Perceived structural vulnerabilities among detained noncitizen immigrants in Minnesota

Across several decades there has been an unprecedented increase in immigration enforcement including detention and deportation. Immigration detention profoundly impacts those experiencing detention and their family members. An emerging area of research has found that immigrants experience a number of challenges which constrain and limit their decisions, choices, and options for security and integration in the United States due to social, political and structural determinants. These determinants lead to greater structural vulnerabilities among immigrants. The purpose of the current study was to illuminate the perceived vulnerabilities of detained noncitizen immigrants as they are raised and described while attending case hearings at the Bloomington, Minnesota immigration court. Through conducting a thematic analysis of notes derived from third party immigration court observers, three areas of perceived vulnerability were identified. These perceived vulnerabilities include 1) migration and motivations to migrate, 2) structural vulnerabilities (e.g., discrimination, financial insecurity, social ties and family support, stable or fixed residence, English language proficiency, health and mental health) in the US, and 3) challenges in navigating immigration detention. These findings demonstrate that noncitizen immigrants who are undergoing immigration detention are experiencing multiple intersecting vulnerabilities which profoundly impact their lives. Collaborative efforts across sectors are needed to work towards comprehensive immigration reforms including both short-term and long-term solutions to address pressing issues for noncitizens undergoing immigration detention.

Challenges Related to Safety and Independence

Advancing age is associated with increasing risk of activities important for independence, such as driving and living alone. Cognitive impairment is more common with older age; financial resources and social support may dwindle. Risk, cognitive impairment, and decisional capacity each change over time. Transparent decision making and harm reduction help balance risk and safety. When a patient lacks decisional capacity, an option that considers the patient's preferences and shows respect for the person is favored. Vulnerable patients making choices that are high risk, and patients for whom others are making such choices, may require state intervention.

Introducing 'Health Vulnerability'. Towards a Human Right Claim for Innovative Orphan Drugs?

Although several European law instruments specifically promote the development of orphan medicines, rare disease patients still suffer from an excessive lack of access to orphan drugs. In order to base a claim for equity of access to research benefits, health vulnerability is introduced as a human rights-based public health concept. It represents a potentially valuable and powerful means in European law for rare disease patients to claim for an improved public action to develop innovative orphan drugs, including through the use of novel data-driven technologies such as computer modelling and simulation, as they have the potential to palliate some of the obstacles in the current development process of orphan medicines. The human rights-based approach would be all the more valuable, as it would simultaneously draw attention on privacy aspects of vulnerability for orphan disease patients, especially regarding increased risks stemming from the processing of highly sensitive health data.

The Abolition or Reform of Mental Health Law: How Should the Law Recognise and Respond to the Vulnerability of Persons with Mental Impairment?

Vulnerability theory challenges the assumption that human beings are abstract and invulnerable liberal subjects and insists that any decent and just society must create law that takes into account and tries to ameliorate human vulnerability. In this article, I explore how vulnerability might apply in the context of the debate about the future of mental health law that has arisen since the entry into force of the Convention on the Rights of Persons with Disabilities (CRPD) in 2008; namely, whether mental health law should be abolished or reformed. In doing so, this article addresses three key issues: (i) how to conceptualise vulnerability; (ii) whether persons with mental impairments really are vulnerable and in what ways; and (iii) how the law should respond to the vulnerability of persons with mental impairments post-CRPD. It describes and compares three different approaches with respect to how well they address vulnerability: the Abolition with Support, Mental Capacity with Support, and the Support Except Where There is Harm Models. It argues that the law should try to accurately capture and ameliorate the vulnerability of those who are subject to it as much as possible. It also argues that from a vulnerability perspective, the reform of mental health law may be better than its abolition and that decreasing the vulnerability of persons with mental impairment requires systemic reform, resources, and cultural change.

The development of the Police Practices Scale: Understanding policing approaches towards street-based female sex workers in a U.S. City

Policing is an important structural determinant of HIV and other health risks faced by vulnerable populations, including people who sell sex and use drugs, though the role of routine police encounters is not well understood. Given the influence of policing on the risk environment of these groups, methods of measuring the aggregate impact of routine policing practices are urgently required. We developed and validated a novel, brief scale to measure police patrol practices (Police Practices Scale, PPS) among 250 street-based female sex workers (FSW) in Baltimore, Maryland, an urban setting with high levels of illegal drug activity. PPS items were developed from existing theory and ethnography with police and their encounters with FSW, and measured frequency of recent (past 3 months) police encounters. The 6-item scale was developed using exploratory factor analysis after examining the properties of the original 11 items. Confirmatory factor analysis was used to model the factor structure. A 2-factor model emerged, with law enforcement PPS items and police assistance PPS items loading on separate factors. Linear regression models were used to explore the relative distribution of these police encounters among FSW by modeling association with key socio-demographic and behavioral characteristics of the sample. Higher exposure to policing was observed among FSW who were homeless (β = 0.71, p = 0.037), in daily sex work (β = 1.32, p = 0.026), arrested in the past 12 months (β = 1.44, p<0.001) or injecting drugs in the past 3 months (β = 1.04, p<0.001). The PPS provides an important and novel contribution in measuring aggregate exposure to routine policing, though further validation is required. This scale could be used to evaluate the impact of policing on vulnerable populations’ health outcomes, including HIV risk.

