Reevaluating Mandated Reporting: A Case Study in Sexual Assault

By Douglas Meyer

In light of recent personal events, I have been forced to reevaluate my views on mandated reporting. By mandated reporting, I am referring to the collection of laws and professional codes of conduct that force people to file a variety of reports for situations including, but not limited to, child and elder abuse, sexual assault and self-harm. While the specifics of the situations that must be reported vary widely, a general theme is that an adult must report any risky situation they observe in a professional capacity so that those involved can get necessary help. What follows should not be taken as a comprehensive argument against mandated reporting, but rather as a suggestion for why “getting someone the help they need” is not strong enough to warrant mandated reporting.

Imagine a sixteen year old, we’ll call him Sam, who was recently sexually assaulted. Sam is showing mild signs of depression and has night terrors almost every night as a result of the assault. He knows that some psychological help may prove beneficial, but is unwilling to forfeit his privacy, even if necessary to get the help he needs. I’m going to make a few assumptions for the purposes of analyzing Sam’s case:

1.     Sam’s peers would be supportive, but lack sufficient training to help him.

2.     Sam’s high school has guidance counselors who are well trained in helping sexual assault survivors.

3.     Sam would not be able to afford a psychiatrist without financial assistance.

One of Sam’s options would be to seek the help of a Mental Health Professional (MHP). For the purposes of this discussion, I will define an MHP as a person who has received extensive training in offering psychological assistance and who maintains patient confidentiality. This would be Sam’s best chance of getting the help he would need for his depression and night terrors because the mental health professional would be able to help Sam work through his traumatic experience. In addition, this option would let Sam maintain his privacy, since the only person who would find out about his experiences would be the MHP. Unfortunately, Sam would likely need to explain why he was in need of an MHP to his parents in order to receive their financial assistance. Sam’s unwillingness to forfeit his privacy coupled with his inability to afford an MHP on his own means that this option is unavailable to him.

There are likely only two free options available to Sam. First, are anonymous helplines (AHs) which include services such as online support groups and hotlines Sam could use. AHs would be helpful to Sam, but they would only be beneficial as supplements to other forms of help. Most support groups are comprised of well-meaning peers who bond over shared tragedies, but without sufficiently trained professionals included, they just do not have the capacity to provide all the help Sam needs. Hotlines are very often staffed by volunteers who have minimal training to provide basic guidance and support to callers, but these volunteers would only be able to guide Sam in finding MHPs and another type of assistance, which will be discussed momentarily. As a result, AHs could provide Sam with a lot of support, but only supplementally.

The other possibility would be a cluster of psychological services, which I’ll call Nonconfidential Psychological Agents (NPAs.) As the name suggests, NPAs are services and people, including school guidance counselors and teachers, who cannot offer their clients confidentiality because of their mandated reporting obligations. NPAs can be assumed to have sufficient training to provide Sam with the help he is seeking, and I’ll assume that there are sufficient NPAs available at little to no cost such that cost would not be a barrier to Sam.

Unfortunately for Sam, these three options are insufficient to deal with his case. Option 2 (AHs) would only be able to provide supplementary assistance, but on its own, couldn’t provide Sam with the necessary assistance. Options 1 and 3 (MHPs and NPAs, respectively) would be able to provide the necessary assistance to Sam. However, option 1 would be inaccessible to Sam due to financial barriers.

Earlier, I mentioned that my interpretation of the purpose of mandated reporting was to get someone the help they need. However, this would seem to fall apart when applied to Sam’s case. Mandated reporting does nothing to alleviate the financial burden associated with psychological counseling, and so it would not make MHPs a valid option to Sam. Mandated reporting does have a very strong effect on Sam’s access to NPAs. By preventing NPAs from protecting client confidentiality, mandated reporting actually acts as a barrier to these services. Ironically, the program that was implemented to get people help actually prevents many people seeking counseling from accessing those services. Moving forward, programs that promote access to counseling, like financial assistance programs, should be considered as replacements for mandated reporting strategies.

Douglas Meyer recently completed his first year at UCLA studying microbiology and the intersection between advancements in biology and society. Next fall, he will serve as Co-president of UCLA's Undergraduate Bioethics Club.

The Home in Nursing Homes

By: Rebecca Kaebnick

The sitting room, living area, and community space of the skilled nursing facility in my grandparents’ staged living community was often the hallway. There was a harshly-lit room with tables and a TV around the corner, and a cafeteria-like dining room down the hall. However, the aides tended to gather residents in the hallway, lined up in their wheelchairs in front of the nurses’ and aides’ station. The forbidding front of this station, a pedestal for charts and computers, was an impossible height for many of the wheelchair or walker-bound residents. Strung along this main hall and around some corners were the residents’ spaces, not quite oriented to watch the activity outside the windows, but not quite arranged to focus inward, on each other, either.

