Arquivo da tag: Medicalização

Should Doctors Treat Lack of Exercise as a Medical Condition? Expert Says ‘Yes’ (Science Daily)

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ScienceDaily (Aug. 13, 2012) — A sedentary lifestyle is a common cause of obesity, and excessive body weight and fat in turn are considered catalysts for diabetes, high blood pressure, joint damage and other serious health problems. But what if lack of exercise itself were treated as a medical condition? Mayo Clinic physiologist Michael Joyner, M.D., argues that it should be. His commentary is published this month in The Journal of Physiology.

Physical inactivity affects the health not only of many obese patients, but also people of normal weight, such as workers with desk jobs, patients immobilized for long periods after injuries or surgery, and women on extended bed rest during pregnancies, among others, Dr. Joyner says. Prolonged lack of exercise can cause the body to become deconditioned, with wide-ranging structural and metabolic changes: the heart rate may rise excessively during physical activity, bones and muscles atrophy, physical endurance wane, and blood volume decline.

When deconditioned people try to exercise, they may tire quickly and experience dizziness or other discomfort, then give up trying to exercise and find the problem gets worse rather than better.

“I would argue that physical inactivity is the root cause of many of the common problems that we have,” Dr. Joyner says. “If we were to medicalize it, we could then develop a way, just like we’ve done for addiction, cigarettes and other things, to give people treatments, and lifelong treatments, that focus on behavioral modifications and physical activity. And then we can take public health measures, like we did for smoking, drunken driving and other things, to limit physical inactivity and promote physical activity.”

Several chronic medical conditions are associated with poor capacity to exercise, including fibromyalgia, chronic fatigue syndrome and postural orthostatic tachycardia syndrome, better known as POTS, a syndrome marked by an excessive heart rate and flu-like symptoms when standing or a given level of exercise. Too often, medication rather than progressive exercise is prescribed, Dr. Joyner says.

Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center researchers found that three months of exercise training can reverse or improve many POTS symptoms, Dr. Joyner notes. That study offers hope for such patients and shows that physicians should consider prescribing carefully monitored exercise before medication, he says.

If physical inactivity were treated as a medical condition itself rather than simply a cause or byproduct of other medical conditions, physicians may become more aware of the value of prescribing supported exercise, and more formal rehabilitation programs that include cognitive and behavioral therapy would develop, Dr. Joyner says.

For those who have been sedentary and are trying to get into exercise, Dr. Joyner advises doing it slowly and progressively.

“You just don’t jump right back into it and try to train for a marathon,” he says. “Start off with achievable goals and do it in small bites.”

There’s no need to join a gym or get a personal trainer: build as much activity as possible into daily life. Even walking just 10 minutes three times a day can go a long way toward working up to the 150 minutes a week of moderate physical activity the typical adult needs, Dr. Joyner says.

Deeply Held Religious Beliefs Prompting Sick Kids to Be Given ‘Futile’ Treatment (Science Daily)

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ScienceDaily (Aug. 13, 2012) — Parental hopes of a “miraculous intervention,” prompted by deeply held religious beliefs, are leading to very sick children being subjected to futile care and needless suffering, suggests a small study in the Journal of Medical Ethics.

The authors, who comprise children’s intensive care doctors and a hospital chaplain, emphasise that religious beliefs provide vital support to many parents whose children are seriously ill, as well as to the staff who care for them.

But they have become concerned that deeply held beliefs are increasingly leading parents to insist on the continuation of aggressive treatment that ultimately is not in the best interests of the sick child.

It is time to review the current ethics and legality of these cases, they say.

They base their conclusions on a review of 203 cases which involved end of life decisions over a three year period.

In 186 of these cases, agreement was reached between the parents and healthcare professionals about withdrawing aggressive, but ultimately futile, treatment.

But in the remaining 17 cases, extended discussions with the medical team and local support had failed to resolve differences of opinion with the parents over the best way to continue to care for the very sick child in question.

The parents had insisted on continuing full active medical treatment, while doctors had advocated withdrawing or withholding further intensive care on the basis of the overwhelming medical evidence.

The cases in which withdrawal or withholding of intensive care was considered to be in the child’s best interests were consistent with the Royal College of Paediatrics and Child Health guidance.

Eleven of these cases (65%) involved directly expressed religious claims that intensive care should not be stopped because of the expectation of divine intervention and a complete cure, together with the conviction that the opinion of the medical team was overly pessimistic and wrong.

Various different faiths were represented among the parents, including Christian fundamentalism, Islam, Judaism, and Roman Catholicism.

Five of the 11 cases were resolved after meeting with the relevant religious leaders outside the hospital, and intensive care was withdrawn in a further case after a High Court order.

