Orientador: Joel Carlos Lastoria / Resumo: A hanseníase é uma doença crônica infecciosa, de evolução lenta, que se manifesta sobretudo mediante sinais e sintomas dermatológicos, tais como lesões na pele e nervos, especialmente nos olhos, mãos e pés cujo agente etiológico é o Mycobacterium leprae. A doença é considerada um grande problema de saúde pública, devido a sua magnitude e alto poder incapacitante. O reconhecimento precoce e o tratamento oportuno são elementos chave para cessar a transmissão prevenindo incapacidades. A assistência integral à pessoa com hanseníase requer a organização de equipes multidisciplinares da rede pública de serviços do Sistema Único de Saúde (SUS), da atenção básica à média e alta complexidade, de acordo com a necessidade de cada caso e com os princípios de equidade e integralidade. Diante desse cenário, compete ao Estado nos termos do artigo 1°, III e do artigo 5° da Constituição Federal de 1988 disponibilizar ferramentas para que o cidadão tenha condições de subsistir com dignidade, assegurando meios de efetivação dos seus direitos. Diante do exposto, este estudo tem por objetivo descrever os direitos da pessoa atingida pela hanseníase com vistas a oferecer aos profissionais da saúde ferramentas para que estes possam informar e orientar a existência e o acesso a esses direitos. É um estudo quantitativo, que foi realizado no ambulatório de referência de hanseníase do Hospital das Clínicas - UNESP em Botucatu/SP e também nas unidades de saúde das cidades que compõem o Polo Cuesta.Partic... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Leprosy (etiological agent Mycobacterium leprae) is a chronic infectious disease of slow growth, manifesting itself mostly through dermatological signs and symptoms, such as skin and nerve lesions particularly on the eyes, hands and feet. The disease is regarded as a major public health problem due to its magnitude and high incapacitating power. Early detection and timely treatment are key elements in stopping transmission thus preventing incapacities. Comprehensive healthcare assistance for Leprosy sufferers requires the organization of multidisciplinary teams across the national healthcare service network of Brazil (SUS), from basic to mid and highly complex care, in accordance with the necessities of each case and based on equity and integrality principles. It is therefore, the role of the State as per the terms under Article 1°, III and Article 5° of the 1988 Constitution of the Federative Republic of Brazil, to provide the citizen with tools to allow subsistence with dignity by ensuring ways in which to implement their rights. In view of the aforementioned, this study aims to describe the rights of the person affected by Leprosy, in order to offer health professionals tools to guide and inform about the existence and access to these rights. It is a quantitative study that was conducted at the Reference Centre for Leprosy at the Hospital das Clínicas (São Paulo State University – UNESP- Medical School’s Clinical Hospital) in Botucatu/SP, as well as health care units in th... (Complete abstract click electronic access below) / Mestre

