It has been suggested by some commentators that the ‘real’ damage (as opposed to that pleaded) in the cases of Rees v Darlington Memorial Hospital NHS Trust [2004] 1 AC 309 and Chester v Afshar [2005] 1 AC 134 was the claimant’s lost autonomy. Arguments have consequently been put forward that lost autonomy either already is or should be recognised as a new form of actionable damage in medical negligence cases. Given the value placed on respecting patient autonomy in medical law and bioethics, it might be thought that such a development should be welcomed. But if lost autonomy is accepted as a new form of damage in negligence, it will not be confined to the two scenarios that were present in those cases and it may be inconsistent with other established negligence principles. This thesis considers whether lost autonomy ought to be recognised as a new form of damage in negligence and concludes that it should not. A close textual analysis of Rees and Chester is undertaken in order to determine whether a ‘lost autonomy’ analysis actually provides the best explanation of those two cases. I then look at how the concepts of autonomy and harm should be understood to determine whether, ethically speaking, to interfere with someone’s autonomy is to cause them harm. The final part of the thesis considers important doctrinal tort law considerations that have been overlooked in the medical law literature. I argue that the nature of autonomy means that it cannot coherently be considered actionable damage within the tort of negligence and that recognising a duty of care to avoid interfering with people’s autonomy would be inconsistent with the restrictive approach the courts take to recovery for psychiatric injury and economic loss. My ultimate conclusion is that the benefits of allowing such claims do not outweigh the undermining of established principles that would ensue if lost autonomy were recognised as a form of actionable damage in negligence.

Mental health screening is frequently recommended to facilitate earlier detection of mental illness in prisons. For this goal to be achieved: (1) the screening process must be accurate; (2) appropriate follow-up treatment must be provided; (3) the treatment must lead to improved outcomes. The current thesis aimed to evaluate mental health screening in relation to these three criteria by studying 13, 281 prisoners admitted to Correctional Service of Canada. Screening achieved comparable accuracy to tools that have been studied internationally and many inmates received at least some treatment. However, interruptions in treatment were frequent and long-term treatment was rare. There was weak evidence that treatment led to reduced rates of institutional incidents of suicide, self-harm, victimization and violence. While screening remains widely endorsed, further study of its impacts is needed to maximize its value. This could include considering alternatives to screening itself, or as follow-up for those who screen positive.

Background: The current literature concerning self-harm and suicide has shown firstly that self-harm is a major public health problem, secondly that people who self-harm are at increased risk of suicide and thirdly, that women prisoners have a higher rate of self-harm than women in the general population and than male prisoners. Women prisoners are therefore particularly high risk of self-harm and suicide and yet to date, no specific intervention has been developed for this group. Aims: This study intends to build on an intervention found to be effective in the community and to describe a methodology of conducting a therapeutic intervention in a prison environment. Method: The research utilized both qualitative and quantitative methods conducted over four phases. In Phase 1, semi-structured interviews were completed with women prisoners who self-harm and with prison staff. Data was analysed thematically. In Phase 2, the results from the analysis were then used to inform the modification of a Psychodynamic Interpersonal skills Therapy (PIT) model originally used in the community. During the third phase of the study, prison staff were recruited and trained to deliver the therapy. Finally, the fourth phase consisted of a feasibility and acceptability study with 64 women prisoners who had recently self-harmed. Thirty-two were randomized to the treatment group which consisted of four sessions of individual PIT therapy and 32 to the control condition which consisted of four sessions with a member of staff not trained in the therapy. Rates of self-harm were measured pre- and post-treatment. Standardized measures for depression, suicide intention, hopelessness and interpersonal skills were also administered. These data were further supported by interviews conducted with participants who completed the intervention, therapists and therapy supervisors. The methods used in the study were constantly evaluated and amended when required to describe a methodology suitable for this environment. Results: There was evidence of a lack of understanding of self-harm by prison officers. The trial phase of the study did not show evidence of efficacy for the intervention. There was an overall reduction in rates of self-harm pre- and post- treatment across the sample. Comparison of scores on outcome measures, pre- and post-intervention, showed a reduction on all tests in both treatment groups but this was not significant. It was not feasible to deliver the therapy as originally envisaged and substantial changes to the methods were needed. The results showed that prison staff had the skill and capacity to deliver PIT therapy but that the prison was not able to support such a role. As a result external therapists had to be brought in to the study. Conclusions: It is acknowledged that the study was not feasible as originally designed, but due to the small sample size we cannot say it was not effective and therefore, not worthy of further study.

