sex offenders use their power and authority over vulnerable children to whom they have easy access. Teachers, coaches, clergy, family members and childcare workers have been exposed as sex offenders. The Pennsylvania State University football coach, Jerry Sandusky, is now in prison for his many crimes. The widespread cover up of sexual abuse by Catholic priests in the USA and other countries is a horrendous scandal. It is not surprising that law enforcement, mental health professionals, victims and their families are outraged. It is no surprise that radical interventions such as chemical or surgical castration are a response to the public pressure to protect children from molestation. I agree with Professor John McMillans thoughtful discussion and nuanced analysis of surgical castration.1i He concludes that surgical castration of sex offenders is ethically permissible if these conditions are met: 1. Castration should be requested by the sex offender. 2. Informed consent (including positive and negative side effects) from a competent sex offender is required. 3. Consent to castration must not be coerced via threats or inducements. He also says that “castration might be useful for the reconfiguring of a life that has gone badly awry.” To supplement his discussion I will describe a state law in Texas2 that permits voluntary surgical castration (orchidectomy) for repeat child molesters while they are incarcerated as …

Review of Brain, Body and Mind: Neuroethics with a Human Face by Walter Glannon

Chapter 11 defends the use of civil disobedience— intentional lawbreaking—to bring about moral change and to prevent a serious moral wrong, provided doing so is likely to be successful. However, Singer makes clear: “If the means used involve undeniable harm to innocent people, and hold no promise of gaining their ends, it is wrong to use them” (274), and thus, “terrorism is never justified” (274). Singer has argued that morality often requires us to sacrifice our own interests for the greater interests of others. If morality is so demanding, why act morally? The final chapter addresses this question. After clarifying the question, Singer gives what is perhaps the best answer that can be given: Living one’s life in accordance with one’s fundamental moral beliefs and values is one of the most meaningful ways one can live. Outspoken critics have objected vehemently to Singer’s views on abortion and infanticide. But far more important than what one might find objectionable in the book is what one can learn from the book. If readers were to follow the recommendations of chapter 8 and donate 1–5% of their income to famine relief, there would be far fewer children living in extreme poverty and far fewer children dying of hunger and hunger-related disease—a state of affairs that pro-life critics of Singer’s position on abortion should be actively working to bring about. If readers were to take seriously Singer’s compelling arguments for extending moral consideration to animals and make the conscious choice to stop eating them, as many of his readers have, there would be significantly fewer animals suffering unnecessarily in factory farms. Important lessons, indeed!

The minimally conscious patient: when can life support be terminated?

Distinguished Visiting Professor of Law University of Houston Law Center Houston, Texas REHABILITATION FOR persons who have experienced traumatic brain injury is often lengthy, arduous, and expensive. Progress is often slow; recovery is uncertain and incomplete. For example, Robert Wendland, seriously brain injured after rolling his truck at a high speed, remained in a coma for 16 months before regaining consciousness. After 6 months of rehabilitation, Robert remained severely cognitively impaired, emotionally volatile, and physically handicapped. He was paralyzed on his right side, unable to communicate verbally, or interact consistently with his environment. He was, however, able to respond to simple commands, communicate (inconsistently) by means of a yes/no board, and engage in some simple physical movements (e.g., throw and catch a ball, operate a wheelchair with assistance, and draw circles and an “R”). Because he was unable to feed himself, a jejunostomy tube was surgically inserted. It became dislodged three times and was surgically reinserted with the consent of Robert’s wife Rose. The fourth time the tube came out, Rose refused to consent to the surgical repair. Rose, their daughters, and Robert’s brother,

In a Survivor's Voice@@@Confronting Traumatic Brain Injury: Devastation, Hope and Healing

Traumatic brain injury is the fourth most common cause of death in the developed world: in the United States alone, 75,000 to 100,000 people die of brain trauma each year, and another 70,000 to 90,000 are left permanently impaired. This book explains what it is, how it is caused and what can be done to treat, cope with and prevent it. William Winslade presents facts about traumatic brain injury; information about its financial and emotional costs to individuals, families and society; and key ethical and policy issues. He illustrates each aspect with case studies, including his own childhood brain injury. He explains how the brain works and how severe injuries affect it, both immediately and over the long term, pointing out how resources are often squandered on patients with poor prognoses and adequate insurance, while underinsured patients with better prognoses do not receive appropriate care. He tells about the lack of regulation in the rehabilitation industry and what federal and state legislatures are doing to correct the situation. And he offers recommendations for policy changes to lower the instances of traumatic brain injury (such as raising the minimum driving age) as well as practical steps that individuals can take to protect themselves from brain trauma.

Paternalism and Individualism in Legal and Ethical Aspects of Medicine

In the United States, the physician-patient relationship is legally shaped by the principle of self-determination, ethically shaped by the principle of personal autonomy, and often pragmatically shaped by psychological paternalism. Because self-determination, autonomy and paternalism do not lie easily together, the legal and ethical dimensions of clinical practice and clinical judgment are frequently unclear and their resolution often disputed.