Examining the impact of medical legal partnerships in improving outcomes on the HIV care continuum: rationale, design and methods

BACKGROUND

Over the past two decades, we have seen a nationwide increase in the use of medical-legal partnerships (MLPs) to address health disparities affecting vulnerable populations. These partnerships increase medical teams' capacity to address social and environmental threats to patients' health, such as unsafe housing conditions, through partnership with legal professionals. Despite expansions in the use of MLP care models in health care settings, the health outcomes efficacy of MLPs has yet to be examined, particularly for complex chronic conditions such as HIV.

METHODS

This on-going mixed-methods study utilizes institutional case study and intervention mapping methodologies to develop an HIV-specific medical legal partnership logic model. Up-to-date, the organizational qualitative data has been collected. The next steps of this study consists of: (1) recruitment of 100 MLP providers through a national survey of clinics, community-based organizations, and hospitals; (2) in-depth interviewing of 50 dyads of MLP service providers and clients living with HIV to gauge the potential large-scale impact of legal partnerships on addressing the unmet needs of this population; and, (3) the development of an MLP intervention model to improve HIV care continuum outcomes using intervention mapping.

DISCUSSION

The proposed study is highly significant because it targets a vulnerable population, PLWHA, and consists of formative and developmental work to investigate the impact of MLPs on health, legal, and psychosocial outcomes within this population. MLPs offer an integrated approach to healthcare delivery that seems promising for meeting the needs of PLWHA, but has yet to be rigorously assessed within this population.

Emergencies and Equivocality Under the Inherent Jurisdiction: A Local Authority v BF [2018] EWCA CIV 2962 and Southend-On-Sea Borough Council v Meyers [2019] EWHC 399 (FAM)

In A Local Authority v BF [2018] EWCA Civ 2962, the Court of Appeal refused to grant permission to appeal against an interim judgment that deprived a capacitous man, Mr Meyers, of his liberty. The deprivation of liberty was held to be justified on the basis that there was evidence suggesting that he was of unsound mind under Article 5(1)(e) of the European Convention on Human Rights and, in any event, it was an emergency which temporarily obviated the need to establish that he was of unsound mind. In this commentary, I argue that the decision was flawed in two respects. First, the need to establish 'unsound mind' could not be dispensed with because it was not an emergency and, secondly, the Court's interpretation of 'unsound mind' was overly broad and cannot be reconciled with the jurisprudence of the European Court of Human Rights. Subsequently, in Southend-On-Sea Borough Council v Meyers [2019] EWHC 399 (Fam), which was the substantive hearing of Mr Meyers' case, Hayden J made an order preventing Mr Meyers from living with his son, with the decision being framed as a restriction on movement rather than a deprivation of liberty. I contend that the restrictions placed on Mr Meyers may amount to a deprivation of liberty. On a broader level, I argue that the use of the inherent jurisdiction to deprive vulnerable adults of their liberty is incompatible with Article 5, and that these cases demonstrate the potential for draconian decisions to be made when using a jurisdiction with shifting parameters to protect adults who are deemed to be 'vulnerable', a concept that is equivocal in nature.

Legal Regulation of Psychosurgery: A Fifty-State Survey

Following the rise and fall of lobotomy, a majority of U.S. states took legislative aim at psychosurgical procedures. This article canvasses, organizes, and analyzes the existing body of United States statutes and regulations mentioning psychosurgery. Many states regulate psychosurgery without defining the term; existing definitions are imprecise, but many would arguably apply to contemporary procedures like deep brain stimulation. Common to many states are restrictions on surrogate consent to psychosurgery, codifications of patients' consent or refusal rights, and situation-specific bans on the practice targeting certain contexts of vulnerability. Many states have only a handful of scattered laws bearing on psychosurgery, but a few have wide-ranging and well-integrated regulatory regimes. In reviewing these laws we perceive much room for harmonization and modernization. Greater consistency in protecting vulnerable persons from troubling uses of psychosurgery is achievable even alongside an effort to remove undue legal obstacles impeding patient access to potentially therapeutic procedures. Our hope in surveying current psychosurgery law is to inaugurate a conversation on how best to shape its future.