In July 2008, the UK Information Commissioner launched a review of EU Directive 95/46/EC on the basis that: “European data protection law is increasingly seen as out of date, bureaucratic and excessively prescriptive. It is showing its age and is failing to meet new challenges to privacy, such as the transfer of personal details across international borders and the huge growth in personal information online. It is high time the law is reviewed and updated for the modern world.” Legal practitioners such as Bergkamp have expressed a similar sense of dissatisfaction with the current legislative approach: “Data Protection as currently conceived by the EU is a fallacy. It is a shotgun remedy against an incompletely conceptualised problem. It is an emotional, rather than rational reaction to feelings of discomfort with expanding data flows. The EU regime is not supported by any empirical data on privacy risks and demand…A future EU privacy program should focus on actual harms and apply targeted remedies.” Accordingly, this thesis critiques key concepts of existing data protection legislation, namely ‘personal’ and ‘sensitive’ data, in order to explore whether current data protection laws can simply be amended and supplemented to manage privacy in the information society. The findings from empirical research will demonstrate that a more radical change in EU law and policy is required to effectively address privacy in the digital economy. To this end, proposed definitions of data privacy and private data was developed and tested through semi-structured interviews with privacy and data protection experts. The expert responses indicate that Bergkamp et al have indeed identified a potential future direction for privacy and data protection, but that further research is required in order to develop a coherent definition of privacy protection based on managing risks to personal data, and harm from misuse of such information.

This dissertation 1) described prevalence and correlates of poly-tobacco use among US youth and young adults; 2) addressed positive and negative transitions of e-cigarettes among US youth and adults and 3) examined the 2-year transition of dual e-cigarette/cigarette use among US adults in relation to nicotine dependence (ND) symptoms, interest in quitting, and cardiovascular disease (CVD) factors. Data from 2013-2016 of the Population Assessment of Tobacco and Health Study were used. In the first study, 3.6% of youth (12-17years) and 18.3% of young adults (18-34years) were current poly-tobacco users between 2013-2014. Common poly-tobacco products combination was cigarettes and e-cigarettes for youth and young adults. Among youth, heavy drinking was associated with higher odds of poly-tobacco use. Factors associated with higher odds of poly-tobacco use among young adults included males, younger adults (18-24years), those with lower levels of educational attainment, residing in the South, heavy drinking, and marijuana use. In the second study, between 2013-2016, e-cigarette use increased only in youth. Young e-cigarette users were more likely to be never cigarette smokers compared to older users. Among youth e-cigarette users at each wave, the proportion of never cigarette smokers rose from 24.1% in Wave 1 to 42.6% in Wave 3 (p=0.0001 for trends). Among adult e-cigarette dual users in Wave 1, 8.8% transitioned to no tobacco use at Wave 3, 6.2% to mono e-cigarette use, while 85% either relapsed to cigarettes (53.5%) or continued dual use (31.5%). In the final study, among 1,870 adult dual tobacco users from Wave 1, 25·8% (95% CI 23·5-28·3) remained dual users 2 years later, 11·9% (95% CI 10·5-13·5) reported no tobacco use (cessation transition), 7·0% (95% CI 5·5-8·7) reported e-cigarette mono use (harm reduction transition), and 55·3% (95% CI 52·6-58·0) reported cigarette mono use (relapse transition). In the adjusted regression analysis, ND severity was associated with lower odds of cessation (OR 0·36; 95% CI 0·15-0·88) and harm reduction (OR 0·18; 95% CI 0·04-0·82) transitions. Interest in quitting and CVD factors were not associated with cessation or harm reduction. Collectively, our study findings emphasize the need for stricter tobacco regulatory policies to prevent another tobacco epidemic.

Since their introduction to the United States in 2008, synthetic cannabinoids became the most widely used recreational drug behind marijuana, then regressed to an estimated prevalence of less than 1%. Contrary to expectations for a drug declining in use, emergency department presentations and acute poisonings related to the use of synthetic cannabinoids are increasing. Alongside this phenomenon, a growing body of literature is beginning to uncover a relationship between psychosis and synthetic cannabinoid use. A current gap in the literature exists surrounding harm prevention methods and targeted intervention strategies for users of synthetic cannabinoids. To date, no known studies have examined individuals with a history of use of these substances and investigated the reasons they decided to discontinue recreational use. The purpose of the current study was to fill this gap in the literature while also further confirming and expanding existing research on the characterization of synthetic substance use, perceived harm of synthetic cannabinoids, and users’ knowledge about synthetic cannabinoids. Cross sectional survey methods in a non-experimental comparative design was utilized with participants recruited through the online crowd sourcing platform Amazon MTurk. Significant motivating factors for both discontinuation and continuation of synthetic cannabinoid use were found including personal experience, accessibility, preference towards other substance, and questions surrounding the source and purity of the synthetic cannabinoids. It was also found that individuals who currently use synthetic cannabinoids have less general knowledge about the substance class when compared to individuals who have discontinued use. These results suggest that psychoeducational campaigning surrounding general knowledge about the substance class as well as information on the physiological effects of synthetic cannabinoids may be an effective harm reduction method.