Este trabalho ambiciona compreender a origem e o funcionamento do sistema de prestação de serviços de saúde a todos os brasileiros sem distinção, e, para tanto, esmiúça as origens a partir do qual sua organização se ergueu. São estudadas as formas de federalismo existentes desde o seu surgimento no Estado Moderno, e o desenvolvimento das limitações aos poderes centrais e dos entes federados, com ênfase na maneira sob as quais as responsabilidades foram e são divididas ou compartilhadas, bem assim como a maneira pelas quais suas balizas foram estabelecidas e modificadas no decorrer do tempo. O direito à saúde no Brasil é colocado no centro do debate e as formas como foi exercido, bem assim como as suas deficiências, foram todas observadas durante a investigação do processo que originou a criação de um formato inédito, amplamente respaldado pela participação popular. Esta legitimidade impressa ao que se denomina Direito Sanitário foi de crucial relevância para o enfrentamento do federalismo sob o prisma do direito à saúde, que se denomina atualmente federalismo sanitário, e é referência para a compreensão das políticas públicas que sucederam sua construção e exercício efetivo. A partir daí, foi possível proceder na avaliação da divisão das responsabilidades entre os integrantes do sistema, a forma de efetivação da divisão, sua vinculação estrita ao sistema federativo e aferir sobre a pertinência de que o federalismo sanitário seja reconhecido como a forma de responsabilização compartilhada nos termos em que o sistema único de saúde foi estruturado. Diante da conclusão a que se chegou, são apreciadas as decisões proferidas pelo Supremo Tribunal Federal. Por fim, são avaliadas de modo a que se conclua pela tese construída, que rechaça a responsabilização solidária da forma como compreendida pelo STF, por não se harmonizar com a estrutura federativa estabelecida para cumprimento do dever de assistência à saúde pelo Estado Brasileiro. / This work aims to understand the origin and functioning of the provision of health care system to all Brazilians without distinction, and, therefore, deeply analyzes the sources from which its organization arose. Existing forms of federalism are studied since its emergence in the Modern State, and the development of limitations to the central authorities and federal agencies, emphasizing the way in which the responsibilities were and are divided or shared, as well as the way the that their beacons have been established and modified over time. The entitlement to health in Brazil is placed in the center of the debate and the ways in which it was exercised, as well as its shortcomings were all observed during the investigation of the process that led to the creation of an unprecedented format, widely supported by popular participation. This printed legitimacy to what is called Health Law was of crucial importance to face the federalism through the prism of the right to health, which is now called health federalism, and is a reference to the comprehension of public policies that followed its construction and effective exercise. From there, it was possible to proceed in assessing the division of responsibilities between system integrators, how to effect the division, their strict adherence to the federal system and check on relevance of the health federalism is recognized as a form of shared accountability in terms in the unified health system was structured. Before the conclusion arrived at, they are appreciated judgments given by the Supreme Court. Finally, are evaluated so that it is determined by the built thesis, which rejects the joint accountability of how understood by the Supreme Court, by not harmonize with the federal structure established to comply with the health care obligation by Brazil.

Alors que l'application des règles du droit de la concurrence dans le secteur sanitaire est un phénomène croissant, il est pertinent de s'interroger sur son éventuelle remise en cause. L'étude de l'entrecroisement du droit de la concurrence et du droit de la santé, en effet, n'a pas encore fait l'objet d'une analyse d'ensemble. Celle-ci fait apparaître que l'entrelacement de principe des deux disciplines provient de ce qu'il est, à la fois, possible et favorisé. Le droit de la santé ne crée pas d'obstacles à l'emprise du droit de la concurrence, et participe même de s a mise en œuvre, en créant des mécanismes susceptibles de porter atteinte au processus concurrentiel. Le recours aux normes concurrentielles, par ailleurs, semble opportun. Bénéfique, l'application des règles de concurrence renforce les règles du droit de la santé. Bien qu'instrumentalisée par les normes sanitaires, la concurrence n'est pas suffisamment protégée. L'application des règles concurrentielles, alors, apparaît nécessaire. Mais les rapports qu'entretiennent les deux disciplines montrent également des aspects négatifs. Si le droit de la concurrence offre une protection indirecte aux «consommateurs de soins», ses mécanismes, exclusivement orientés vers l'intérêt général concurrentiel, ne permettent pas, en réalité, d'accueillir directement les finalités sanitaires. S'élèvent, en outre, des conflits entre les deux corps de règles, conduisant à leur neutralisation et à leur altération mutuelles. Aussi convient-il de rechercher un moyen d'améliorer leur articulation. C'est donc à un recours renouvelé au droit de la concurrence qu'il s'agit finalement de songer. / As the Judicial Enforcement of Competition Law in health services is increasing, it seems relevant to wonder whether this phenomenon could somehow be questioned. Indeed, Competition Law and Health Law have not yet been investigated together through an overall study – though the intertwining of these disciplines is not only possible, but also visibly encouraged. In fact, far from thwarting the influence of Competition, Health Law even participates in its enforcement, triggering mechanisms likely to provoke it. Besides, the application of Competition Rules is advisable whenever it strengthens Health Rules. Sanitary norms have nonetheless used Competition without it being satisfactorily protected. Consequently, the application of Competition Rules appears necessary. The relation between disciplines has also known negative effects : even though Competition Law offers indirect protection to “health consumers”, its mechanisms do not, in actuality, take sanitary objectives into account. Conflicts between the disciplines compel them to alter one another, leading to their mutual neutralization. Consequently, the interaction between Competition and Health norms needs to be improved. Limited or residual rights of appeal could be the key under Competition Law.

