Beyond Disadvantage: Disability, Law, and Bioethics

The above is the title of the 2018 Petrie-Flom Center Annual Conference, which took place in June. I had registered for the event because the topic interests me greatly and I have so much to learn in this area. Unfortunately, I turned out to be away and unable to attend after all.

I am delighted that the Petrie-Flom Center not only decided to make some of the lecture materials available beforehand, but recorded the lectures and has made the videos shareable.

Prominent point of discussion at he conference was the question whether a disability is merely a difference, or a bad difference. Putting the question like this is an oversimplification but it is a good starting point. I will discuss this matter and these lectures in greater detail in coming posts.

For now, here are the opening remarks, and first talks.

“Beyond Disadvantage: Disability, Law, and Bioethics” Opening Remarks and Panel 1: Theory and Definitions of Disability from Petrie-Flom Center on Vimeo.

 

 

 

Stress is bad for your body, but how? Studying piglets may shed light

While I do wonder what is being done to piglets in the name of academic research, the article makes valid points and I want to share it with you. We need to find a way of living that is much more balanced, not only for the planet, but also for ourselves.

-Ange

File 20180611 191965 1g834yf.jpg?ixlib=rb 1.1
Pigs and humans have a lot in common, particularly their digestive tracts.
Krumanop/Shutterstock.com

Adam Moeser, Michigan State University

Stress affects most of us to one degree or another, and that even includes animals. My lab studies early-life stress in pigs and how it impacts their health later in life, specifically in the gastrointestinal (GI) tract. Pigs, whose GI tracts are extremely similar to those of humans, may be one of the clearest windows we have into researching stress, disease, and new therapies and preventatives – both in livestock and people.

In my study of how stress makes humans and pigs vulnerable to disease, I have seen the profound impact that stress-related chemical substances, such as hormones and peptides, can have on a body’s tissues. I’m hopeful that our research in piglets could eventually lead to treatments for both people and animals designed to mitigate the adverse effects of stress on the GI health.

How stress can save your life

Not all stress is bad. When we perceive a threat, our hypothalamus – one of our most basic parts of the brain – kicks in to protect us by triggering what many recognize as the “fight or flight” response. It is a primal evolutionary response programmed in our brains to help us first survive and then restore us to a normal set point, or what feels like stability.

The stress response is essential to helping escape a dangerous situation, such as an attacking dog.
Dmitri Ma/Shutterstock.com

What actually is happening has to do with something called the hypothalamic-pituitary-adrenal (HPA) axis, which is at the core of the stress response. During stress, the hypothalamus, a region in the brain, makes and sends out a chemical called corticotrophin-releasing factor, which signals for the pituitary gland to release another chemical, adrenocorticotrophic hormone.

This stimulates the adrenal gland to release adrenalin and cortisol. Adrenalin and cortisol, two of the most well-known stress hormones, power our bodies to react during the fight or flight response. They can heighten our response time in a fight. They can pump blood to our extremities when we flee. They can boost our immune system to protect against pathogens. That stress response gives us what we need to resolve the situation.

How stress can harm your life

Fortunately for many of us, we don’t have to deal with life-threatening situations on a regular basis. However, we still experience stress. This stress can be chronic, due to a specific situation or overall lifestyle.

But, our stress response is meant for short-term resolvable conflict. So, in a way, the stress response is misplaced in today’s world of enduring stressors. Danger comes when we experience repeated elevations of these stress hormones, or when we are exposed to too much of these stress hormones at a young age. Instead of physical threats, many of us experience psychosocial stress, which triggers a similar stress response but is often not resolvable.

For example, stress in the workplace, such as feeling overworked or undervalued, could be perceived as a threat and in turn activate the stress response. However, in these situations, the survival aspects of the stress response, such as increased heart rate and immune activation, is not effective in resolving this threat.

This results in continued production and higher levels of these stress chemicals in the body. They bind to target receptors in many organs, which can have profound effects on physiology and function.

Stress is particularly damaging to the developing brain.
Mcimage/Shutterstock.com

High levels of stress are also especially harmful when they occur at a young age, when many of the body’s important stress regulatory systems – for example, the brain and nervous systems – are still developing. Exposure to stress in early life can alter the normal development and physiology of many organ systems, resulting in increased sensitivity to stress and lifelong health risks in offspring.

Also, a mother’s stress during pregnancy can be “transmitted” to the fetus, resulting in permanent changes to the stress response system and health in offspring.

