The Role of Relational Knowing in Advance Care Planning

Medical decision making when a patient cannot participate is complicated by the question of whose voice should be heard. The most common answer to this question is that "autonomy" is paramount, and therefore it is the voice of the unwell person that should be given priority. Advance care planning processes and practices seek to capture this sentiment and to allow treatment preferences to be documented and decision makers to be nominated. Despite good intentions, advance care planning is often deficient because it is unable to facilitate a relational approach to decision making in cases when the patient's competence is reduced. In this article we present findings from a study of the ways in which older people and their significant others understand decision making in such circumstances. Critical to the participants' understanding was the emergent concept of "relational knowing," a concept that is poorly articulated in the advance care planning literature. Our findings suggest that the dominant understanding of decision making in conditions of impaired competence is incomplete and obscures much of what matters to people. We conclude that, having recognized a broader set of ethical concerns, it is necessary to develop a relational and narrative based approach that applies in appropriate settings.

On the fragility of medical virtue in a neoliberal context: the case of commercial conflicts of interest in reproductive medicine

Social, political, and economic environments play an active role in nurturing professional virtue. Yet, these environments can also lead to the erosion of virtue. As such, professional virtue is fragile and vulnerable to environmental shifts. While physicians are often considered to be among the most virtuous of professional groups, concern has also always existed about the impact of commercial arrangements on physicians' willingness and capacity to enact their professional virtues. This article examines the ways in which commercial arrangements have been negotiated to secure medical virtue from real or perceived threats of erosion. In particular, we focus on the concern surrounding conflicts of interest arising from commercial arrangements that have developed as a result of neoliberal economic and social policies. The deregulation of medical markets and privatization of services have produced new commercial relationships that are often misunderstood by patients, publics, and physicians themselves. 'Conflicts of interest' policies have been introduced in an attempt to safeguard ethical conduct and medical practice. However, a number of virtue ethicists have critiqued these policies as inadequate for securing virtue. We examine the ways in which commercial arrangements have been seen to impact upon medical virtue, both historically and in the context of modern medicine (using the example of fertility services in Australia). We then describe and critique current efforts to restore clinical virtue through both conflict of interest policies and through virtue ethics. Finally, we suggest some possible ways of addressing the corrosive effects of neoliberalism on medical virtue.

Obese people's perceptions of the thin ideal

The media play a key role in promoting the thin ideal. A qualitative study, in which we used in depth interviews and thematic analysis, was undertaken to explore the attitudes of 142 obese individuals toward media portrayals of the thin ideal. Participants discussed the thin ideal as a social norm that is also supported through the exclusion of positive media portrayals of obese people. They perceived the thin ideal as an 'unhealthy' mode of social control, reflecting on their personal experiences and their concerns for others. Participants' perceptions highlighted the intersections between the thin ideal and gender, grooming and consumerism. Participants' personal responses to the thin ideal were nuanced--some were in support of the thin ideal and some were able to critically reflect and reject the thin ideal. We consider how the thin ideal may act as a form of synoptical social control, working in tandem with wider public health panoptical surveillance of body weight.

"NEVER REGARD YOURSELF AS ALREADY SO THOROUGHLY INFORMED": THE WITHDRAWAL OF ITS INVITATION TO RODNEY SYME TO ADDRESS ITS 2015 CONGRESS BY THE ROYAL AUSTRALASIAN COLLEGE OF PHYSICIANS

In 1628, William Harvey presented his revolutionary theory of the circulation to ears at the Royal College of Physicians that had been deafened by the unquestionable authority of Galen's teachings, from one and a half millennia in the past. Harvey's theory was initially rejected, despite his faith in his colleagues being eager for truth and knowledge, and never regarding themselves as so well informed that they would not welcome "further information". Recently Rodney Syme, the retired Melbourne urologist who for a long time has agitated for the legalisation of assisted dying, and also challenged the authorities to apply the current law in response to his admitted assistance to a number of individuals, was invited to address the 2015 Congress of the Royal Australasian College of Physicians. At the eleventh hour, the invitation to speak was withdrawn. In this column, we trace the course of events leading to this withdrawal of the invitation, and describe some of the correspondence to and from the College in response to the withdrawal. We draw parallels between the experiences of Harvey and Syme, and point to lessons to be learnt from the recent episode of apparent unwillingness, on the part of an institution that seeks to present itself as outward-looking, progressive and socially aware, to fulfil this promise in the increasingly important area of the end-of-life.

