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Doctors may make recordings without consent in exceptional circumstances buy 100 mg silagra visa, such as when it is believed that a child has been the victim of abuse cheap silagra 50 mg without prescription. If a recording has been made in the course of investigation or treatment of a patient but the doctor now wishes to use it for another purpose buy 50 mg silagra with mastercard, the patient’s consent must be obtained order silagra 50mg visa. Recordings are not to be published or broadcast in any form without the explicit 100mg silagra mastercard, written consent of the patient. Consent is required before recordings are published in textbooks or journals or before the public is allowed access to them. If patients can be identified from recordings, a doctor must ensure that the interests and well-being of the patient take precedence over all other con- siderations. This is especially so for patients who are mentally ill or disabled, Fundamental Principals 45 seriously ill, or children or other vulnerable people. Recording Telephone Calls Many countries have laws or regulations that govern the electronic record- ing of telephone conversations, which are designed to protect individuals’ rights. Commonly, a provision will be included stating that persons whose telephone calls are being recorded must be informed of the fact—the details vary from country to country. In the United Kingdom, for example, the Tele- communications Act of 1984 requires that the person making a recording shall make “every reasonable effort to inform the parties” of doing so. Reasonable ef- fort may be achieved by the use of warning tones, prerecorded messages, ver- bal warnings given by a telephone operator, or written warnings in publicity material. A recording may be an invaluable aid for forensic evidence or to help refute a complaint or claim for compensation, but practitioners who make elec- tronic recordings of telephone calls must ensure that they comply with local laws and practice codes. Emergencies Before leaving the topic of consent, it is necessary to state clearly that in a medical emergency in which a patient is unconscious and thus unable to give or withhold consent and there is no clear instruction to the contrary in the form of a valid, extant advance directive made by the patient, treatment that is clearly essential to save life or prevent serious harm may and indeed should be given. However, nonurgent treatment should be deferred until the patient is able to give consent. Information acquired by a medical practitioner from or about a patient in the course of his or her professional work is confidential and must never be disclosed to others without either the consent of the patient or other proper justification. Confidentiality is primarily a professional conduct matter for the medi- cal practitioner, but patients also have a legal right to confidentiality, pro- tected by law. Doctors are responsible for the safekeeping of confidential information against improper disclosure when it is stored, transmitted to others, or dis- carded. If a doctor plans to disclose information about a patient to others, he or she must first inform the patient of that intention and make clear that the patient has an opportunity to withhold permission for its disclosure. Patients’ requests for confidentiality must be respected, except for exceptional circum- stances, such as where the health or safety of others would otherwise be at serious risk. If confidential information is disclosed, the doctor should release only as much as is necessary for the purpose and must always be ready and will- ing to justify the disclosure—for example, to the relevant medical council or board or to the courts. Where confidential information is to be shared with healthcare workers or others, the doctor must ensure that they, too, respect confidentiality. Death and Confidentiality The duty of confidentiality extends beyond the death of the patient. The extent to which information may properly be disclosed after the death of a patient depends on the circumstances. In general, it is prudent to seek the Fundamental Principals 47 permission of all the personal representatives of the deceased patient’s estate, such as the executors or administrators, before any information is disclosed. A doctor with any doubt should take advice from a professional advisory organization, such as a protection or defense organization. Detention and Confidentiality A forensic physician (or equivalent) should exercise particular care over confidentiality when examining persons who are detained in custody. When taking the medical history and examining the detainee, it is common for a police or other detaining official to be in attendance, perhaps as a “chaperone” or simply as a person in attendance, nearby to overhear the conversation. Such officials will not owe to the detainee the same duty of confidentiality that is owed by a medical or nurse practitioner nor be subject to similar professional sanctions for a breach of confidentiality. The doctor called on to examine a detainee must take great care to ensure that the person being examined clearly understands the role of the forensic physician and the implications for confidentiality. The detainee must under- stand and agree to the terms of the consultation before any medical informa- tion is gathered, preferably giving written consent. The examining doctor should do everything possible to maintain the con- fidentiality of the consultation. An accused person’s right of silence, the pre- sumption of innocence, rights under human rights legislation, and so forth may produce areas of conflicting principle.