Among the features that distinguish British Columbia’s mental health laws from those in other provinces in Canada is that they accord a high level of discretion to psychiatrists to impose involuntary treatment on patients who have the mental capacity to withhold consent to this treatment. In this research I examine the nature of the medico-legal regime in British Columbia that permits this coercive treatment, describe how it came into existence, and explore how it works in the lives of specific patients. Michel Foucault’s philosophy informs the historical, theoretical, and empirical dimensions of this research and provides a framework for a normative critique of British Columbia’s mental health law regime. In establishing the background to British Columbia’s current mental health laws, I give a historical account of the social forces that produced this province’s laws, which reflect a strong orientation toward neurobiological psychiatric ways of understanding and treating people diagnosed as having mental disorders. Foucault’s writings on governmentality, discourse and human agency provide the theoretical basis in this research for understanding the operation of psychiatric power in British Columbia. These writings also inform the methodology for the analysis of institutional discourse, which I use in the empirical component of this research. In order to conduct an empirical investigation of this British Columbia’s current mental health law regime, I gathered data from transcripts of three administrative tribunal hearings before the Mental Health Review Board of British Columbia and two other decisions from hearings before that board for which transcripts were not available. In these hearings, patients who had been subjected to involuntary psychiatric treatment orders under mental health legislation sought release from detention by challenging the psychiatrists who had issued the orders. The Review Board is legislatively empowered to affirm these orders or discharge the patients from involuntary psychiatric treatment. I use critical discourse analysis to analyze discursive exchanges between patients, psychiatrists and other participants at the hearings, exchanges that disclose power relations between the participants and have significant effects in shaping the outcomes for the patients. My critical discourse analysis of the transcript data and Review Board decisions discloses discriminatory and prejudicial psychiatric practices shaped by British Columbia’s mental health laws. This research lays the groundwork for a normative framework, based on Foucault’s writings on ethics and relational agency, for understanding patients’ rights to consensual medical treatment that overcomes problems associated with traditional liberal conceptions of individual rights and is a philosophically coherent basis for making recommendations to change British Columbia’s mental health law regime. / Graduate

The thesis deals with an issue of legal aspects of stem cell research with a special emphasis on the use of embryonic stem cells which is connected with the most of ethical and legislative controversies. At first, there are presented biological and ethical aspects of the topic necessary for its understanding. The thesis further analyses related legislation relevant for the research conducted in the Czech Republic. With respect to international law, the thesis focuses mainly on the Council of Europe system of protection of human rights. Then, the thesis presents regulation in primary and secondary European Union law. In the two final chapters, there is presented Czech regulation in the constitutional order (in the Charter of Fundamental Rights and Freedoms) and laws, which is then viewed in European context as moderately permissive and relatively well prepared. Its greatest weakness is the lack of discussion about the topic in the Czech public.

