Step therapy, also termed fail-first policy, describes a practice of insurance and pharmacy benefit management companies denying reimbursement for a specific treatment until after other treatments have first been found ineffective (i.e. failed). Laws to limit step therapy have been passed in 29 states of the United States. Using extrapolated data on fully insured employees, we find that except for New York and New Mexico, enacted State laws don't apply to even one-third of a state's population. Using the more robust Kaiser Family Foundation (KFF) data, which do not include fully insured employees, we find that only 2–10% of a state's population is covered. Advocating for these laws has been an expensive and time-consuming process, likely to become more so for the 21 states without such laws. The laws that have been enacted can be near impossible, to enforce, and loopholes exist. As a result, using KFF data, more than 90% of people in the United States with health insurance may still be unable to access the treatment chosen as most appropriate for them with their physician. Based on these data, we conclude federal step-therapy legislation is needed.

Although significant progress has been made in Irish mental health law in recent decades, the Mental Health Act, 2001 still falls short of properly protecting human rights. A consideration of human rights developments, both domestically and internationally, highlights the urgent need for reform. In this paper we consider Sections 4 (‘Best interests’), 3 (‘Mental disorder’) and 57 (‘Treatment not requiring consent’) of the 2001 Act and related recommendations in the 2015 Report of the Expert Group on the Review of the Mental Health Act, 2001, and suggest specific areas for reform. Just as medicine evolves over time, so too does our understanding of human rights and law. While embracing a human rights-based approach to the extent suggested here might be seen as aspirational, it is important to balance achievable goals with higher ideals if progress is to be made and rights are to be respected.

I draw attention to a 12-page Vorarbeit to Kant’s Prolegomena from the so-called Scheffner-Nachlaß and argue that the parallel Kant draws there between the possibility of theoretical and practical synthetic a priori propositions provides important insight into the development of his account of practical autonomy in the Groundwork. Based on a brief sketch of the role synthetic a priori propositions play in the development of Kant’s critical philosophy, I conclude that for Kant the objective validity of any science depends on the objective validity of a number of synthetic a priori propositions.

Patient safety is a complex systems issue. In this study, we used a scoping review of peer-reviewed literature and a case study of provincial and territorial legislation in Canada to explore the influence of mandatory reporting legislation on patient safety outcomes in hospital settings. We drew from a conceptual model that examines the components of mandatory reporting legislation that must be in place as a part of a systems governance approach to patient safety and used this model to frame our results. Our results suggest that mandatory reporting legislation across Canada is generally designed to gather information about – rather than respond to and prevent – patient safety incidents. Overall, we found limited evidence of impact of mandatory reporting legislation on patient safety outcomes. Although legislation is one lever among many to improve patient safety outcomes, there are nonetheless several considerations for patient safety legislation to assist in broader system improvement efforts in Canada and elsewhere. Legislative frameworks may be enhanced by strengthening learning systems, accountability mechanisms and patient safety culture.

In 2010, Ireland found itself at the eye of an international storm as a network of head shops emerged selling new psychoactive substances (NPS) and Irish youth rapidly became the heaviest users of NPS in Europe. Within months, the Irish government enacted novel legislation, which has since been copied by other countries, which effectively stopped the head shops selling NPS. Critics of this policy argued that it could cause harms to escalate. A number of separate studies indicate that a range of drug-related harms increased amongst Irish youth during the period of head shop expansion. Within months of their closure, health harms began to decline. NPS-related addiction treatment episodes reduced and admissions to both psychiatric and general hospitals related to any drug problem began to fall. Population use underwent sustained decline. Consequently, the closure of head shops can be viewed as a success in terms of public health.

In Brazil, the buffalo milk market has been growing. However, identity and quality standards have not been established for this raw material, nor have proper distinctions between buffalo milk and bovine milk been defined. Currently, the State of Rio Grande do Sul (RS) has only three producers that supply raw material for officially marketed derivatives. The aim of this study was to determine the identity and quality standards of raw buffalo milk in this region. Samples were obtained biweekly from three farm cooling tanks between June 2017 and August 2018, to reach a total of 69 samples. The averages for the results of the physicochemical parameters fat, protein, lactose, total solids, SNF (solids-not-fat), calcium, density, FP, acidity and SCC were 5.5 g/100 g, 4.06 g/100 g, 5.07 g/100 g, 15.5 g/100 g, 9.96 g/100 g, 0.161 g/100 g, 1.034 g/ml, −0.527°C, 16°D and 95 × 103 cells/ml, respectively. With reference to the microbiological parameters, the mean of the Standard Plate Count (SPC) and thermotolerant coliforms were 9,0 × 104 CFU/ml and 1.6 × 102 MPN/ml, respectively. Regarding coagulase-positive staphylococci, 36 samples tested positive (52% of total). Neither Salmonella spp. nor Listeria monocytogenes, nor antibiotic or antiparasitic residues were detected in any sample. In conclusion, the buffalo milk used as raw material for dairy products in southern Brazil demonstrated satisfactory physicochemical and microbiological characteristics, in accordance with recent scientific literature.

Care-leavers – those transitioning from alternative care towards young adulthood – are widely recognized as a vulnerable population, yet child protection legislation seldom applies to them because they have reached adulthood. Despite this, little internationally comparative research on care-leaving policy and legislation has been conducted. This paper maps multinational policy and legislation and its impact on the services to care-leavers and the challenges they experience. An online survey was conducted with key informants in 36 countries and analysed by a multinational team of care-leaving scholars. Findings reveal that few countries have well-developed care-leaving legislation. Most countries provide little aftercare beyond the age of 18, even when legislation provides for it. Within the context of suboptimal social policy and limited aftercare services, findings also reveal high vulnerability among care-leavers. Recommendations for policy development, global dialogue, further research and advocacy are proposed.

Although some studies have revealed practitioner disempowerment in cases of older adult mistreatment, this experience is poorly understood. In addition, dementia and contextual influences further complicate cases; yet,  little is known about the experience of practitioners with this complexity. This critical inquiry, based on Critical social theory, critical consciousness, and professional agency, aimed to address these gaps. Fifty-one practitioners from diverse health care and social service disciplines from rural and urban communities in Northeastern Ontario participated in interviews, journals, and focus groups. Analysis of data revealed the need for empowerment within a perpetual cycle of non-resolution, to refocus on legal clarity and intervention versus the current legal complexity and education focus, and to develop adequate infrastructure to support interprofessional efforts. The infusion of this knowledge into policy, practice, and research has great potential to improve outcomes for older adults with dementia who are mistreated in their homes.

This article considers the interpretive significance of legislative inaction. Section I considers the nature of arguments based on legislative inaction. Section II explores the practical, conceptual and constitutional problems with trying to rely on legislative inaction as an interpretive aid. Section III concludes that attempts to draw inferences from legislative inaction alone are deeply flawed, but that inferences might legitimately be drawn from inaction if it forms part of the context against which the legislation is enacted. Even then, however, there are practical difficulties in determining what inferences to draw.