Ambiguities and inconsistencies in relation to the obligations of proxies under corporations law: a model for reform

This article reconsiders the important question which came to light as a result of the controversial 2002 Coles Myer annual general meeting: do directors that are appointed as proxy have an obligation to vote as directed (and indeed should they)? A recent decision of the New South Wales Supreme Court, which was subsequently approved on appeal, stands for the proposition that proxy holders are agents of the shareholders that appointed them. However, currently the Corporations Act only requires a Chairman appointed as proxy to vote as directed — not an ordinary director. This article briefly explains the present state of the law in Australia on this issue, and then explores some interesting recent judicial remarks which may suggest that ordinary directors appointed as proxy must vote as directed in order to satisfy their director’s duties (both common law and statutory) to the company. We finally outline a proposed statutory reform initiative which seeks to remove the present uncertainty in the law by introducing a blanket requirement that all proxy holders must vote as directed.

Disentangling the stigma of HIV/AIDS from the stigmas of drugs use, commercial sex and commercial blood donation - a factorial survey of medical students in China

Background
HIV/AIDS related stigma interferes with the provision of appropriate care and support for people living with HIV/AIDS. Currently, programs to address the stigma approach it as if it occurs in isolation, separate from the co-stigmas related to the various modes of disease transmission including injection drug use (IDU) and commercial sex (CS). In order to develop better programs to address HIV/AIDS related stigma, the inter-relationship (or 'layering') between HIV/AIDS stigma and the co-stigmas needs to be better understood. This paper describes an experimental study for disentangling the layering of HIV/AIDS related stigmas.

Methods
The study used a factorial survey design. 352 medical students from Guangzhou were presented with four random vignettes each describing a hypothetical male. The vignettes were identical except for the presence of a disease diagnosis (AIDS, leukaemia, or no disease) and a co-characteristic (IDU, CS, commercial blood donation (CBD), blood transfusion or no co-characteristic). After reading each vignette, participants completed a measure of social distance that assessed the level of stigmatising attitudes.

Results
Bivariate and multivariable analyses revealed statistically significant levels of stigma associated with AIDS, IDU, CS and CBD. The layering of stigma was explored using a recently developed technique. Strong interactions between the stigmas of AIDS and the co-characteristics were also found. AIDS was significantly less stigmatising than IDU or CS. Critically, the stigma of AIDS in combination with either the stigmas of IDU or CS was significantly less than the stigma of IDU alone or CS alone.

Conclusion
The findings pose several surprising challenges to conventional beliefs about HIV/AIDS related stigma and stigma interventions that have focused exclusively on the disease stigma. Contrary to the belief that having a co-stigma would add to the intensity of stigma attached to people with HIV/AIDS, the findings indicate the presence of an illness might have a moderating effect on the stigma of certain co-characteristics like IDU. The strong interdependence between the stigmas of HIV/AIDS and the co-stigmas of IDU and CS suggest that reducing the co-stigmas should be an integral part of HIV/AIDS stigma intervention within this context.

Lack of integration of medical education in Australia: the need for change

The lack of cohesion across health and education sections and national and state jurisdictions is counterproductive to effective national policies in medical education and training. Existing systems in Australia for medical education and training lack coordination, and are under resourced and under pressure. There is a need for a coordinated national approach to assessment of international medical graduates, and for meeting their education and training needs. The links between prevocational and vocational training must be improved. Tensions between workforce planning, education and training can only be resolved if workforce and training agencies work collaboratively. All prevocational positions should be designed and structured to ensure that service, training, teaching and research are appropriately balanced. There is a need for more health education research in Australia.

Historical evolution and modern implications of concepts of consent to, and refusal of, medical treatment in the law of trespass

Many mischiefs arise on the change of a maxim and rule of the Common Law, which those who altered it could not see when they made the change.

Use of medical orders in acute care oxygen therapy

The life of every living organism is sustained by the presence of oxygen and the acute deprivation of oxygen will, therefore, result in hypoxia and ultimately death. Although oxygen is normally present in the air, higher concentrations are required to treat many disease processes. Oxygen is therefore considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription. Administration is typically authorized by a physician following legal written instructions to a qualified nurse. This standard procedure helps prevent incidence of misuse or oxygen deprivation which could worsen the patients hypoxia and ultimate outcome. Delaying the administration of oxygen until a written medical prescription is obtained could also have the same effect. Clearly, defined protocols should exist to allow for the legal administration of oxygen by nurses without a physicians order because any delay in administering oxygen to patients can very well lead to their death.

Enhancing the health of medical students : outcomes of an integrated mindfulness and lifestyle program