In many jurisdictions, including England and Wales, psychopaths are unable to succeed with an insanity defence. This has been influenced by a legal view of psychopathy as a condition characterised by a reduced ability to comply with the law, which is otherwise fully understood. Evidence from cognitive neuroscience, however, may potentially challenge this traditional legal conception of psychopathy. In this regard it has already been suggested, based partly on scientific evidence, that it may be appropriate for at least some psychopaths to succeed with an insanity defence where they can be shown to lack moral competence. In this thesis, I critically examine this possibility. I first examine the insanity defence in English law, showing how psychopaths have effectively been excluded from the defence by judicial interpretation of the insanity defence criteria. Consequently, if psychopaths lacking moral competence were to be identified, reform (or reinterpretation) of the defence would be required. I then present philosophical arguments in favour of the case that some psychopaths should gain access to an insanity defence, before clarifying which psychopaths ought potentially to succeed, and which criminal offences ought potentially to be relevant, for the purposes of a reformed or reinterpreted defence. In order to clarify which psychopaths are relevant psychopaths (RPs), it is necessary to go beyond existing scientific evidence. It is argued, based on emerging neuroscientific findings and current research techniques, that while it is not currently possible to identify RPs, it may be possible in the future. Even if it this becomes possible, however, the philosophical case for access to an insanity defence remains deeply problematic. Although RPs may lack moral competence, for example, they may nevertheless possess other capacities relevant to criminal responsibility. After closer examination, it is argued that the case for access to an insanity defence may be best viewed as a case for mitigation rather than exculpation. I conclude by considering some of the implications of this analysis in an English legal context, should it become possible to identify RPs. Of particular relevance is the possibility that RPs may be at high risk of causing serious harm to others. This illuminates important possible relationships between responsibility and risk, and diagnostic advancements and risk assessment, in this area. There are also broader implications for the management of psychopaths in the future, given that greater scientific understanding may lead to enhanced predictive abilities that could tempt policymakers towards more radical strategies. This thesis contributes to an ongoing debate about the role that cognitive neuroscience may play in decisions about the criminal responsibility of psychopaths. My main contribution is to clarify how psychopaths lacking moral competence may be identified in the future, and relate this neuroscientific discourse to arguments for providing these persons with access to an insanity defence. It is argued, however, by reference to legal, policy, scientific and philosophical considerations, that the risk such persons would pose, rather than their capacity for criminal responsibility per se, may have significant legal and policy implications in England and Wales in the future.

Located squarely within the experiences of legal aid lawyers, with particular emphasis on the challenges they face in delivering effective representation, this dissertation, designed as an institutional ethnography, problematizes the provisions and practices related to involuntary admission in psychiatric facilities in Poland, as well as the organization of legal aid representation in involuntary admission cases. Through detailed accounts of paramedics, psychiatrists, judges, and legal aid lawyers’ work, connected and coordinated by legal and administrative texts, I demonstrate how the disjuncture between institutional regimes and lawyers’ experiences is institutionally produced by the set of legal, professional, financial, and social relations that organize both the involuntary admission procedure and the system of legal aid in Poland. While I start my exploration with legal aid lawyers’ embodied experiences of performing their work, accounting for how that work is organized and coordinated in local sites, this dissertation moves beyond a solo ethnographic description in seeking to discover relations, especially the social and legal relations mediated by the texts that govern these local experiences and practices. I trace the material and discursive practices that operate in key sites to organize the legal aid system, involuntary commitment procedures, and judicial decision-making. In Poland, the overwhelming majority of involuntary commitment cases are taken on by legal aid lawyers, whose work conduct is bound by both the law and a code of professional ethics. In this dissertation, I advance my thesis by closely reviewing the legal context of involuntary commitment; the material practices associated with legal aid lawyers, such as appointment, client access, and remuneration; the processes through which psychiatric documents are created and attached to admittees; and the role psychiatrist-generated texts play in court. I argue that within the context of involuntary admission, lawyering is organized in such a way that legal aid attorneys are unable to perform at their utmost, in a way that would most benefit their clients. Moreover, through my research I show that―despite perhaps their best intentions―legal aid lawyers not only actively participate in the practices that circumscribe the space for their legal advocacy for admittees, but also reproduce the very discourses and practices that objectify people during involuntary admission procedures to psychiatric facilities in Poland. / Graduate