Addressing Global Human Rights Violations in Rhode Island: The Brown Human Rights Asylum Clinic

The Brown Human Rights Asylum Clinic (BHRAC) is a medical student-led organization affiliated with Physicians for Human Rights that collaborates with medical and mental health clinicians, lawyers, and community organizations to provide pro bono medical affidavits to undocumented individuals seeking legal status in the United States. Affidavits can document and corroborate the physical and psychological evidence of trauma alleged by asylum seekers, leading to better legal outcomes. This article describes our innovative program, partnerships, and workflow, as well as demographics and statistics from our past seven years of operation. Since its founding in 2013, BHRAC has conducted 55 medical evaluations, the majority involving Spanish-speaking female-identifying individuals from Guatemala, El Salvador, and the Dominican Republic. Thirteen individuals have been granted legal status, one individual was denied status, and the rest of the cases are pending. BHRAC has experienced a marked increase in affidavit requests. This paper serves as a call to action for medical professionals to become involved in this work.

Situating dementia in the experience of old age: Reconstructing legal response

This paper examines the intersection of dementia with the physiological processes and social contexts of old age; assesses the current legal response to problems arising through that intersection; and considers the potentially transformative effect of re-thinking legal response with those contextualised problems in mind. Two distinctive problems are identified: a heightened risk of exploitation, and an increasingly intense need for care coinciding with a decreasing ability to recognise and respond to that need. These problems require a social (rather than medical) response, of which law is an integral part. Several areas of law (including adult guardianship, legislation and common law doctrine relating to health care consent/refusal, and the body of law relating to decision-making about agreements, transactions, and bequests) provide for that response through the medico-legal construct of mental capacity. This legal idea of mental capacity has survived extensive critique, particularly in relation to interpretation and implementation of Article 12 of the Convention on the Rights of Persons With Disabilities. The survival of the mental capacity construct can be attributed to its usefulness as a theoretical mechanism that provides both a justification for over-ruling choice and preference (locating autonomy in the mentally capable decision) and a process for doing so (the mental capacity assessment and determination). This ambit of usefulness is particularly relevant to the problems (arising in the context of dementia in old age) identified in this paper. Both problems engage the public interest, together with the fundamental legal principle of fairness, in ways that call for legal response of some kind. Supported decision-making, as the suggested replacement for mental capacity based legal response, applies awkwardly in these contexts; as far as the individual is concerned, her decision has been made (and she does not need assistance in making one). This paper concludes that the mental capacity construct is problematic both for the reasons identified in the CRPD discourse (in which the experience of dementia in old age has been largely invisible) and because of the complicated intersections between mental capacity, dementia, and old age. The paper concludes by setting out an alternative conceptual basis and framework for legal response, including over-ruling expressed choice and preference, constructed around a principled theory of vulnerability as an alternative to and replacement for the mental capacity construct.

Gendered denials: Vulnerability created by barriers to legal capacity for women and disabled women

This article explores the vulnerability that is created when legal capacity is denied to women and disabled women. It argues that vulnerability is largely contingent on social constructs - as opposed to being an inherent quality of disability or gender. It discusses barriers to the exercise of legal capacity that women and disabled women experience - such as limitations on reproductive choice, higher rates of substituted decision-making, and unique experiences with forced mental health treatment. It then explores evidence that such barriers are disempowering and can leave women and disabled women vulnerable to abuse and marginalisation. It explores financial, physical and sexual abuse that can occur as a result of this vulnerability. Finally, it concludes that autonomy and power are inextricably linked and can be essential for minimising vulnerability.

The inherent jurisdiction of the High Court

Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers the recent use of the High Court's inherent jurisdiction to protect capable but vulnerable adults at risk of exploitation, coercion or harm.

Public mental health crisis management and Section 136 of the Mental Health Act

The interface between mental health services and the criminal justice system presents challenges both for professionals and patients. Both systems are stressed and inherently complex. Section 136 of the Mental Health Act is unusual being both an aspect of the Mental Health Act and a power of arrest. It has a long and controversial history related to concerns about who has been detained and how the section was applied. More recently, Section 136 has had a public profile stemming from the use of police cells as places of safety for young, mentally disturbed individuals. This paper explores the current state of health of this piece of legislation. Specifically, we consider whether alternative approaches are more suitable for those individuals in crisis and/or distress who come into contact with the police. This requires careful thought as to the proper role of both health and criminal justice professionals who are daily grappling with an ethically contentious domain of multiagency work.

Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review

This systematic review evaluates efforts to date to involve community health workers (CHWs) in delivering evidence-based mental health interventions to underserved communities in the United States and in low- and middle-income countries. Forty-three articles (39 trials) were reviewed to characterize the background characteristics of CHW, their role in intervention delivery, the types of interventions they delivered, and the implementation supports they received. The majority of trials found that CHW-delivered interventions led to symptom reduction. Training CHWs to support the delivery of evidence-based practices may help to address mental health disparities. Areas for future research as well as clinical and policy implications are discussed.

Communication Capacity Research in the Majority World: Supporting the human right to communication specialist services

Receipt of accessible and appropriate specialist services and resources by all people with communication and/or swallowing disability is a human right; however, it is a right rarely achieved in either Minority or Majority World contexts. This paper considers communication specialists' efforts to provide sustainable services for people with communication difficulties living in Majority World countries. The commentary draws on human rights literature, particularly Article 19 of the Universal Declaration of Human Rights and the Communication Capacity Research program that includes: (1) gathering knowledge from policy and literature; (2) gathering knowledge from the community; (3) understanding speech, language and literacy use and proficiency; and (4) developing culturally and linguistically appropriate resources and assessments. To inform the development of resources and assessments that could be used by speech-language pathologists as well as other communication specialists in Fiji, the Communication Capacity Research program involved collection and analysis of data from multiple sources including 144 community members, 75 school students and their families, and 25 teachers. The Communication Capacity Research program may be applicable for achieving the development of evidence-based, culturally and linguistically sustainable SLP services in similar contexts.

Navigating the Perfect Storm: Ethical Guidance for Conducting Research Involving Participants with Multiple Vulnerabilities

The development of ethical guidelines and regulations regarding human subjects research has focused upon protection of vulnerable populations by relying on a categorical approach to vulnerability. This results in several challenges: First, Institutional Review Boards (IRBs) struggle to interpret and apply the regulations because they are often vague and inconsistent. Second, applying the regulations to subjects who fit within multiple categories of vulnerability can lead to contradictions and the rejection of research that would be permissible if only one category were applicable. Finally, some potential subjects have social and other context-based vulnerabilities that are not described in the federal regulations and therefore not considered in IRB deliberations. IRBs and investigators lack guidance on how to address the problem of multiple vulnerabilities in a way that strikes a balance between protection and respect for persons. In this essay, we evaluate the acceptability of the existing federal regulations with respect to research participants with multiple vulnerabilities, offer strategies for rethinking the concept of vulnerability, and outline a context-based normative framework to account for the compounding effects of multiple vulnerabilities.

That's what friends are for: how intergroup friendships promote historically disadvantaged groups' substantive political representation

The interests of historically disadvantaged groups risk being overlooked if they are not present in the decision-making process. However, a mere presence in politics does not guarantee political success. Often groups need allies to promote their interests successfully. We argue that one way to identify such allies is to judge politicians by whether they have friends in historically disadvantaged groups, as intergroup friendships have been shown to make people understand and feel empathy for outgroups. In other words, intergroup friendships may function as an important complement to descriptive representation. We test our argument with a unique survey that asks all elected political representatives in Sweden's 290 municipalities (response rate 79 per cent) about their friendship ties to, and their representation of, five historically disadvantaged groups: women, immigrants, youths, pensioners and blue-collar workers. We find a strong correlation between representatives' friendship ties to these groups and their commitment to represent them. The correlation is especially strong for youths and blue-collar workers, which likely can be explained by the fact that these groups usually lack crucial political resources (such as experience and education). We conclude that friendship ties function as an important complement to descriptive representation for achieving substantive representation.

Justice or Injustice: a History and Critique of the New York State Justice Center for the Protection of People with Special Needs

The creation of the New York State Justice Center for the Protection of People with Special Needs ("Justice Center") was announced with great fanfare in 2013. Its goal is laudable: strengthening and standardizing "the safety net for vulnerable persons, adults and children alike, who are receiving care from New York's human service agencies and programs." Its jurisdiction is broad: covering residential and non-residential programs and provider agencies that come within the purview of six state oversight agencies, namely, the Office of Mental Health, the Office for People with Developmental Disabilities, the Office of Alcohol and Substance Abuse Services, the Office of Children and Family Services, the Department of Health, and the State Education Department. Its powers are comprehensive: investigating allegations of abuse, neglect, and significant incidents, and disciplining individuals and agencies pursuant to administrative authority. In addition, it can prosecute crimes of neglect and abuse pursuant to criminal prosecutorial authority. Given that over 270,000 vulnerable children and adults live in residential facilities overseen by the state and that numerous other individuals receive services from "day programs operated, licensed[,] or certified by the state[,]" the creation of the Justice Center is consistent with New York's history of oversight of vulnerable individuals. The state has overseen various state and municipal programs and private organizations that have addressed the needs of vulnerable individuals practically since New York's first poorhouse opened in 1736. The development of that oversight has been a series of responses to perceived deficiencies of an existing system, and the creation of the Justice Center is, much in the same way, a response to a 2011 study commissioned by the Governor to examine the treatment and care of vulnerable adults. The Justice Center’s jurisdiction reflects a departure, however, from traditional oversight. State administrative and regulatory review has been carried out by specialized state agencies established during the late nineteenth and twentieth centuries to address specific categories of individuals receiving care and treatment according to their needs. Residential and day treatment programs, as well as their custodians and employees, have been disciplined for abuse and neglect in accordance with state regulations created by these agencies. Criminal prosecutions have also been referred to county district attorneys. The Justice Center unites all specialized agencies, all vulnerable individuals with diverse needs, and all custodians and employees trained to meet those needs under one additional layer of uniform rules and regulations, with potential administrative discipline, civil liability, and criminal prosecution also under the same umbrella. This article explores the history of state oversight in New York and the departure represented by the Justice Center. This article first traces the early history of oversight. It then discusses the role of the Commission on Quality of Care for the Mentally Disabled, an antecedent organization similar to the Justice Center. Next, it examines the Justice Center itself. Last, this article concludes with some reflections on the Center.