On paper, this wing had it all: compliance to health codes, caring nurses and aides, physical therapy. In fact, the facility was top-of-the line. But there was also an unsettled feeling that upset any possibility for a homey feel. Time moved bizarrely: residents sat silently in their rooms or in their wheelchairs in the hallway while the aides swept around and shifts turned over; the clock by the aides’ desk seemed to be counting down to many things and to nothing. When my family visited, we perched in odd places around my grandmother’s room, or gathered near the doorway. When we passed residents, we did not feel as if we were supposed to smile and greet them; one does not greet patients she passes in a hospital, and that’s what it felt like. This was a place where people were on their way to somewhere else; like a hospital, nurses and visitors and patients moved in and out, but these spaces were not a home.

Why are such facilities like this? If they were designed differently, could they feel different? While many of the residents living in this area need careful medical attention, this phase of life is not just about medical and physical care, and doesn’t always have to feel like a hospital.

There are some successful efforts to break the mold, mainly sprung from the culture change movement in the nineties to “deinstitutionalize” nursing homes. The Green House project, developed in the early 2000s, is a key example of an accessible and efficient elder care home that still manages to create a more hospitable environment. Green Homes look more like houses than institutions. They are set up like family residences too, with a living room containing a hearth, a dining table seating all 7-10 of the residents, and the appearance of few medical instruments and technology. Green Homes redesign personal and communal space to make residents feel they are living in a home, rather than a glorified hospital, and give nursing assistants the role of “universal workers” who do everything from dispensing medications to cooking dinner. They have more interaction with residents than do aides in traditional nursing homes, and reportedly increased job satisfaction. The new physical characteristics of the homes and different roles of the aides reconfigure interactions between residents and staff, between residents, and even between residents and their family, during visits.

Another inspiring nursing home is Beatitudes Campus in Phoenix, Arizona. In a New Yorker article published last May, “The Sense of an Ending,” Rebecca Mead describes efforts made to replicate the comfortable, residential feel like that of the Green Homes in a more traditional facility. Tena Alonzo, the Beatitudes director of education and research, adjusts details of a resident’s lifestyle in unconventional ways that can make the resident much more comfortable. For example, a resident’s bed is lowered when there is a higher risk of falling out during the night. The “neighborhood,” as the staff call the facility, is not run on strict schedules; individuals create their own timetables based on what works for them. Food is available around the clock. The layout of the space and interactions between residents and staff are influenced by the characteristics of dementia, not by what is the cheapest or easiest. Instead of a heavy metal door at the entrance of the facility, residents are more subtly reminded not to wander by a velvet rope, like that of a classy restaurant, and a large black carpet, which dementia patients don’t like to walk on because they might interpret it as a hole. Alonzo develops strategies like these to make residents comfortable in more respectful and logical ways than those of traditional nursing homes. She also wishes for the staff to be more understanding of the lifestyle and needs of their residents; she encourages the staff members to try acting as residents for a day, in situations that can be embarrassing or uncomfortable, such as wearing a diaper.  This is another take on the Green House “universal worker” idea, to create more equal and warm relationships between residents and their caretakers. Mead mentions several other establishments that apply concepts similar to Alonzo’s. Like Beatitudes, the Pioneer Network in Chicago attempts to satisfy residents without the heavy use of psychotropic medications. The Isabella Geriatric Center and the Cobble Hill Health Center, both in New York City, are working to integrate Alonzo’s ideas into their practices.

In a study  published in The American Geriatrics Society Rosalie A. Kane et al. assess the success of Green Houses, finding that “GH residents reported significantly higher satisfaction with the nursing home as a place to live than residents of the [comparison facilities].” These feelings of comfort and happiness go hand-in-hand with particular trends in emotional and physical health, such as depression and the loss of independence in a set of activities called Activities of Daily Living, which include eating and using the bathroom. Alonzo and her co-director, Long, found strong trends in weight-maintenance and even healthy weight gain among their residents, due to their adaptive, flexible eating and daily schedules. Pam Belluck, in her New York Times article “Giving Alzheimer’s Patients Their Way, Even Chocolate,” cites various studies showing that space, activities, and medication can be adapted to make a dementia patient more comfortable. Making the lights brighter can have a big effect. Prescribing medication specifically for pain instead of an antipsychotic for dementia can keep side effects under control. Alonzo’s tendency to allow residents comforting rituals, such as sucking on chocolate and playing with dolls, has scientific basis: habitual pleasurable activities have been proven to correlate to depression and decreased cognitive activity. Belluck mentions a University of Iowa study that found that although many dementia patients no longer have the strongest memories, a happy mood can persist hours after the activity ends.  Living in an environment that makes them happier has significant effects on many dimensions of the residents’ health, interpersonal relations, and can help them see themselves as people fit to live in a real home, even if it requires some new accommodations.

