Ethical consensus and appellate court decisions view artificial nutrition and hydration (ANH) as medical treatment that can be refused like other treatments. However, advance directive statutes may produce obstacles for refusal of ANH, as distinct from other life-sustaining treatments, in patients who lack capacity. This paper reviews state statutes and appellate case law regarding medical decision making for patients who lack decisional capacity. Twenty states (39%) have one or more explicit statutory provisions delineating a separate and more stringent standard for ANH refusal. These standards include higher evidentiary standard; requirement for specific preauthorization, qualifying medical conditions, second medical opinion, or judicial review; refusal not permitted; refusal not permitted if death would result from "starvation" or "dehydration"; and previous law with higher standard applies to old documents. In 11 of these states and in eight others, statutory law contains language that could be misinterpreted, implying, but not rising to, an explicitly higher standard. Four appellate decisions departed from the judicial consensus that ANH can be refused like other treatments, but subsequent court decisions or legislative enactments reduced or eliminated their impact. Legislators and the courts should ask whether higher standards for ANH refusal are appropriate in light of case law authority that ANH should not be treated differently and in light of statutory language that preserves those common law rights. These higher standards may make it more difficult in certain states to refuse ANH for patients who lack capacity or place a burden on good practice by making providers fearful of the law.

Context: Opioid-related overdoses in the United States have increased by 33% over the past 5 years. America's opioid crisis is increasing across demographic groups and spreading geographically. South Carolina is one of the states in the southern region of the United States that experiences an unusually high rate of opioid-related deaths. In 2016, 616 deaths occurred in South Carolina from drug overdoses from prescription opioid drugs, up 9% from 2015. South Carolina residents filled nearly 4.5 million opioid prescriptions in 2015, which is greater than 1.5 times the national average. Implementation: In 2017, the governor of South Carolina declared a statewide public health emergency in response to the growing opioid crisis. In response, a committee of the South Carolina House of Representatives released a report in January 2018 on its opioid abuse prevention study and made recommendations on ways to reduce the number of opioid-related deaths. Evaluation: This article examines the strengths and weaknesses of South Carolina's state action plan to combat opioid-related deaths in the context of what other states have done to address opioid abuse, as well as the scientific literature on pain management. Several state opioid action plans, including South Carolina's and West Virginia's, were identified and evaluated. Discussion: This article describes (1) several legislative and nonlegislative strategies being considered in South Carolina for addressing the crisis, (2) an assessment of the strengths and weaknesses of these proposals and how they compare with other states that have also implemented response plans, and (3) an examination of the scientific literature to determine best practices for treating patients who are currently taking opioids, as well as discussing alternative approaches to pain management. The authors make several recommendations to improve upon South Carolina's opioid abuse prevention plan, such as engaging communities and encouraging multistakeholder collaboration to expand access to treatment, particularly among the most vulnerable populations.

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This article provides pragmatic advice for organizations interested in creating a research ethics consultation service (RECS). A robust RECS has the potential to build capacity among investigators to identify and consider the ethical issues they encounter while conducting their research. Determining whether to establish an RECS should begin with an institutional‐needs assessment that includes three key questions: What are the current resources available to research teams to navigate ethical concerns that arise from their research? Is there a demand or perceived need for more resources? Is there institutional support (financial and otherwise) to establish and maintain an RECS? If this results in the decision to establish the consultation service, relevant institutional stakeholders must be identified and consulted, and personnel with the requisite skills recruited. The next step is to establish an RECS and build the infrastructure to process and respond to requests. The RECS's long‐term sustainability will depend on a stable source of funding and a mechanism to receive constructive feedback to ensure that the service is meeting the institutional needs it set out to address.

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