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These system is that both continuity and change can exist are examples of homeorhetic processes or self- across the life span purchase silagra 100 mg mastercard. Instead order silagra 50mg with amex, the issue should be cast in with illness buy silagra 100mg online, he or she is subject to biopsychosocial terms of determining patterns of interactions perturbations purchase silagra 100mg. The nurse purchase silagra 100mg with amex, according to Johnson among levels of the behavioral system that may (1980, 1990), acts as the external regulator and promote continuity for a particular subsystem at a monitors patient response, looking for successful given point in time. If behavioral system balance tinuity is in the relationship of the parts rather than returns, there is no need for intervention. Johnson (1990) noted that at nurse intervenes to help the patient restore behav- the psychological level, attachment (affiliative) and ioral system balance. It is hoped that the patient dependency are examples of important specific be- matures and with additional hospitalizations the haviors that change over time while the representa- previous patterns of response have been assimilated tion (meaning) may remain the same. Adaptation is defined as balance, this pattern of dependence to independ- change that permits the behavioral system to main- ence may be repeated as the behavioral system en- tain its set points best in new situations. To the ex- gages in new situations during the course of a tent that the behavioral system cannot assimilate lifetime. The nurse acts to provide con- respond to contextual changes by either a homeo- ditions or resources essential to help the accommo- static or homeorhetic process. Systems have a set dation process, may impose regulatory or control point (like a thermostat) that they try to maintain mechanisms to stimulate or reinforce certain be- by altering internal conditions to compensate for haviors, or may attempt to repair structural com- changes in external conditions. A behavioral system is embedded in an tion of ability or effort are behavioral homeostatic environment, but it is capable of operating inde- processes we use to interpret activities so they are pendently of environmental constraints through the consistent with our mental organization. Hierarchic Interaction The combination of systems theory and develop- Each behavioral system exists in a context of hier- ment identifies “nursing’s unique social mission archical relationships and environmental relation- and our special realm of original responsibility in ships. Hierarchies, or a pattern of Next, we review the model as a behavioral system relying on particular subsystems, lead to a degree of within an environment. A disruption or failure will not destroy the Person whole system but leads instead to a decomposition to the next level of stability. Johnson conceptualized a nursing client as a behav- The judgment that a discontinuity has occurred ioral system. The behavioral system is orderly, is typically based on a lack of correlation between repetitive, and organized with interrelated and in- assessments at two points of time. For example, terdependent biological and behavioral subsys- one’s lifestyle prior to surgery is not a good fit post- tems. These discontinuities can provide op- subsystems that interrelate to form the behavioral portunities for reorganization and development. Dialectical Contradiction The client is seen as a collection of behav- ioral subsystems that interrelate to form The last core principle is the motivational force for the behavioral system. Johnson (1980) described these as drives and noted that these responses are devel- oped and modified over time through maturation, system. A person’s activities in the plex, overt actions or responses to a variety of stim- environment lead to knowledge and development. Behavioral system balance is restored and a new level of development The parts of the behavioral system are called sub- is attained. They carry out specialized tasks or func- Johnson’s model is unique, in part, because it tions needed to maintain the integrity of the whole takes from both general systems and developmental behavioral system and manage its relationship to theories. She did not consider the seven subsys- in this author’s operationalization of the model, as tems as complete, because “the ultimate group of in Grubbs (1980), I have included eight subsystems. Johnson noted new subsystems or indicated changes in the struc- that these subsystems are found cross-culturally ture, functions, or behavioral groupings in the orig- and across a broad range of the phylogenetic scale. Each subsystem has functions that serve to meet structural components that interact in a specific the conceptual goal. These parts are goal, set, choice, and ac- activities carried out to meet these goals. The goal of a subsystem is defined as the de- haviors may vary with each individual, depending sired result or consequence of the behavior. The on the person’s age, sex, motives, cultural values, basis for the goal is a universal drive whose exist- social norms, and self-concepts. In subsystem goals to be accomplished, behavioral general, the drive of each subsystem is the same for system structural components must meet func- all people, but there are variations among individ- tional requirements of the behavioral system.