If my grandparents’ experience is typical, then it is difficult for the average elder care consumer to ascertain just how homelike the nursing facility is when looking at retirement communities.  Many attempt to channel cheerfulness and hospitality into their built environments by adding special features to their more independent-living wings— fire-lit libraries, easy-access greenhouses, and welcoming dining rooms. Yet it is just as important for the visitor to learn about the functional wings. Maybe consumers do not expect areas designated for increased medical attention to have the same atmosphere, or maybe these areas are just not fully presented to them. Do companies tend to push some aspects of the independent living options and downplay some of the dependent ones? When potential customers visit, they may be more focused on the near future, when they will be living in the apartments and visiting the dining rooms. It is hard to fully picture a time when one’s health may have changed enough to need around-the-clock care, but many will arrive at that point.

Welcoming and peaceful environments seem even more important in the wings where residents deal with more advanced conditions and illnesses. Many residents, like my grandmother, juggle health-related anxieties with the pressure of moving somewhere entirely unfamiliar. Much of the stress my grandmother experienced seemed to be derived from a feeling of displacement. She was always someone who took great pains to make her living space feel like hers, and in this wing she lost this capability. Green Houses and Beatitudes illustrate that it is possible to unite medical care to homeliness, even though a straightforward set-up following the lines of a hospital wing might seem more efficient. Green Houses are certifiedskilled nursing facilities, run by a dependable team of certified nursing assistants, and a “clinical support team” made up of professionals who supervise the medical experience of the residents. Half of the residents in the studied Green House were certified dementia patients, and InformeDesign, a research tool for design professionals, asserts in a short piece about Green Homes that this model could be applied to “even the most heavy-care facility.” Quality of care is not compromised in this environment; reports on the quality of care by the Green House residents overall were either at the same level or better at the Green Houses than at the comparison nursing facilities. At Beatitudes, the directors found that patients were happier months after their arrival, and sometimes were able to make health gains: one resident was able to stop taking insulin because she began eating so well. Beatitudes won an award from the American Association of Homes and Services for the Aging. These models have found ways to successfully integrate medical technology and accessibility into a warm environment.

The basic premise of the Green House project is to find a way to make living areas cohesive units in which the medical structure isn’t the dominant aesthetic factor, detracting from the quality of life of the residents. While it is unclear how affordable Green Houses are, and it is true that the movement is not big enough to be an option for everybody, the success of Beatitudes proves that the goals of the project can be successfully applied to traditional models that still make up the most common elder care options. Beatitudes’s innovations go farther than the built environment, to making the schedules and activities of the patients, and the responses of the staff to residents’ distress, more adaptive to the individual patients themselves. Learning this makes me optimistic and hopeful that this trend will grow. Thinking back to my grandparents’ situation, I can see that my grandmother would have been well suited to be cared for by a collection of staff who are not afraid to make unconventional changes to make a resident more comfortable. Green Homes and homes like Beatitudes take the time to organize themselves according to what they see helps their patients, not according to tradition. They create environments in which conversation between residents, and between residents and staff, is encouraged. Visitors can join the residents in these spaces, bringing in pieces of the outside world but at the same time integrating themselves into this life, at least for a day. The residents can feel like they belong there; they aren’t stored in their rooms or lined neatly in the hall. Instead they can congregate around a puzzle, meet with a friend, pick out a book for themselves. They don’t just stay here until the end—they live here, enjoying each moment with vigor.

Rebecca is a junior at Ithaca College where she is majoring in Sociology and minoring in Spanish, art, and honors. She is interested in issues relating to globalization and vulnerable populations.