An unequivocal good? Acknowledging the complexities of advance care planning

Over the past few decades advance care planning (ACP) has become the subject of debate, research and legislation in many countries. Encouraging people to express their preference for treatment in advance, ideally in written form, seems a natural way to identify what someone might have wanted when they can no longer participate in decision-making. The notion of ACP as an unequivocal good permeates much of the research and policy work in this area. For example, ACP is now actively encouraged in Australian federal and state government policies and the Victorian Government has recently published a practical ACP strategy for Victorian health services (2014-2018). However, advance care plan is ethically complex and the introduction of the Victorian health services strategy provides an opportunity to reflect on this complexity, particularly on the benefits and risks of ACP.

"At 150 kg, you can't run" men's weight loss stories in a popular health magazine provide appropriate examples of good health practice

We explore weight loss stories from 47 men collected from the Australian edition of Men's Health magazine between January 2009 and December 2012. Our analysis uses a mixed methods approach that combines thematic analysis and descriptive statistics to examine weight loss strategies against clinical practice guidelines for the management of overweight and obesity. All the stories reported the use of physical activity for weight loss and most stories detailed dietary changes for weight loss. Our findings indicate that most of the men reportedly used some form of behavioural strategies to assist them in their behaviour change efforts. The weight loss methods used were consistent with clinical practice guidelines, with the exception of some dietary practices. As narratives may assist with behaviour change, stories like those examined in this study could prove to be very useful in promoting weight loss to men.

Physiological effects of androgens on human vascular endothelial and smooth muscle cells in culture

Androgenic hormones are associated with atherosclerotic cardiovascular disease, although the underlying cellular and molecular mechanisms remain unclear. This study examines the impact of androgens on the physiology of human vascular endothelial cells (EC) and smooth muscle cells (SMC) in culture. Cells were incubated with testosterone, dihydrotestosterone (DHT) or dehydroepiandrosterone (DHEA) at various physiological concentrations (5-50 nM) in the present or absence of an androgen receptor (AR) blocker flutamide (100 nM). Cell growth and death, DNA and collagen synthesis, and gene protein expression were assessed. It was shown that: (1) DHEA protected EC from superoxide injury via AR-independent mechanisms; (2) testosterone induced DNA synthesis and growth in EC via an AR-independent manner with activation of ERK1/2 activity; (3) DHT inhibited DNA synthesis and growth in EC in an AR-dependent manner; (4) testosterone and DHT enhanced ERK1/2 activation and proliferation in SMC via AR-independent and -dependent pathways, respectively; and (5) these androgens did not significantly affect collagen synthesis in SMC. We conclude that androgens possess multiple effects on vascular cells via either AR-dependent or -independent mechanisms. Testosterone and DHEA may be "beneficial" in preventing atherosclerosis by improving EC growth and survival; in contrast, stimulation of VSMC proliferation by testosterone and DHT is potentially "harmful". The relationship of these in vitro effects by androgens to in vivo vascular function and atherogenesis needs to be further clarified.

"The solution needs to be complex." Obese adults' attitudes about the effectiveness of individual and population based interventions for obesity

BACKGROUND

Previous studies of public perceptions of obesity interventions have been quantitative and based on general population surveys. This study aims to explore the opinions and attitudes of obese individuals towards population and individual interventions for obesity in Australia.

METHODS

Qualitative methods using in-depth semi-structured telephone interviews with a community sample of obese adults (Body Mass Index >or=30). Theoretical, purposive and strategic recruitment techniques were used to ensure a broad sample of obese individuals with different types of experiences with their obesity. Participants were asked about their attitudes towards three population based interventions (regulation, media campaigns, and public health initiatives) and three individual interventions (tailored fitness programs, commercial dieting, and gastric banding surgery), and the effectiveness of these interventions.

RESULTS

One hundred and forty two individuals (19-75 years) were interviewed. Participants strongly supported non-commercial interventions that were focused on encouraging individuals to make healthy lifestyle changes (regulation, physical activity programs, and public health initiatives). There was less support for interventions perceived to be invasive or high risk (gastric band surgery), stigmatising (media campaigns), or commercially motivated and promoting weight loss techniques (commercial diets and gastric banding surgery).

CONCLUSION

Obese adults support non-commercial, non-stigmatising interventions which are designed to improve lifestyles, rather than promote weight loss.