京都大学 / 0048 / 新制・課程博士 / 博士(地球環境学) / 甲第21937号 / 地環博第183号 / 新制||地環||36(附属図書館) / 京都大学大学院地球環境学舎地球環境学専攻 / (主査)教授 宇佐美 誠, 教授 佐野 亘, 准教授 森 晶寿 / 学位規則第4条第1項該当 / Doctor of Global Environmental Studies / Kyoto University / DFAM

Background: Suicidal behaviour is increasingly widespread in South Africa and constitutes a significant burden of disease, often within resource-constrained hospital settings. Little is known about the factors associated with psychiatric admission following an act of deliberate self-harm (DSH) in South Africa. Aim: The aim of this study was to investigate the sociodemographic and clinical factors which differentiated DSH patients who were admitted to an emergency psychiatric unit compared to those who were treated in the emergency department and discharged. Setting: Data were collected for 272 consecutive patients presenting to the emergency department of a tertiary, public, urban hospital in South Africa, as a result of self harm, between 16 June 2014 and 29 March 2015, for an initial epidemiological study of DSH at the hospital. This study had a data subset of 174 of those patients (84 admitted to the emergency psychiatric unit and 90 treated in the emergency department and discharged). Methods: This study was a retrospective cross-sectional analysis, and it analysed existing data from the epidemiological study, using bivariate and multivariate logistic regression analysis. Results: Of the patients admitted to the emergency psychiatric unit, a greater proportion of patients were female (61,9%), were not in a relationship (83,3%), had no dependents (60,7%), were unemployed (73,8%), and had a low socioeconomic status (59,5%). Having dependants was associated with an increased likelihood of admission to the emergency psychiatric unit in bivariate analysis; however, when controlling for other sociodemographic variables, this was no longer significant. None of the clinical variables were significantly associated with admission to the emergency psychiatric unit. Conclusion: The lack of significant findings in the sociodemographic and clinical factors associated with an admission to the emergency psychiatric unit (compared to being treated in the emergency department and discharged) is surprising. At face value, it suggests that there are no obvious differences between the two groups. The use of a validated screening tool or more accurate measure of the clinical correlates (e.g. screening tool for substance-related 6 disorders) could have better highlighted, perhaps subtle, differences between the two groups. It is perhaps more important to question whether the perceived risk factors in DSH patients are associated with suicidal behaviour and whether emergency psychiatric unit admission, based on these factors, is more effective at treating DSH short-term, and reducing suicidal behaviour long-term, than say outpatient-based treatment interventions. Clinician-related factors that influence psychiatric admission decisions following DSH is also an important area for future research.

Multicultural counselling and psychotherapy theory and research that focuses on ethnicity and race in cross-cultural counselling have pointed to concerns of oppression within counselling processes; however, an open exploration of oppression that may occur in session is not readily available from the perspective of clients. As such, this thesis research explores the lived experiences of oppression for ethnoracial minority clients who have engaged in counselling with white counsellors, with the aim of gaining a deeper understanding of oppression and power in counselling, and possible resulting harm. This research is positioned within feminist and multicultural lenses, influencing the interviews themselves and the interpretations of participant experiences of oppression in counselling. Philosophical hermeneutics was used as the methodology to inform data collection and analysis. Five participants were interviewed using a semi-structured protocol to explore their counselling experiences for the following domains of interest: oppression, power, and harm. Through the analysis process, four major themes emerged for oppression (i.e., Whiteness of Therapy, Therapist Cultural Positioning in Sessions, Microinvalidations by Therapist, Disconnection Between Therapist and Client), four for power (i.e., Relational Power Differences in Therapy, Power Over by Therapist, Client Disempowerment, Client Empowerment Through Resistance), and three for harm (i.e., Hindered Counselling Process, Impeded Psychological Wellbeing, Generalized Negative Beliefs). Implications are discussed with the hope of informing multicultural research and training to improve competencies of professionals working within cross-cultural contexts.

1 Abstract The objective of this thesis is to analyse the liability in civil law, mainly from the prospective of individual preconditions that together result in such liability for inflicted harm. The text is divided into nine parts including introduction and conclusion. The first part comprises the analysis of the legal term of liability from the prospective of existing theoretical concepts, then the approach as set forth under Act no. 89/2012 Sb, Civil Code, as amended (hereinafter referred to as "Civil Code") and the author's own approach is presented at the end of this part. The next part discusses in details the preconditions of liability for harm and then the sets of preconditions that together result in such liability are analysed. The author calls these sets as liability systems, as they are actually a variant of the objective and subjective liability. A separate chapter is dedicated to the objective liability. A separate chapter is also dedicated to the division of types of liabilities such as for defects, harm, default, etc., as this is crucial for the discussed topic. Next parts focus on individual preconditions for liability for harm, namely on violating legal obligations and relevant damage, harm, causality and fault as on the precondition typical for subjective liability, i.e. liability for...