Inflicting Harm to Prevent Harm: Creating Policy for Vulnerable Populations Seeking Asylum in Australia

By Amy Louise Constable 

Australian asylum seeker policy is currently riddled with a series of ethical conundrums. Being party to the 1951 United Nations Convention and Protocol Relating to the Status of Refugees, Australia is obligated to accept those claiming asylum from persecution, violence or fear either who enter into Australian territory and respect the principle of non-refoulment and not send refugees to an environment from which they are fleeing. Detention of asylum seekers has been a bipartisan policy in Australia since 1992 when Australian Prime Minister Paul Keating introduced off-shore detention, with bipartisan support. The zealous implementation of increasingly cruel offshore detention policies has been described as a ‘race to the bottom’.

The 2013 Australian federal government was characterized by the promise of increasingly ‘tough’ and cruel policies seeking to deter asylum seekers entering Australia by boat and protect Australian sovereignty by both major parties. The conservative Government initiated Operation Sovereign Borders, an extension of existing asylum seeker policy. Operation Sovereign Borders is an extension of pre-existing off-shore processing policy which instructs that all asylum seekers arriving by boat, ‘illegal maritime arrivals’, are to be processed off-shore at Manus Island, a northern territory of Papua New Guinea (PNG), and at Nauru with “no chance of being settled in Australia as refugees”. This policy has been justified by both major Australia political parties as preventing further deaths at sea. Between 2008-2013 approximately 1200 people died at sea trying to come to Australia by boat. This begs the question, what is the ethically acceptable cost of preventing death at sea?

The ‘tough’ new stance on asylum seekers has recently inflamed debate surrounding exactly what the ethical, medical and legal responsibility of the Australian Government to the asylum seekers on Australian territory and on international territory in Australian Government funded detention centers is. The logic for this policy is justified by the Department of Immigration and Border Protection as stopping deaths at sea and protecting national security. Consequently, this policy sees the compulsory detention of thousands of adults, minors and children, of whom 91% are declared to be refugees, with higher protection visa rates for specific ethnic groups (i.e., the Afghani’s receiving a protection visa being approximately 99.7%)

Operation Sovereign Borders dictates that all asylum seekers be transferred from Australian sovereign territory within 48 hours, as instructed by Minister for Immigration and Border Protection, Scott Morrison. This rapid process involves all medicines, prostheses, and medical equipment being confiscated, and often not returned, and does not provide sufficient time for a comprehensive diagnosis of potential diseases. Consequently the process has seen several healthcare horrors:

--Potential exposure of asylum seekers to tuberculosis following a non-diagnosis while being processed on Christmas Island (remote north-western Australian territory).

--A 23 year old Iranian-Kurdish man dragged from a computer room and beaten to death by a G4S security employee.

--Detainees attacked with machetes and throats slashed during attacks by locally-hired security guards.

--A Rohingyan asylum seeker who was identified as having a ‘very high risk’ pregnancy was transferred to Nauru for the purpose of ‘setting an example’.

--a woman being told she should not ‘expect a lot’ of healthcare after miscarrying.

--An Iranian man lapsing into severe epilepsy following a refusal of access to confiscated epilepsy medication.

A 92 page letter from fifteen doctors working at the Christmas Island and Manus Island detention center has highlighted the inadequate resourcing of centers and the degradation of those seeking treatment. They have stated that they are being paid to compromise medical ethics and have explicitly stated that doctors are expected to participate in ‘unethical conduct and in gross departures from clinical standards’.

Issues of reciprocity have further confounded exactly what Australia’s obligations are to people fleeing their home countries. A particularly stark example of this is the employment of Afghan Hazāra, a persecuted ethnic minority in Afghanistan, as interpreters by the Australian Defense Forces during the NATO led military invasion in Afghanistan, many of whom have applied for asylum in Australia. Reports have surfaced that Afghani-Hazāra interpreters who have had their asylum application rejected have been killed by the Pashtun led Taliban due to their ethnic and religious difference to the Taliban and their assistance to the allied NATO forces. While this itself is an issue largely outside the scope of this short essay (what responsibility do we have to those who have offered us assistance?), it highlights the incredible complexity of ethical, moral and legal issues associated with formulating policy that may harm incredibly vulnerable or precarious populations.

These few specific issues among a sea of thousands of complaints and detailed reports by security contractors Serco of self-harm, sexual assault, hunger strikes and the transferal of unaccompanied minors to detention centers for indefinite prolonged periods. Transferal of minors into detention has been criticized for exposing children to distressing situations, children referring to themselves by their client number as opposed to their name (see 46.18-59.12 of attached video) report, confronting developmental delays due to lack of access to education and exposure to environments riddled with self-harm, sexual and physical assault. The ‘tough stance’ taken by the Government highlights the ethical fallacy of invoking a policy causing medical and psychological harm in the name of trying to deter people from taking a dangerous journey.

