To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
This chapter introduces the book by providing some background and context to the medico-legal nexus for treatment of trans youth with gender dysphoria in Australia, England and Wales. The guiding research questions for the book are outlined, followed by the structure of chapters. The chapter descriptions are interwoven with the relevant methods employed to examine the law in the relevant jurisdictions. Lastly, the scope and limitations of the book are noted to guide future researchers in this area.
This chapter presents an overview of the medical literature to outline what is known about gender dysphoria in childhood and adolescence. This chapter begins with a discussion of terminology commonly used in literature on gender diversity, as well as the preferred terms within this book. Second, literature on the medicalisation of gender diversity is reviewed to contextualise the relationship between gender and the medical establishment. Third, the diagnoses that may be given to trans children and adolescents that present to a medical professional for treatment are reviewed alongside critical commentary. Fourth, the research on gender variance in children and adolescents is reviewed broadly. Key themes identified in the literature include: prevalence; determinants of gender diversity; the natural history of gender dysphoria; and co-occurring conditions of trans youth. This area of research has advanced significantly in recent years. However, it is also in constant flux and answers to key questions are unsettled. This review of the medical literature provides context for treatment recommendations for children and adolescents discussed in Chapter 3.
When is life-sustaining treatment not in the best interests of a minimally conscious child? This is an extremely difficult question that incites seemingly intractable debate. And yet, it is the question courts in England and Wales have set out to answer in disputes about appropriate medical treatment for children.
This chapter discusses the growth of military systems in Western Europe during the period from 1460 to 1560, the preliminary stage of what has often, controversially, been called the ‘military revolution’. The main characteristics of military violence generated by dynastic wars were the inexorable growth of armies and the problems of pay and supply which accompanied this. Military technology affected both the nature and duration of wars: artillery came to dominate both in siege warfare, naval warfare and on the open battlefield. The lives of professional soldiers were drastically affected by new forms of trauma and medical treatment remained rudimentary. At the same time, the relations between soldiery and civilians continued to be conflictual, especially in war zones. Endemic violence accompanied any war. The features specific to this period combine a more intensive kind of violence brought about by changes in military technology and the scale of war with a broadly dysfunctional control system. This meant that the larger armies and more destructive campaign had an impact of casualties and losses among the soldiery as well as a chaotic impact on the ‘civilian’ population, though the patterns of ‘collateral’ violence remained much the same as they had been for centuries.
Critical psychiatry has often been confused with what is widely known as ‘anti-psychiatry’. In this article the distinction is clarified and the particular contribution critical psychiatry makes is outlined. That contribution is constructive criticism: of the relationship between medicine and mental health practice, of the way drug and psychotherapeutic treatments for mental health difficulties might be better understood. These have implications for everyday clinical practice and there is much to be gained by openly embracing the controversies critical psychiatry highlights.
• Understand the origins of critical psychiatry and recognise some of the difficulties that arise from identifying psychiatry with medicine
• Appreciate the differences between disease-centred and drug-centred approaches to prescribing psychiatric medication
• Become aware of implications that arise from psychotherapeutic outcomes research
DECLARATION OF INTERESTS
H. M. and J. M. are co-chairs of the UK Critical Psychiatry Network.
Use of the best-interests test as the legal standard to justify medical treatment (or its cessation) in respect to legally incompetent adults or minors has come under sustained critique over the years. “Best interests” has variously been alleged to be indeterminate as well as susceptible to majoritarian ideology and inherent bias. It has also been alleged to be inferior to rights-based approaches. Against the background of several particularly hard cases involving minors discussed by Gillett in a prior article in this journal, this article considers some of these critiques. It concludes that these critical accounts make significant contributions to enabling a more procedurally and substantively robust consideration of what might be in a child’s best interests. However, it is argued that none of these accounts alone provide a superior framework that would justify jettisoning the concept of best interests. Further, it is suggested that best interests still has an important role in achieving patient-centered decisionmaking in this context. It concludes by suggesting a taxonomy of considerations when determining best interests.