[Paradigm shift in the legislative approach of vulnerable people in Belgium]

The application since September 2014 of the new 17 March 2013 law «reforming disability schemes and introducing a new protection status in accordance with human dignity», restates the legal approach to helping vulnerable people. The changes are complex and wide-ranging. This article describes the key elements of the reform, focusing particularly on the role of the medical doctor.

[Protecting people with diminished intellectual autonomy, respecting their wishes]

How do we respect, and at the same time protect, people unable to look after their own interests alone, due to the impairment of their faculties? A solid knowledge base regarding the legal framework which is common to us all and which forms the foundation of our freedom is essential. French law, with regard to people losing their intellectual autonomy, notably in the case of neurodegenerative diseases, aims to respect patients' wishes while at the same time protecting them.

Ethical Issues in Adolescent Consent for Research

Different opinions are expressed in the literature regarding when children and adolescents can start to make decisions to participate in research and give informed consent. Nurses are frequently involved in research, either as investigators or caregivers, and must therefore have a thorough understanding of consent and related issues. In this article the issues are explored from a Canadian perspective. The argument is put forward that adolescents may be capable of a greater involvement in the research consent process than is the norm. Increasing adolescents’ involvement in research has the potential to enhance their growing autonomy and capabilities. Adolescents appreciate being treated with respect and dignity by adults. This can be achieved in an environment in which protection from harm does not also mean prevention from decision making. The use of empowering processes by nurses to enhance adolescent involvement will provide benefit to adolescents in their transition to adult levels of responsibility.

Giving Economically Disadvantaged, Minority Food Pantry Patrons' a Voice: Implications for Equitable Access to Sufficient, Nutritious Food

This study provides economically disadvantaged, minority food pantry patrons (hereafter, patrons) a meaning-ful voice by examining their experiences trying to obtain sufficient, nutritious food. Five focus groups were conducted using a semistructured discussion guide. Atlast.ti software was used to manage and analyze the data. Patrons reported that pantry staff who preserved their dignity by showing compassion were highly valued. Stigma and shame associated with pantry use were major concerns. Patrons suggested environmental and policy changes to improve their food acquisition experiences. These findings suggest that multilevel interventions addressing food access, food distribution policies, and patron-staff interactions are warranted.

The 2005 Reauthorization of the Violence Against Women Act

The author provides an overview of the history of congressional involvement with the Violence Against Women Act's (VAWA) provisions to protect immigrant victims of domestic violence and other forms of violence against women. He also outlines the reasoning behind, and purpose of, the most recent enhancements in legal protections for immigrant victims of domestic violence, sexual assault, trafficking, and foreign fiancés and spouses that were included in the recently reauthorized VAWA 2005, also describing the bipartisan work that resulted in this newest piece of legislation.

Population targeting amid complex mental health programming: Are California's Full Service Partnerships reaching underserved children?

California's Mental Health Services Act (MHSA) created Full Service Partnership programs (FSPs) targeting socially and economically vulnerable children with mental illness who are underserved by counties' public mental health treatment system. To determine whether FSPs reach a distinctive group of children, this study compares indicators of FSP-targeted underservice for FSP entrants (n = 15,598) versus everyone treated in the counties' public mental health systems (n = 282,178) and for FSP entrants versus entrants in the most intensive Medicaid delivered program in California, Therapeutic Behavioral Services (TBS, n = 11,993). Results identify that, despite first encountering mental health services systems at earlier ages, FSP clients had fewer months of treatment and were less likely to have been treated in the prior 6 months, except for crisis care, as compared to all other children served, after considering clinical severity and indicators of service need. FSP entrants also had more substance abuse and trauma-related problems. Although less seriously ill than TBS served children, FSP served children were significantly underserved. The results indicate that, amid overlapping policies and programs, carving out and reaching a distinctly underserved population can be achieved in practice, and that specialized programs, such as the FSP program, which target underserved children, have the potential to augment a system's ability to reach the underserved. (PsycINFO Database Record