This early-life stress can fuel a constant stress response inside the body. This can include inflammation, or increased activity of the immune system, or immune suppression as its new “normal.”

Inflammation and immune suppression are unpredictable and can manifest in many parts of our body, with different consequences. For example, stress and inflammation near blood vessels can cause blood vessels to constrict. This causes elevated blood pressure, which can lead to a slew of other conditions like coronary artery disease and heart attack.

Immune suppression can reduce the body’s ability to heal wounds and make it more susceptible to other pathogens. Inflammation and immune suppression can affect anything, including our mental health. Chronic stress can traffic immune cells into the brain, where they can cause neuroinflammation, which can affect our mood and fuel diseases like depression and anxiety.

Your GI tract and you

The GI tract is our largest interface with the outside world. If you think about it, your GI system is “outside” your body; it experiences many of the pathogens and other foreign entities with which we come into contact. If you unfolded your entire GI system, it would cover a tennis court. The GI system also contains just as many neurons as your spinal cord and houses the largest collection of immune cells in the body. A system of that size is as powerful as it is susceptible.

Chronic stress that affects your GI tract can manifest as abdominal pain, diarrhea or constipation and can lead to common diseases such as irritable bowel syndrome or inflammatory bowel disease.

Early-life stress is especially concerning; scientists only now are beginning to understand the long-term consequences. My research demonstrates the impacts of early-life stress on animal health and productivity, as well as human health. In pigs, this stress can result from early weaning and other management practices. In humans, it could be from physical or emotional trauma like abuse or neglect.

What we can learn from piglets

Pigs and humans have similar digestive tracts, making pigs an excellent model for human GI disease. My research team has demonstrated early stress in piglets results in GI symptoms (e.g. diarrhea, GI infections) that are remarkably similar to stress-related GI disorders in people: Irritable bowel syndrome, inflammatory bowel disease and food allergies are examples.

Through my lab’s research of piglets and early-life stress, we have been able to significantly lower the stress and GI disease that they experience through their life by eliminating individual early-life stressors.

Much of their stress is caused through early weaning, social change due to maternal separation and mixing with unfamiliar pigs. These pigs then experience a higher rate of gastrointestinal and respiratory diseases, as well as reduced growth performance and feed efficiency into adulthood.

We also learned that a particular type of immune cell, called the mast cell, becomes highly activated during stress, which in turn causes much of the stress-associated GI disease. By focusing on animal welfare and implementing new management practices to eliminate individual stressors or intervene therapeutically with mast cell blockers, we can lower the overall threshold of stress that the piglets experience.

This basic research could result in future breakthroughs regarding how we combat stress in humans. Maybe with more fundamental research in animal models, we can develop a therapy to help lessen the impact of bad stress on our bodies.

The ConversationIn the meantime, those of us experiencing stress can take action. If you experience a lot of stress on a daily basis, focus on what you can and cannot control, and then apply your energy to the things within your control while taking care of your body by eating properly, getting enough sleep, and maintaining some level of physical activity. Then, learn to cope with the things you cannot control through therapy, meditation and other stress management practices.

Adam Moeser, Matilda R. Wilson Endowed Chair, Associate Professor of Large Animal Clinical Sciences, Michigan State University

This article was originally published on The Conversation. Read the original article.

How seeing problems in the brain makes stigma disappear

 

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A pair of identical twins. The one on the right has OCD, while the one on the left does not.
Brain Imaging Research Division, Wayne State University School of Medicine, CC BY-SA

David Rosenberg, Wayne State University

As a psychiatrist, I find that one of the hardest parts of my job is telling parents and their children that they are not to blame for their illness.

Children with emotional and behavioral problems continue to suffer considerable stigma. Many in the medical community refer to them as “diagnostic and therapeutic orphans.” Unfortunately, for many, access to high-quality mental health care remains elusive.

An accurate diagnosis is the best way to tell whether or not someone will respond well to treatment, though that can be far more complicated than it sounds.

I have written three textbooks about using medication in children and adolescents with emotional and behavioral problems. I know that this is never a decision to take lightly.

But there’s reason for hope. While not medically able to diagnose any psychiatric condition, dramatic advances in brain imaging, genetics and other technologies are helping us objectively identify mental illness.

Knowing the signs of sadness

All of us experience occasional sadness and anxiety, but persistent problems may be a sign of a deeper issue. Ongoing issues with sleeping, eating, weight, school and pathologic self-doubt may be signs of depression, anxiety or obsessive-compulsive disorder.