Physicians make at least an informal decision on a continual basis regarding the patient's ability to give informed consent. The difference between competency and capacity is a common misconception, and the terms, competency and capacity, are often used interchangeably in consult requests. Capacity is often considered an all-or-none phenomenon, and this may be the most common fallacy. The most common diagnoses which prompt request for capacity evaluation include dementia and delirium. Other diagnoses include substance abuse, affective disorders, personality factors, and psychotic disorders. Some states have laws which limit the ability to give consent to medical treatment for certain groups of patients. For instance, patients who are involuntarily committed for mental illness in Louisiana may not give consent for major surgery without a court order. Denial, a defense mechanism utilized to avoid unpleasant effects by denying aspects of reality, can be helpful for patients in some cases.
Liaison psychiatrists are frequently asked to advise when patients refuse consent to medical intervention. This chapter aims to give practising clinicians a framework for understanding legal issues surrounding refusal of treatment in the general hospital context. Non-psychiatrists in general hospitals are unaware of the limitations of the mental health act (MHA) with respect to issues of non-consent, and may erroneously expect that it normally has a role where there is refusal of treatment for physical health in persons with mental disorder. Every adult who has reached the age of majority (18 years) has, a priori, the right and capacity to decide whether or not he/she will accept medical treatment, even if a refusal may risk permanent damage to his/her physical or mental health, or even lead to premature death. The chapter provides a series of case vignettes and commentaries with regard to law applied to clinical situations.
Matthew F. Giles, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, OX2 6HE, UK,
Peter M. Rothwell, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, OX2 6HE, UK
Patients with carotid stenosis are at high risk of stroke and acute ischemic events in other vascular territories and require intensive medical treatment. This chapter reviews the evidence for specific medical treatments in patients with carotid stenosis. Antiplatelet agents, cholesterol-lowering drugs and blood-pressure-lowering drugs should be considered in all patients with carotid stenosis. The use of drug combinations has the theoretical advantage of inhibiting platelet activity through more than one pharmacological mechanism, hence potentially conferring a greater antiplatelet effect. Loss of the normal autoregulatory capacity of the cerebral circulation such that cerebral blood flow is directly dependent on perfusion pressure, is common and there has been concern that blood pressure lowering may reduce cerebral perfusion and increase the risk of stroke. Intima-media thickness (IMT) is correlated with the presence of cardiovascular risk factors and possibly with the future risk of vascular events including stroke and myocardial infarction.
Epistaxis associated with hereditary haemorrhagic telangiectasia (HHT) is a challenging condition. Septodermoplasty, electrocautery and laser treatment often provide short-term relief only. The surgical closure of the nostrils (‘Young’s procedure’) represents a longer term solution but has the disadvantage of causing permanent complete nasal obstruction. A Silastic™ obturator has the advantage of being a non-surgical intervention and allows temporary relief of the nasal obstruction. We present the cases of three patients with HHT who used the obturator with good clinical effect, suggesting that this is a realistic non-surgical alternative to Young’s procedure for patients with HHT.
Myasthenia gravis (MG) is a rare disease, even though its incidence and prevalence rates are growing: for example, its prevalence was 7.8-14.2 per 100 000 population in the 1970s and 1980s while it was 2.5-6.4 per 100 000 in the 1960s. Transient neonatal myasthenia occurs in 8-14% of births to myasthenic mothers. Myasthenia was also found to be relatively frequently associated with malignancy. The diagnosis of MG is based on the clinical findings of weakness and fatigue in muscle group(s), aggravated by exercise and relieved by rest. Edrophonium is a very short-acting anticholinesterase drug used as a diagnostic probe. The prognosis of MG depends upon the age of the patient at onset of the disease, the clinical stage, and the presence or absence of thymoma. Five years after MG was diagnosed, the probability of achieving complete remission reaches 13% while 33% achieve pharmacological remission, that is, symptom-free while under treatment.
Aging with grace and confidence would, for most people, be facilitated by the assurance that life would conclude with dignity. Unfortunately, such assurance is not available, especially if diminished competence does not allow the expression of a refusal to the continued administration of medical treatment. Health care professionals maintaining mentally incompetent patients on life supports should be aware of the legal risks of terminating treatment without valid informed consent. Yet who can give such consent? Does our law provide any guidance?
This paper will examine the Canadian legal realities of obtaining valid informed consent to cessation of medical treatment for the terminally or chronically ill. References will be made to The Canadian Charter of Rights and Freedoms and the leading American jurisprudence.
Email your librarian or administrator to recommend adding this to your organisation's collection.