Challenges of regulatory rights of half-capacitated persons: A sociological perspective on the French Civil Code reform

Democratic societies are based on the principle of equal legal capacity of all citizens to decide and act for themselves in all areas of social life. This "socio-civil capacity", which may involve both material property of an individual, as well as private life in matters ranging from health to personal relationships, is recognized by the law (both codified law and common law). These rights guarantee the autonomy and freedom of individuals in the name of respect for human dignity. Civil capacity of a person is legally diminished because his or her "natural" abilities, capacity, or competence are reduced. Recent social changes have lead to increased uses of legal measures of protection. The reasons for these changes are complex and they are accompanied by legislative reforms that modify the rights of half-capacitated persons. In this article, we examine certain issues of civil capacity rights based on the French example. We start present a perspective of the historical definition and practice of these rights as well as their democratization.

Legal professionals and witness statements from people with a suspected mental health diagnosis

Individuals with mental health problems are considered to be part of a group labeled 'vulnerable' in forensic psychology literature and the legal system more generally. In producing witness statements, there are numerous guidelines in the UK, designed to facilitate the production of reliable and valid accounts by those deemed to be vulnerable witnesses. And yet, it is not entirely clear how mental health impacts on reliability and validity within the judicial system, partly due to the diversity of those who present with mental health difficulties. In this paper, we set out to explore how legal professionals operating in the UK understand the impact of mental distress on the practical production of witness testimonies. Twenty legal professionals, including police officers, judges, magistrates and detectives were involved in a semi-structured interview to examine their knowledge and experience of working with mental health problems, and how they approached and worked with this group. A thematic analysis was conducted on the data and specific themes relevant to the overall research question are presented. These include a) dilemmas and deficiencies in knowledge of mental health, b) the abandonment of diagnosis and c) barriers to knowledge: time restrictions, silence, professional identity and fear. Finally, we explore some of the implications of these barriers, with regard to professional practice.

Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Margaret McGregor and colleagues consider Bradford Hill's framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.

Ambiguous articles in new EU Regulation may lead to exploitation of vulnerable research subjects

Research involving minors or other incompetent subjects is ethically complex, particularly if the research does not directly benefit the subjects. Thus, many guidelines and regulations state that incompetent research subjects must not be included in such research unless it entails minimal risk and minimal burden. The new EU Clinical Trials Regulation adds the following to this well-known requirement: 'in comparison with the standard treatment of the subjects' condition'. In this paper, I argue that this addition can be interpreted in different ways. According to one of the possible interpretations, it means that research risks and burdens can be regarded as minimal for a certain group of subjects if they are comparable to those that the subjects have to undergo when being treated for their conditions. As the standard treatments of many conditions are quite risky and burdensome, this interpretation allows for research with risks and burdens far exceeding the level usually regarded as minimal, without explicitly saying so. This is worrisome, because such a lack of clarity may compromise thorough review and valid informed consent procedures and consequently may lead to exploitation of these vulnerable groups. If Europe wants to allow for exceptions to the minimal risk and burden requirement, it should explicitly acknowledge this step as such and accurately formulate in which cases such exceptions are justified.

Oral Healthcare Implications of Mass Migration

Population movements, whether voluntary or forced, are an integral part of an increasingly globalized society and, while the health needs of migrant populations cannot be generalized, some migrants can have worse oral health outcomes compared with their host-country counterparts, with their first dental contact typically being for emergency care. Failure to provide immediately necessary treatment may be unlawful under the Human Rights Act 1998. CPD/Clinical Relevance: NHS dental services need to evolve and address the challenges inherent in caring for vulnerable migrants. Education and appropriate training needs to be developed for the dental profession in order to enable new ways of promoting intersectoral care and community engagement.