Indiana University-Purdue University Indianapolis (IUPUI) / The United States is experiencing a severe opioid use epidemic with more than 2 million people currently suffering from opioid use disorder (OUD), of which, over 1 million need treatment. Opioid treatment programs (OTPs) are evidence-based modality providing comprehensive care to individuals experiencing OUD. OTPs provide counseling, medical assessments, and medication-assisted treatment, which decrease the use of illicit opioids, reduce associated deaths, criminality, and improve the psychosocial wellbeing of its patients. However, OTPs have been extensively regulated at the federal, state, and local levels with little consistency and varying degrees of enforcement across the country, particularly at the state level, creating a “regulatory fog”. This complex regulatory environment has made it challenging to study new or changing regulations and their impact on health outcomes. In order to better understand the variation of OTP regulation, this dissertation: (1) employs public health law research methods to map the entire landscape of state-level regulation of OTPs and associated state characteristics in effect on January 1, 2017; (2) examine how state-level regulations affect the delivery of care from the perspective of OTP administrators through key-information interviews; and (3) examines associations between regulatory burden and related health outcomes of individuals experiencing OUD, by state.

Examining the persistence of disparities over time is an important obligation in terms of rectifying, maintaining, and improving community health and social well-being for all. This study analyzed the individual factors of (a) race/ ethnicity and (b) dual eligibility, as a proxy measure of socioeconomic status, as well as the environmental factor of (c) place of residence, and the organizational factor of (d) Rural Health Clinic (RHC) type on emergency room (ER) utilization of older adult Medicare patients treated by RHCs within the Department of Health and Human Services' (DHHS) Region 4. A prospective, multi-level, longitudinal design was employed to analyze potential health disparities or gaps that may exist among RHC Medicare beneficiary patients (+65) using longitudinal, mixed multilevel modeling in SPSS. The years of investigation were 2010 through 2012. R4 has continually lagged behind other Regions in the Nation in having higher Health Disparities and ER Utilization rates related to Race, Poverty, and Rural Isolation. A key question is: Do these disparities persist? This study's findings support that dual eligible RHC patients utilized ER services at higher rates than non-dual eligible, Medicare only RHC patients at: 77%, 80%, and 66%, in 2010, 2011, and 2012, respectively; and above the White reference group, Black RHC Medicare patients utilized ER services at higher rates of: 18%, 20%, and 34%, in 2010, 2011, and 2012, respectively. These findings support that dual Medicare and Medicaid eligibility, as a proxy measure of socioeconomic status, and race continue to influence higher rates of ER utilization in Region 4. In terms of health and utilization disparities, strikingly and persistently, as recent as 2012, Black, dual eligible RHC Medicare beneficiary patients age 65 and over are twice as likely to utilize ER services for health care than their more advantaged counterparts. Health care leaders and policymakers are seeking evidence-based performance measures as tools for detecting gaps in health care and using those subsequent findings as leverage to implement policy change for the purpose of increasing health care delivery performance system-wide while lowering health disparities across various patient populations. Toward that goal, communicating and disseminating the findings of this study contributes to the body of knowledge and enables policy leaders to better make decisions based on empirical evidence in order to strengthen the health care delivery system for older adults in diverse rural contexts. From a health and public affairs policy perspective, crafting in tandem targeted, top-down, population health and bottom-up, community interventions to curb poor health outcomes and high health care utilization would be in the public interest at-large within this region of the Southeastern United States.

No / This chapter will discuss key issues and challenges facing contemporary European environmental health law and policy. It will identify relevant legal and policy regimes as well as key drivers for promotion and protection of environmental health in Europe. It will examine the strengths and limits of evolving European legal and policy responses to the promotion and protection of environmental health. It explores prospects for optimizing health protection in Europe. In this connection, the chapter will propose regulatory options to re-invigorate the current legal and policy regimes governing environmental health at the European and domestic levels. The chapter will conclude by proposing pathways to mapping the future of environmental health law in Europe.