Medical students experience various stresses and many poor health behaviours. Previous studies consistently show that student wellbeing is at its lowest pre-exam. Little core-curriculum is traditionally dedicated to providing self-care skills for medical students. This paper describes the development, implementation and outcomes of the Health Enhancement Program (HEP) at Monash University. It comprises mindfulness and ESSENCE lifestyle programs, is experientially-based, and integrates with biomedical sciences, clinical skills and assessment. This study measured the program’s impact on medical student psychological distress and quality of life. A cohort study performed on the 2006 first-year intake measured effects of the HEP on various markers of wellbeing. Instruments used were the depression, anxiety and hostility subscales of the Symptom Checklist-90-R incorporating the Global Severity Index (GSI) and the WHO Quality of Life (WHOQOL) questionnaire. Pre-course data (T1) was gathered mid-semester and post-course data (T2) corresponded with pre-exam week. To examine differences between T1 and T2 repeated measures ANOVA was used for the GSI and two separate repeated measures MANOVAs were used to examine changes in the subscales of the SCL-90-R and the WHOQOL-BREF. Follow-up t-tests were conducted to examine differences between individual subscales. A total of 148 of an eligible 270 students returned data at T1 and T2 giving a response rate of 55%. 90.5% of students reported personally applying the mindfulness practices. Improved student wellbeing was noted on all measures and reached statistical significance for the depression (mean T1 = 0.91, T2 = 0.78; p = 0.01) and hostility (0.62, 0.49; 0.03) subscales and the GSI (0.73, 0.64; 0.02) of the SCL-90, but not the anxiety subscale (0.62, 0.54; 0.11). Statistically significant results were also found for the psychological domain (62.42, 65.62; p < 0.001) but not the physical domain (69.11, 70.90; p = 0.07) of the WHOQOL. This study is the first to demonstrate an overall improvement in medical student wellbeing during the pre-exam period suggesting that the common decline in wellbeing is avoidable. Although the findings of this study indicate the potential for improving student wellbeing at the same time as meeting important learning objectives, the limitations in study design due to the current duration of follow-up and lack of a control group means that the data should be interpreted with caution. Future research should be directed at determining the contribution of individual program components, long-term outcomes, and impacts on future attitudes and clinical practice.

The influence of medical enduring power of attorney and advance directives on decision making by Australian intensive care doctors

OBJECTIVE: Despite government encouragement for patients to make advance plans for medical treatment, and the increasing numbers of patients who have done this, there is little research that examines how doctors regard these plans.
DESIGN: We surveyed Australian intensive care doctors, using a hypothetical clinical scenario, to evaluate how potential end-of-life treatment decisions might be influenced by advance planning - the appointment of a medical enduring power of attorney (MEPA) or an advance care plan (ACP). Using open-ended questions we sought to explore the reasoning behind the doctors' decisions.
RESULTS: 275 surveys were returned (18.3% response rate). We found that opinions expressed by an MEPA and ACP have some influence on treatment decisions, but that intensive care doctors had major reservations. Most did not follow the request for palliation made by the MEPA in the hypothetical scenario.
CONCLUSIONS: Many intensive care doctors believe end-of-life decisions remain medical decisions, and MEPAs and ACPs need only be respected when they accord with the doctor's treatment decision. This study suggests a need for further education of doctors, particularly those working in intensive care, who are responsible for initiating and maintaining life support treatment.

MAAGs: the next generation. A study of the development of medical audit advisory groups and the arrangements for supporting clinical audit in primary care

Background: MAAGs have, historically, been disparate organisations with a lack of central direction, albeit with the same goal: to develop and support the performance of audit in primary care. This goal has been (and is being) achieved in a number of ways all over the country. In the last two years, MAAGs have witnessed many changes in primary care and are adapting themselves to suit these new arrangements at a local level.

Aim: To formalise our knowledge of where MAAGs are going, how they are getting there and the support they are receiving.

Method: A postal questionnaire to the 104 MAAGs in England and Wales, addressing 6 main issues of relevance to the development of MAAGs and the support they are receiving.

Results: At least two MAAGs have dissolved, leaving a possible total of 102 still in existence. Of these, 76 (74.5%) responded to the survey. The composition of the MAAG committee has changed dramatically since the inception of MAAGs in 1990, and staffing levels appear to have risen substantially. MAAGs appear to be more adequately funded by their health authorities than has previously been reported and many are actively seeking additional sources of funding. There is still large variation in levels of MAAG funding. Furthermore, funding is unrelated to the number of GPs or practices served. Security for MAAG staff appears to have been addressed in many areas, with 84% of MAAGs having at least one member of staff on a permanent employment contract. Many MAAGs are developing rolling programmes in an attempt to eliminate the short-sighted approach to the development of clinical audit that has existed since MAAGs were first set up.

Conclusion: Many MAAGs (with the obvious exception of those that have been dissolved) appear to be thriving without central direction or initiative. It is now evident that we were a little hasty in our concerns for the future of MAAGs beyond April 1996. It would seem that many organisations have taken the situation which arose two years ago as an opportunity to grow and develop in ways that may not have been possible within the confines of the Health Circular.

The politics of medical curriculum accreditation : thoughts, not facts?

The medical profession needs to adapt to the socio-political challenges of the 21st century. These have been described as the ‘Health Society’. Medical professionalism, however, is characterised by conservative values that are perpetuated by the professional attributes of autonomy, authority, and state-sanctioned altruism. The medical education enterprise is a replication and continuation of these values, sanctioned by its accreditation agencies. The Australian Medical Council through its accreditation standards only sanctions the formal curriculum. The status quo, however, is maintained by social, cultural and political parameters enmeshed in the informal and hidden curricula. By not addressing informal and hidden value constructs that maintain elitist medical arrogance the accreditation agency fails to uphold its remit. This paper explores the philosophical and empirical bases of these phenomena and illustrates them by means of a case study. Medical education and its sanctioning structure and agency are confirmed as forceful political enterprises. We conclude that explicit review of the informal and hidden curriculum is a feasible and necessary prerequisite for medical education reform and change.

There are plenty of medical problems, but only one real crisis

Fixing the disgraceful state of indigenous health conditions would benefit us all in the long-term, writes Jim Hyde.