Encouraging Maternal Sacrifice: How Regulations Governing the Consumption of Pharmaceuticals During Pregnancy Prioritize Fetal Safety over Maternal Health and Autonomy

Pregnant women are routinely faced with the stressful decision of whether to consume needed medications during their pregnancies. Because the risks associated with pharmaceutical drug consumption during pregnancy are largely unknown, pregnant women both inadvertently consume dangerous medications and avoid needed drugs. Both outcomes are harmful to pregnant women and their fetuses. This unparalleled lack of drug safety information is a result of ill-conceived, paternalistic regulations in two areas of the law: regulations governing ethical research in human subjects and regulations that dictate the required labels on drugs. The former categorizes pregnant women as "vulnerable" and thus precludes them from most medical research. The result is that ninety-one percent of drugs lack any reliable safety information for pregnant consumers. The latter currently requires all drug labels to encourage drug avoidance during pregnancy, despite ample evidence that avoiding needed medications can harm pregnant women. On June 30, 2015, new pregnancy labeling regulations took effect. Though these regulations make important improvements, they continue to treat pregnant women unlike any population, including other unique subpopulations, such as children. As a result, the new regulations do not fix the problem of over-warning pregnant women about the risks of drug consumption. This article questions the legitimacy of both regulations and suggests three reforms for how to improve access to vital safety information: (1) amend the regulations governing ethical research in human subjects to reclassify pregnant women as non-vulnerable adults; (2) create incentives to generate safety data in pregnant women by granting a period of market exclusivity for drug companies that invest in this research; and (3) make the FDA pregnancy labeling regulations consistent with the routine FDA practice of requiring the display of balanced, human data on risk.

The ethics and regulatory landscape of including vulnerable populations in pragmatic clinical trials

Policies have been developed to protect vulnerable populations in clinical research, including the US federal research regulations (45 Code of Federal Regulations 46 Subparts B, C, and D). These policies generally recognize vulnerable populations to include pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons. The aim has been to protect these populations from harm, often by creating regulatory and ethical checks that may limit their participation in many clinical trials. The recent increase in pragmatic clinical trials raises at least two questions about this approach. First, is exclusion itself a harm to vulnerable populations, as these groups may be denied access to understanding how health interventions work for them in clinical settings? Second, are groups considered vulnerable in traditional clinical trials also vulnerable in pragmatic clinical trials? We argue first that excluding vulnerable subjects from participation in pragmatic clinical trials can be harmful by preventing acquisition of data to meaningfully inform clinical decision-making in the future. Second, we argue that protections for vulnerable subjects in traditional clinical trial settings may not be translatable, feasible, or even ethical to apply in pragmatic clinical trials. We conclude by offering specific recommendations for appropriately protecting vulnerable research subjects in pragmatic clinical trials, focusing on pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons.

Safeguarding vulnerable adults

Nurses have a professional duty to safeguard vulnerable adults from abuse under the provisions of the Nursing and Midwifery Council's (NMC) revised Code (2015). With adult abuse continuing to increase, all members of the nursing team are well placed to identify and take action to safeguard the vulnerable. This article sets out how the Care Act 2014 seeks to improve the safeguarding of vulnerable adults and the role of nurses in that process.

Elder mistreatment: priorities for consideration by the white house conference on aging

Elder mistreatment is recognized internationally as a prevalent and growing problem, meriting the attention of policymakers, practitioners, and the general public. Studies have demonstrated that elder mistreatment is sufficiently widespread to be a major public health concern and that it leads to a range of negative physical, psychological, and financial outcomes. This article provides an overview of key issues related to the prevention and treatment of elder mistreatment, focusing on initiatives that can be addressed by the White House Conference on Aging. We review research on the extent of mistreatment and its consequences. We then propose 3 challenges in preventing and treating elder mistreatment that relate to improving research knowledge, creating a comprehensive service system, and developing effective policy. Under each challenge, examples are provided of promising initiatives that can be taken to eliminate mistreatment. To inform the recommendations, we employed recent data from the Elder Justice Roadmap Project, in which 750 stakeholders in the field of elder mistreatment were surveyed regarding research and policy priorities.

Ethical considerations in research. Focus on vulnerable groups

The purpose of this paper was to describe the need to protect the rights of human subjects participating in nursing research, and procedures for doing so. The path taken to the task at hand was to approach the topic by discussing the philosophical underpinnings of human subject protection and describing the approach for doing this in all cases where humans are used as research subjects. These underpinnings include specific ethical principles of respect for persons, beneficence, and justice, and the procedures used in the U.S. for protecting the rights of human subjects. Once the process was clarified, the considerations necessary to protect the special groups referred to as ''vulnerable'' are discussed. Given the author's access to U.S. documents and the fact that U.S. government agencies took early steps to formalize rules and regulations for the protection of human subjects, vulnerable or otherwise, the experience of the United States was selected for presentation. It is recognized that there are now relevant international documents that are exceedingly helpful, and also, that various countries may have their own guidelines for investigators to follow. In such cases researchers can engage in comparative analysis between their own guidance and the processes described here, and decide their path accordingly.