Separating out normal behavior from problematic behavior can be challenging. Emotional and behavior problems can also vary with age. For example, depression in pre-adolescent children occurs equally in boys and girls. During adolescence, however, depression rates increase much more dramatically in girls than in boys.

It can be very hard for people to accept that they – or their family member – are not to blame for their mental illness. That’s partly because there are no current objective markers of psychiatric illness, making it difficult to pin down. Imagine diagnosing and treating cancer based on history alone. Inconceivable! But that is exactly what mental health professionals do every day. This can make it harder for parents and their children to accept that they don’t have control over the situation.

Fortunately, there are now excellent online tools that can help parents and their children screen for common mental health issues such as depression, anxiety, panic disorder and more.

Most important of all is making sure your child is assessed by a licensed mental health professional experienced in diagnosing and treating children. This is particularly important when medications that affect the child’s brain are being considered.

Seeing the problem

Thanks to recent developments in genetics, neuroimaging and the science of mental health, it’s becoming easier to characterize patients. New technologies may also make it easier to predict who is more likely to respond to a particular treatment or experience side effects from medication.

Our laboratory has used brain MRI studies to help unlock the underlying anatomy, chemistry and physiology underlying OCD. This repetitive, ritualistic illness – while sometimes used among laypeople to describe someone who is uptight – is actually a serious and often devastating behavioral illness that can paralyze children and their families.

In children with OCD, the brain’s arousal center, the anterior cingulate cortex, is ‘hijacked.’ This causes critical brain networks to stop working properly.
Image adapted from Diwadkar VA, Burgess A, Hong E, Rix C, Arnold PD, Hanna GL, Rosenberg DR. Dysfunctional activation and brain network profiles in youth with Obsessive-Compulsive Disorder: A focus on the dorsal anterior cingulate during working memory. Frontiers in Human Neuroscience. 2015; 9: 1-11., CC BY-SA

Through sophisticated, high-field brain imaging techniques – such as fMRI and magnetic resonance spectroscopy – that have become available recently, we can actually measure the child brain to see malfunctioning areas.

We have found, for example, that children 8 to 19 years old with OCD never get the “all clear signal” from a part of the brain called the anterior cingulate cortex. This signal is essential to feeling safe and secure. That’s why, for example, people with OCD may continue checking that the door is locked or repeatedly wash their hands. They have striking brain abnormalities that appear to normalize with effective treatment.

We have also begun a pilot study with a pair of identical twins. One has OCD and the other does not. We found brain abnormalities in the affected twin, but not in the unaffected twin. Further study is clearly warranted, but the results fit the pattern we have found in larger studies of children with OCD before and after treatment as compared to children without OCD.

Exciting brain MRI and genetic findings are also being reported in childhood depression, non-OCD anxiety, bipolar disorder, ADHD and schizophrenia, among others.

Meanwhile, the field of psychiatry continues to grow. For example, new techniques may soon be able to identify children at increased genetic risk for psychiatric illnesses such as bipolar disorder and schizophrenia.

New, more sophisticated brain imaging and genetics technology actually allows doctors and scientists to see what is going on in a child’s brain and genes. For example, by using MRI, our laboratory discovered that the brain chemical glutamate, which serves as the brain’s “light switch,” plays a critical role in childhood OCD.

What a scan means

When I show families their child’s MRI brain scans, they often tell me they are relieved and reassured to “be able to see it.”

Children with mental illness continue to face enormous stigma. Often when they are hospitalized, families are frightened that others may find out. They may hesitate to let schools, employers or coaches know about a child’s mental illness. They often fear that other parents will not want to let their children spend too much time with a child who has been labeled mentally ill. Terms like “psycho” or “going mental” remain part of our everyday language.

The example I like to give is epilepsy. Epilepsy once had all the stigma that mental illness today has. In the Middle Ages, one was considered to be possessed by the devil. Then, more advanced thinking said that people with epilepsy were crazy. Who else would shake all over their body or urinate and defecate on themselves but a crazy person? Many patients with epilepsy were locked in lunatic asylums.

Then in 1924, psychiatrist Hans Berger discovered something called the electroencephalogram (EEG). This showed that epilepsy was caused by electrical abnormalities in the brain. The specific location of these abnormalities dictated not only the diagnosis but the appropriate treatment.

The ConversationThat is the goal of modern biological psychiatry: to unlock the mysteries of the brain’s chemistry, physiology and structure. This can help better diagnose and precisely treat childhood onset mental illness. Knowledge heals, informs and defeats ignorance and stigma every time.