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This chapter aims to pro- vide a broad basis for the understanding of the disease processes and the mecha- nisms that may lead to death and also to provide some understanding of the current thinking behind deaths associated with restraint buy 50 mg silagra amex. The worldwide variations in these definitions have caused 100 mg silagra visa, and continue to cause discount 50mg silagra overnight delivery, considerable confusion in any discussion of this subject buy silagra 50 mg otc. For the purposes of this chapter 50mg silagra sale, “in custody” relates to any individual who is either under arrest or otherwise under police control and, although similar deaths may occur in prison, in psychiatric wards, or in other situations where people are detained against their will, the deaths specifically associated with police detention form the basis for this chapter. It is important to distinguish between the different types of custodial deaths because deaths that are related to direct police actions (acts of commission) seem to cause the greatest concern to the family, public, and press. It is also important to remember that police involvement in the detention of individuals From: Clinical Forensic Medicine: A Physician’s Guide, 2nd Edition Edited by: M. These acts are considerably harder to define and perhaps sometimes result from the police being placed in, or assuming, a role of caring (e. Police involvement with an individual can also include those who are being pursued by the police either on foot or by vehicle, those who have been stopped and are being questioned outside the environment of a police station, and those who have become unwell through natural causes while in contact with or in the custody of the police. The definitions of “death in custody” are therefore wide, and attempts at simple definitions are fraught with difficulty. Any definition will have to cover a multitude of variable factors, in various circumstances and with a variety of individuals. The crucial point is that the police owe a duty of care to each and every member of the public with whom they have contact, and it is essential that every police officer, whether acting or reacting to events, understands and is aware of the welfare of the individual or individuals with whom he or she is dealing. The number of deaths recorded in police custody in England and Wales from 1990 to 2002 (2) shows considerable variation year to year but with an encouraging decline from the peak in 1998 (Fig. In contrast, the data from Australia for much of the same period show little change (3) (Fig. These raw data must be treated with considerable care because any changes in the death rates may not be the result of changes in the policy and practice of care for prisoners but of other undetermined factors, such as a decline in arrest rates during the period. Legal Framework In the United Kingdom, all deaths occurring in prison (or youth custody) (4) must be referred to the coroner who holds jurisdiction for that area. How- ever, no such obligation exists concerning deaths in police custody, although the Home Office recommends (5) that all deaths falling into the widest defini- Deaths in Custody 329 Fig. This acceptance that all deaths occurring in custody should be fully investi- gated and considered by the legal system must represent the ideal situation; however, not every country will follow this, and some local variations can and do occur, particularly in the United States. Protocol No standard or agreed protocol has been devised for the postmortem examination of these deaths, and, as a result, variation in the reported details of these examinations is expected. These differences in the procedures and the number and type of the specialist tests performed result in considerable varia- tion in the pathological detail available as a basis for establishing the cause of death and, hence, available for presentation at any subsequent inquest. The absence of a defined protocol hinders the analysis of the results of these examinations and makes even the simplest comparisons unreliable. There is an urgent need for a properly established academic study of all of these deaths, such as that performed in Australia under the auspices of the Australian Insti- tute of Criminology (6), to be instituted in the United Kingdom and the United States. Terminology In addition to the lack of reproducibility of the postmortem examina- tions, the terminology used by the pathologists to define the cause of death, particularly in the form required for the registration of the death, may often be idiosyncratic, and similar disease processes may be denoted by different pathologists using many different phrases. For example, damage to the heart muscle caused by narrowing of the coronary arteries by atheroma may be termed simply ischemic heart disease or it may be called myocardial ischemia resulting from coronary atheroma or even by the “lay” term, heart attack (7). This variation in terminology may lead to confusion, particularly among lay people attempting to understand the cause and the manner of death. A consid- erable amount of research (1,7) has been produced based on such lay assess- ments of the pathological features of a death, and this has, at times, resulted in increased confusion rather than clarification of the issues involved. If the issues regarding the definition of “in custody,” the variation in the postmortem examinations and the production of postmortem reports, and the use and analysis of subsequent specialist tests all raise problems within a single country, then the consideration of these deaths internationally produces almost insuperable conflicts of medical terminology and judicial systems. Clearly, a death, whether sudden or delayed, may Deaths in Custody 331 Table 1 Expected Types of Deaths in Different Phases of Custody Accidental Self- Deliberately Natural trauma Alcohol Drug inflicted inflicted Prearrest ++ +++ ++ ++ Arrest ++ +++ ++ ++ ± +++ Detention + + +++ +++ ++ ++ Interview + + ++ ++ +++ ++ Charge + + – – +++ ± occur for many reasons even in the absence of police, but because it is the involvement of police that is the sine qua non of “in custody,” deaths in the first phase must be considered to be the presence of police officers at the scene. Subsequently, an arrest may be made with or without the use of restraint tech- niques and the prisoner will then be transported to a police station. This trans- port will most commonly involve a period within a police vehicle, which may be a car, a van with seating, or some other vehicle. Many factors may determine the type of transport used and the position of the individual in that vehicle. Detention in the police station will be followed by an interview period inter- spersed with periods of time incarcerated, usually alone, within a cell. After the interview, the individual may be released directly, charged and then released, or he or she may be detained to appear before a court. It is at this point that custody moves from the police to other authorities, usually to the prison service.