Addressing All Heads of the Hydra: Reframing Safeguards for Mentally Impaired Detainees in Immigration Removal Proceedings

This article concerns the constitutional rights of detained, mentally impaired non-citizens in defending against deportation. Due process requires that such detainees receive a full and fair hearing. However, until recently, they were not provided an attorney to assist them in navigating our extremely complicated immigration system. Mentally impaired detainees were expected to proceed alone in proving the elements of their claims against skilled government attorneys--a daunting task even for those unencumbered by a mental disorder. On December 31, 2013, the Department of Justice ("DOJ") released guidelines detailing new procedures for how immigration courts should handle these cases, including the provision of counsel upon a finding of mental incompetence. The guidelines were issued as a direct response to Franco-Gonzales v. Holder, a class action lawsuit brought by the American Civil Liberties Union in federal district court in California seeking appointed counsel for detained, unrepresented, mentally impaired non-citizens. The guidelines created a three-stage process for assessing competency. Only at the end of this process--and after an individual is declared incompetent--is counsel appointed. This article argues that the DOJ guidelines fall far short of Franco's promise of due process for this particularly vulnerable population. It proposes an alternative model wherein counsel is appointed the moment the court is presented with "indicia" of incompetence, rather than after an adjudication of incompetence. "Indicia" should create a presumption of incompetency that can be rebutted only after a forensic evaluation is conducted and the court holds a robust hearing into the matter. This article reveals, through empirical evidence, the critical role that counsel plays in the investigation of a respondent's ability to participate in the proceedings, and how an attorney is often the only party positioned to marshal all the evidence relevant to the question of competency. Additionally, where a lack of competence is found, the court should appoint a guardian ad litem ("GAL") to assist the attorney in the individual's defense. Counsel and the GAL should work in tandem to achieve the outcome most favorable to the individual, which could be termination, the pursuit of relief, or even deportation in some instances. The expanded use of existing "Deferred Action" categories offers an additional remedy when none of the above proposed options are adequate. The article concludes that the DOJ guidance must be amended in accordance with these recommendations. This proposal best ensures vigorous and informed examination of an individual's competency, while safeguarding the individual against the inherent limits of immigration courts, conflicts of interest, and undue harm.

Health Justice: A Framework (and Call to Action) for the Elimination of Health Inequity and Social Injustice

Every aspect of society is dependent upon the health of its members. Health is essential to an individual’s well-being, quality of life, and ability to participate in society. Yet the healthcare industry, even at its optimal level of functioning, cannot improve the health of the population without addressing the root causes of poor health. The health of approximately 46.7 million individuals, most of whom are low-income and racial minorities, is threatened by economic, societal, cultural, environmental, and social conditions. Poor health in any population group affects everyone, leading to higher crime rates, negative economic impacts, decreased residential home values, increased healthcare costs, and other devastating consequences. Despite this fact, efforts to improve health among low-income and minority communities are impeded by inequitable social structures, stereotypes, legal systems, and regulatory schemes that are not designed to take into account the social determinants of health in decision making models and legal interpretation. As a result, a large segment of the population is continually denied the opportunity to live long, productive lives and to exercise their rights under democratic principles. Health, equity, and justice make up the keystone of a functional, thriving society. These principles are unsatisfied when they do not apply equally to all members of society. This Article describes the social and legal roots of poor health and how health inequity, social injustice, and poverty are inextricably linked. For example, it provides an in depth overview of the social determinants of health, including poverty, institutional discrimination and segregation, implicit bias, residential environmental hazards, adverse childhood experiences, and food insecurity. It then discusses how the law is a determinant of health due to court systems that do not evaluate individual circumstances, the enactment of laws that perpetuate poor health, and the lack of primary prevention laws. It demonstrates how addressing these issues requires true adherence to equality principles and making justice and freedom of opportunity accessible to everyone. Finally, it recommends the creation of "health justice," a new jurisprudential and legislative framework for the achievement and delivery of health equity and social justice.

A qualitative study of legal and social justice needs for people with aphasia

This paper presents an exploratory investigation of situations in which people with aphasia may be vulnerable to legal and access to justice issues. The study used a qualitative descriptive approach to analyse 167 de-identified transcriptions of previously collected interviews, with 50 participants with mild-to-severe aphasia following stroke, 48 family members, and their treating speech-language pathologists. Situations experienced by people with aphasia and their family members were coded using key-word searches based on the previously published framework developed by Ellison and colleagues to describe situations of vulnerability to legal and access to justice needs for older people. Health and financial and consumer situations were most frequently identified in the data. Additionally, there were a number of situations found specifically relating to people with aphasia involving their signatures and credit card use. Instances of discrimination and abuse were also identified, and, although infrequent, these issues point to the profound impact of aphasia on the ability to complain and, hence, to ensure rights to care are upheld. The findings of this study are consistent with previous research in suggesting that legal and access to justice needs are an important issue for people with aphasia and their families.