David Rosenberg, Professor, Psychiatry and Neuroscience, Wayne State University

This article was originally published on The Conversation. Read the original article.

Designing suburbs to cut car use closes gaps in health and wealth

Jerome N Rachele, Australian Catholic University; Aislinn Healy, Australian Catholic University; Jim Sallis, University of California, San Diego, and Takemi Sugiyama, Australian Catholic University

This article is one in a series, Healthy Liveable Cities, in the lead-up to the Designing Healthy Liveable Cities Conference in Melbourne on October 19 and 20.


Large health inequalities exist in Australia. Car ownership and its costs add to the health inequalities between low-income and high-income households. The physical characteristics of neighbourhoods influence our transport use and, in turn, make health inequalities better or worse.

Rising housing prices have forced many low-income families to live on the fringes of Australian capital cities. Residents of these sprawling outer suburbs often have worse access to public transport, employment, shops and services. They need one or more motor vehicles simply to get to work and take children to school.

Buying and maintaining vehicles in Australia is expensive. These costs have a large impact on household budgets. Household finances then affect health in two main ways:

  • through the ability to access health-related resources, such as healthy foods, health care and high-quality living conditions (like heating and cooling)
  • through stress caused by financial difficulties, insecure incomes and exposure to poorer environments such as crowding, crime and noise pollution.

Living in the car-dependent urban fringes also often dooms residents to long sedentary commutes.

Four scenarios of transport costs

The following four hypothetical households demonstrate the costs of varying levels of car ownership and transport behaviours.

Scenario 1: A household with two cars that are 15,000km and 10,000km, respectively, per year. The car that is driven 15,000km is assumed to be less than three years old, bought new and financed with a loan. The other car is assumed to be 10 years old and owned outright. This household aligns with estimates by the Australian Automobile Association.

Scenario 2: Scenario one, minus the used car and substituting five return public transport trips a week to the Melbourne central business district from the outer suburbs.

Scenario 3: No cars, substituting 10 return trips to the CBD from the outer suburbs.

Scenario 4: No cars, substituting three return trips to the CBD (i.e. occasional public transport use), with walking and cycling as the main forms of transport.

Table 1 shows how reducing household car ownership, even after adding the cost of public transport, can improve household finances.

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Moving from a two-car household to a one-car household cuts weekly costs by as much as A$41, even after increased public transport use adds a A$41-a-week cost.

Moving from a two-car household to having no cars can improve weekly finances by as much as A$237, after adding 10 return trips to the CBD.

The fourth scenario, emphasising walking and cycling, shows the greatest improvement in household finances. These families are $294 per week better off.

The impacts on households of each of these car ownership and transport scenarios differ depending on their incomes. To illustrate this, we’ve taken the median disposable household income from the lowest, middle and highest quintiles from the ABS in 2015-16.

Figure 1. Proportion of disposable household income remaining after transport costs for four scenarios of car ownership.

Although becoming car-free will increase disposable household income after paying for transport, the largest proportional differences are for the lowest-income households. This means these households will benefit most from reducing car ownership and switching to more active and affordable forms of transport.

Urban design can boost household health and wealth

So how do we help households make the transition from private car ownership? The answer lies in the environments we live in.

The evidence from research suggests several strategies to improve uptake of active and affordable transport, while reducing car dependence and related health inequities. These include local urban design features such as:

  • connected and safe street networks (including pedestrian and bicycle infrastructure) that reduce exposure to traffic

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  • residential areas mixed with commercial, public service and recreational opportunities
  • public transport that is convenient, affordable, frequent, safe and comfortable
  • higher residential density with different types of housing (including affordable housing) to support the viability of local businesses and high-frequency public transport services
  • cycling education and promotion
  • car-free pedestrian zones, traffic calming measures, signage and accessibility for all (including wheelchair and pram access).

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Australia has yet to fully realise the potential of promoting active transport and reducing car dependency as a way to reduce health inequities.

For example, the Victorian government recently announced 17 new low-density suburbs for Melbourne’s outer fringes (up to 50 kilometres from the CBD). It did so with a goal of creating more affordable housing. But urban planning experts have criticised these plans for increasing car dependence and commute times – due to the lack of nearby destinations and amenities – which have been shown to be bad for health.

In another case, the Planning Institute of Australia described the proposed A$5.5 billion West Gate Tunnel as a “retrograde solution”. The institute expressed concern about “entrenched inequality for those in the outer suburbs”.