The ethical mess of Australian detention center medical administration is highlighted by a co-author of the 92 page letter to the Guardian and Minister Morrison says; “there will one day be a royal commission [the highest level of government-sanctioned inquiry in Australia] into what is taking place on Christmas Island. He suggested we document well.” Creation of policy for vulnerable populations is fraught with ethical difficulty and complexity, and is further confounded when the democratic processes, such as the 2013 Australian federal elections, indicate a seeming majority of the population support increased cruelty to vulnerable persons. Perhaps the easiest way to condense this ethically compromised ‘humanitarian’ policy is to ask: what is the cost of this policy? Is it justifiable to inflict harm onto those individuals in the aim of preventing harm to others?

Amy Constable is an Honours degree candidate at the Australian National University, and was a 2013 summer fellow of the Yale University Interdisciplinary Center for Bioethics.

Organ Donations: It is Time to “Opt-Out” of Our Current Policy

By: Michael DiBello

In bioethics today, there is a wide array of fiercely contested topics such as abortion, euthanasia and novel fertility treatments, which have made the front pages of newspapers around the globe. While these undoubtedly important issues demand a thorough dialogue, some equally important policy issues seem to slip under the radar. 

One of these issues is our policy for organ transplantation.

On average, approximately 18 U.S. residents die per day awaiting a transplant, totaling over 6,500 per year. Only about 45% of the adult U.S. population are registered as donors. Many lives could be saved and significantly enhanced if more people were registered as organ donors. The question becomes: how do we increase the donor pool in a fair, ethically responsible manner?

In the United States, individuals must opt-in to become a donor by checking a box on a driver’s license application or by signing up online. This “opt-in” system of organ donation is inadequate not only from an efficiency perspective, but from a moral perspective as well. Many countries have adopted an alternative system to the opt-in policy, where the default position for adults is set to being a donor, with an option to opt-out. This system is generally referred to as an opt-out policy. Countries with an opt-out style policy like France, Austria, Poland, Hungary and Portugal display donor consent rates of over 99%. Countries with an opt-in style policy like the United Kingdom, Germany, Netherlands and Denmark display rates drastically lower donor consent rates under 30%. 

Why is it exactly that people do not give consent to become an organ donor? One possible reason may be the immediate and intimidating nature of the decision for an individual. Organ transplantation may evoke images of dismemberment, drastic surgery and death, instilling apprehension and anxiety in the individual, resulting in a decision to not actively volunteer to become a donor. While the emotional responses regarding organ transplantation are understandable, they do not make the decision to decline becoming an organ donor morally correct. 

It intuitively seems fair that if one is willing to receive a transplant (I assume the vast majority of people are), then one should also be willing to donate their own organs, especially in the situation of scarcity involved in organ availability. This is exactly why it is the state’s responsibility to provide the guidance of an opt-out system. Part of the reason for the existence of the state is to encourage individual decisions which are beneficial to the overall public, especially when those decisions involve little to no significant sacrifice for the individual. The opt-out system donor pool would include all donors that currently actively choose to be donors under the opt-in system, those who would become donors with a little more consideration and/or state guidance and also those who are simply indifferent to what happens to their organs. This could likely mean a very significant increase in the donor pool with no coercion, injustice or unfairness done. 

 

What if an individual really does have strong feeling against being a donor? In the opt-out system one can imagine, they are entirely free opt-out without consequence. A possible mechanism for the action of opting out could involve checking a box on an application for a government ID. A whole separate debate may be necessary for the issue of automatically registering children as donors, as they may not possess a sufficient degree of autonomy to make a fully informed decision about organ donation. Should the default donor position apply to children, with the decision to opt-out left up to the parents? Should the default donor position simply not apply to children at all? These are difficult but important questions, especially considering the clear physical constraints of other children in need of organs.

One possible objection to the opt-out policy is that is a coercive state policy, since it defaults to an individual giving up something they may consider valuable (the right to an intact body after death). As mentioned previously, the opt-out policy still affords the individual this right. All that is required is simply more conscious consideration about exactly what they are doing.

Adding quality years to as many lives as possible is more important than the temporary preservation of the physical integrity of a corpse. This is the attitude necessary in order to be on track to a policy change. Our current organ donation system is failing, and an opt-out policy would bring about greater fairness in a society where increased access to healthcare is a goal that should be pursued to the highest possible degree. 

Mike graduated from Northeastern University in January 2014 with a major in biology and a minor in ethics. He is interested in a wide range of issues in bioethics and how they are applied in today's world.