But five cases were not resolved, so intensive care was continued. Four of these children eventually died; one survived with profound neurological disability.

Six of the 17 cases in which religious belief was not a cited factor, were all resolved without further recourse to legal, ethical, or socio-religious support. Intensive care was withdrawn in all these children, five of whom died and one of whom survived, but with profound neurological disability.

The authors emphasise that parental reluctance to allow treatment to be withdrawn is “completely understandable as [they] are defenders of their children’s rights, and indeed life.”

But they argue that when children are too young to be able to actively subscribe to their parents’ religious beliefs, a default position in which parental religion is not the determining factor might be more appropriate.

They cite Article 3 of the Human Rights Act, which aims to ensure that no one is subjected to torture or inhumane or degrading treatment or punishment.

“Spending a lifetime attached to a mechanical ventilator, having every bodily function supervised and sanitised by a carer or relative, leaving no dignity or privacy to the child and then adult, has been argued as inhumane,” they argue.

And they conclude: “We suggest it is time to reconsider current ethical and legal structures and facilitate rapid default access to courts in such situations when the best interests of the child are compromised in expectation of the miraculous.”

In an accompanying commentary, the journal’s editor, Professor Julian Savulescu, advocates: “Treatment limitation decisions are best made, not in the alleged interests of patients, but on distributive justice grounds.”

In a publicly funded system with limited resources, these should be given to those whose lives could be saved rather than to those who are very unlikely to survive, he argues.

“Faced with the choice between providing an intensive care bed to a [severely brain damaged] child and one who has been at school and was hit by a cricket ball and will return to normal life, we should provide the bed to the child hit by the cricket ball,” he writes.

In further commentaries, Dr Steve Clarke of the Institute for Science and Ethics maintains that doctors should engage with devout parents on their own terms.

“Devout parents, who are hoping for a miracle, may be able to be persuaded, by the lights of their own personal…religious beliefs, that waiting indefinite periods of time for a miracle to occur while a child is suffering, and while scarce medical equipment is being denied to other children, is not the right thing to do,” he writes.

Leading ethicist, Dr Mark Sheehan, argues that these ethical dilemmas are not confined to fervent religious belief, and to polarise the issue as medicine versus religion is unproductive, and something of a “red herring.”

Referring to the title of the paper, Charles Foster, of the University of Oxford, suggests that the authors have asked the wrong question. “The legal and ethical orthodoxy is that no beliefs, religious or secular, should be allowed to stonewall the best interests of the child,” he writes.

Psychopaths Get a Break from Biology: Judges Reduce Sentences If Genetics, Neurobiology Are Blamed (Science Daily)

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ScienceDaily (Aug. 16, 2012) — A University of Utah survey of judges in 19 states found that if a convicted criminal is a psychopath, judges consider it an aggravating factor in sentencing, but if judges also hear biological explanations for the disorder, they reduce the sentence by about a year on average.

The new study, published in the Aug. 17, 2012, issue of the journalScience, illustrates the “double-edged sword” faced by judges when they are given a “biomechanical” explanation for a criminal’s mental disorder:

If a criminal’s behavior has a biological basis, is that reason to reduce the sentence because defective genes or brain function leave the criminal with less self-control and ability to tell right from wrong? Or is it reason for a harsher sentence because the criminal likely will reoffend?

“In a nationwide sample of judges, we found that expert testimony concerning the biological causes of psychopathy significantly reduced sentencing of the psychopath” from almost 14 years to less than 13 years, says study coauthor James Tabery, an assistant professor of philosophy at the University of Utah.

However, the hypothetical psychopath in the study got a longer sentence than the average nine-year sentence judges usually impose for the same crime — aggravated battery — and there were state-to-state differences in whether judges reduced or increased the sentence when given information on the biological causes of psychopathy.

The study was conducted by Tabery; Lisa Aspinwall, a University of Utah associate professor of psychology; and Teneille Brown, an associate professor at the university’s S.J. Quinney College of Law.

The researchers say that so far as they know, their study — funded by a University of Utah grant to promote interdisciplinary research — is the first to examine the effect of the biological causes of criminal behavior on real judges’ reasoning during sentencing.

Biological Explanation of Psychopathy Helps Defendant

The anonymous online survey — distributed with the help of 19 of 50 state court administrators who were approached — involved 181 participating judges reading a scenario, based on a real Georgia case, about a psychopath convicted of aggravated battery for savagely beating a store clerk with a gun during a robbery attempt.

The judges then answered a series of questions, including whether they consider scientific evidence of psychopathy to be an aggravating or mitigating factor that would increase or decrease the sentence, respectively, and what sentence they would impose. They were told psychopathy is incurable and treatment isn’t now an option.