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Based on your understanding of psychodynamic theories discount silagra 50mg with amex, how would you analyze your own personality? Are there aspects of the theory that might help you explain your own strengths and weaknesses? Based on your understanding of humanistic theories silagra 100 mg with visa, how would you try to change your behavior to better meet the underlying motivations of security purchase silagra 50 mg overnight delivery, acceptance purchase silagra 100mg without prescription, and self-realization? Terror management and aggression: Evidence that mortality salience motivates aggression against worldview-threatening others discount 100mg silagra mastercard. A new look at defensive projection: Thought suppression, accessibility, and biased person perception. Self-discrepancies and emotional vulnerability: How magnitude, accessibility, and type of discrepancy influence affect. Self-discrepancies as predictors of vulnerability to distinct syndromes of chronic emotional distress. Self-discrepancies and emotional vulnerability: How magnitude, accessibility, and type of discrepancy influence affect. Outline the methods of behavioral genetics studies and the conclusions that we can draw from them about the determinants of personality. Explain how molecular genetics research helps us understand the role of genetics in personality. One question that is exceedingly important for the study of personality concerns the extent to which it is the result of nature or nurture. If nature is more important, then our personalities will form early in our lives and will be difficult to change later. If nurture is more important, however, then our experiences are likely to be particularly important, and we may be able to flexibly alter our personalities over time. In this section we will see that the personality traits of humans and animals are determined in large part by their genetic makeup, and thus it is no surprise that identical twins Paula Bernstein and Elyse Schein turned out to be very similar even though they had been raised separately. A gene is the basic biological unit that transmits characteristics from one generation to the next. These common genetic structures lead members of the same species to be born with a variety of behaviors that come naturally to them and that define the characteristics of the species. These abilities and characteristics are known as instincts—complex inborn patterns [1] of behaviors that help ensure survival and reproduction(Tinbergen, 1951). Birds naturally build nests, dogs are naturally loyal to their human caretakers, and humans instinctively learn to walk and to speak and understand language. Rabbits are naturally fearful, but some are more fearful than others; some dogs are more loyal than others to their caretakers; and some humans learn to speak and write better than others do. Personality is not determined by any single gene, but rather by the actions of many genes working together. Furthermore, even working together, genes are not so powerful that they can control or create our personality. Some genes tend to increase a given characteristic and others work to decrease that same characteristic—the complex relationship among the various genes, as well as a variety of random factors, produces the final outcome. Furthermore, genetic factors always work with environmental factors to create personality. Having a given pattern of genes doesn‘t necessarily mean that a particular trait will develop, because some traits might occur only in some environments. For example, a person may have a genetic variant that is known to increase his or her risk for developing emphysema from smoking. Studying Personality Using Behavioral Genetics Perhaps the most direct way to study the role of genetics in personality is to selectively breed animals for the trait of interest. In this approach the scientist chooses the animals that most strongly express the personality characteristics of interest and breeds these animals with each other. If the selective breeding creates offspring with even stronger traits, then we can assume that the trait has genetic origins. In this manner, scientists have studied the role of genetics in Attributed to Charles Stangor Saylor. Although selective breeding studies can be informative, they are clearly not useful for studying humans. For this psychologists rely onbehavioral genetics—a variety of research techniques that scientists use to learn about the genetic and environmental influences on human behavior by comparing the traits of biologically and nonbiologically related family members (Baker, [2] 2010). Behavioral genetics is based on the results of family studies, twin studies, and adoptive studies. A family study starts with one person who has a trait of interest—for instance, a developmental disorder such as autism—and examines the individual’s family tree to determine the extent to which other members of the family also have the trait.

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