While psychopathy isn’t yet a formal diagnosis in the manual used by psychiatrists, it soon may be added as a category of antisocial personality disorder, Tabery says. The study cited an expert definition of psychopathy as “a clinical diagnosis defined by impulsivity; irresponsibility; shallow emotions; lack of empathy, guilt or remorse; pathological lying; manipulation; superficial charm; and the persistent violation of social norms and expectations.”

The researchers recruited 207 state trial court judges for the study. Six dropped out. Twenty others were excluded because they incorrectly identified the defendant’s diagnosis. That left 181 judges who correctly identified the defendant as a psychopath, including 164 who gave complete data on their sentencing decisions.

The judges were randomly divided into four groups. All the judges read scientific evidence that the convicted criminal was a psychopath and what that means, but only half were given evidence about the genetic and neurobiological causes of the condition. Half the judges in each group got the scientific evidence from the defense, which argued it should mitigate or reduce the sentence, and half the judges got the evidence from the prosecution, which argued it should aggravate or increase the sentence.

Judges who were given a biological explanation for the convict’s psychopathy imposed sentences averaging 12.83 years, or about a year less than the 13.93-year average sentence imposed by judges who were told only that the defendant was a psychopath, but didn’t receive a biological explanation for the condition. In both cases, however, sentencing for the psychopath was longer than the judges’ normal nine-year average sentence for aggravated battery.

Even though the year reduction in sentence may not seem like much, “we were amazed the sentence was reduced at all given that we’re dealing with psychopaths, who are very unsympathetic,” Brown says.

Aspinwall notes: “The judges did not let the defendant off, they just reduced the sentence and showed major changes in the quality of their reasoning.”

The study found that although 87 percent of the judges listed at least one aggravating factor in explaining their decision, when the judges heard evidence about the biomechanical causes of psychopathy from the defense, the proportion of judges who also listed mitigating factors rose from about 30 percent to 66 percent.

Psychopathy was seen as an aggravating factor no matter which side presented the evidence, but it was viewed by the judges as less aggravating when presented by the defense than when presented by the prosecution.

A Disconnect between Sentencing and Criminal Responsibility

One surprising and paradoxical finding of the study was that even though the judges tended to reduce the sentence when given a biological explanation for the defendant’s psychopathy, the judges — when asked explicitly — did not rate the defendant as having less free will or as being less legally or morally responsible for the crime.

“The thought is that responsibility and punishment go hand in hand, so if we see reduced punishment, we would expect to see the judges feel the defendants are less responsible,” Tabery says. “So it is surprising that we got the former, not the latter.”

The researchers also counted explicit mentions by the judges of balancing or weighing factors that increase or reduce sentencing. When evidence of a biological cause of the defendant’s psychopathy was presented by the defense, the judges were about 2.5 times more likely to mention weighing aggravating and mitigating factors than when it was presented by the prosecution or when no biological evidence was presented.

The data show that “the introduction of expert testimony concerning a biological mechanism for psychopathy significantly increased the number of judges invoking mitigating factors in their reasoning and balancing them with aggravating factors,” the researchers conclude. “These findings suggest that the biomechanism did invoke such concepts as reduced culpability due to lack of impulse control, even if these concepts did not affect the ratings of free will and responsibility.”

Brown adds: “In the coming years, we are likely to find out about all kinds of biological causes of criminal behavior, so the question is, why does the law care if most behavior is biologically caused? That’s what is so striking about finding these results in psychopaths, because we’re likely to see an even sharper reduction in sentencing of defendants with a more sympathetic diagnosis, such as mental retardation.”

State Variations in Sentencing

While the overall results showed a reduction in sentencing when judges read biological evidence about the cause of psychopathy, the reduction was greater in some of the 19 states surveyed and nonexistent in others. That is not surprising due to variations in sentencing guidelines, rules of evidence and the extent of judges’ discretion.

There were too few responses from eight states to analyze them individually. In three states — Colorado, New York and Tennessee — biological evidence of psychopathy actually increased the sentence, although the findings weren’t statistically significant.

In eight other states — Alabama, Maryland, Missouri, Nebraska, New Mexico, Oklahoma, Utah and Washington state — biological evidence of psychopathy reduced the sentence or had no effect, and the reduction was statistically significant in two of those states: Utah and Maryland. When just those eight states were examined, the defendant received an average sentence of 10.7 years if evidence was introduced that psychopathy has a biological cause, versus 13.9 years without such evidence.

“We saw sentencing go up in a few states and down in most, and that’s just evidence that it [the double-edge sword] could cut either way,” Brown says.

Aspinwall adds: “When you look at the reasons the judges provide, what is striking to us is the vast majority found the psychopathy diagnosis to be aggravating and, with the presentation of the biological mechanism, also mitigating. So both things are happening.”