Changes to city transport environments can take years or even decades, and funding is often limited. Phased interventions that target lower-income neighbourhoods should be considered first as these are likely to produce the greatest gains in health equity.

This approach does have some caveats. Urban renewal projects carry a risk of gentrification, whereby higher and middle-income households displace those on lower incomes. Place-based government investment, such as improvements to public transport, has been shown to increase local housing prices. That could force lower-income households to relocate, often to car-dependent neighbourhoods on the urban fringes.

In these scenarios, a lack of government policies that safeguard against displacement of low-income residents can make health inequities worse.


You can read other articles in the series here.

The ConversationThe Designing Healthy Liveable Cities Conference is being hosted by the NHMRC Centre of Research Excellence in Healthy Liveable Communities in Melbourne on October 19-20. You can register here.

Jerome N Rachele, Research Fellow in Social Epidemiology, Institute for Health and Ageing, Australian Catholic University; Aislinn Healy, PhD Candidate, Institute for Health and Ageing, Australian Catholic University; Jim Sallis, Professorial Fellow, Institute for Health and Ageing, Australian Catholic University, and Emeritus Professor, Department of Family Medicine and Public Health, University of California, San Diego, and Takemi Sugiyama, Professor of Built Environment, Institute for Health & Ageing, Australian Catholic University

This article was originally published on The Conversation. Read the original article.

Here’s why your sustainable tuna is also unsustainable

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Not all tuna are caught using sustainable methods.
(Pixabay)

Megan Bailey, Dalhousie University

Tuna is one of the most ubiquitous seafoods. It can be eaten from a can or as high-end sashimi and in many forms in between. But some species are over-fished and some fishing methods are unsustainable. How do you know which type of tuna you’re eating?

Some tuna is certified as sustainably caught by groups such as the Marine Stewardship Council (MSC) that set standards for sustainable fishing. But these certifications are only good if they are credible.

In late August, several media outlets published stories about On the Hook, a new campaign by a consortium of retailers and academics who have taken issue with some fishing practices allowed by the MSC. As a university professor whose research focuses on private seafood governance, including certifications and traceability, and fisheries policy, I am deeply familiar with the issues at hand. I support the campaign, but don’t stand to gain from the outcome.

The Western and Central Pacific skipjack tuna fishery is one of the world’s biggest. Some of the tuna caught here carries the MSC’s blue label, identifying it as the best environmental choice for consumers. But the same boats making that sustainable catch may also use unsustainable methods to catch unsustainable fish on the same day.

The On the Hook coalition sees this as at odds with the MSC certification, as do I. Yes, sustainable and unsustainable fish can be separated; there are people on board whose sole job is to do this. But rewarding fishermen for their sustainable catch, while allowing them to fish unsustainably, dupes consumers into supporting companies that take part in bad behaviour.

Does sorting work?

The On the Hook campaign singles out one fishery in particular: the “purse seine” fishery in the tropical western Pacific Ocean. This fishery covers the waters of eight island nations, including Micronesia, the Marshall Islands, Papua New Guinea and the Solomon Islands. Under the Nauru Agreement, these nations, usually referred to as the Parties to the Nauru Agreement (PNA), collectively control access to about one quarter of the world’s tuna supply.

Fishermen can use nets to catch free-swimming adult tuna and earn MSC certification for their catch. But these same fishermen can also use fish aggregating devices (FADs) — instruments that attract all kinds of marine life, including adult tuna, juvenile tuna and hundreds of species of sharks, turtles and other fish — to net their catch. Fishing on FADs is faster and less costly, but these devices are associated with high levels of bycatch, one of the main sustainability concerns in many fisheries. Fishing on FDAs does not earn MSC certification.

Fish aggregating devices attract ocean-going fish such as tuna.
(Shutterstock)

Under normal operations, the fishermen use both methods. “Compartmentalization” is a technique that allows the unsustainable portion of the fish to be separated on board the vessel from the sustainable portion. This is supposed to provide assurance to consumers that they are making a sustainable choice. Yet the negative environmental impacts connected to FAD fishing operations should surely also be considered in an MSC assessment. Currently, this does not happen.

Compartmentalization remains necessary because there isn’t enough of an economic advantage for companies to make only sustainable catches. It costs fishermen more to fish sustainably because they have to find the tuna, instead of waiting for it to come to the FAD.

A fleet using both methods can be part of a higher value premium market and earn financial security from the high volume, yet unsustainable, fishery. If purse-seining tuna vessels need to subsidize their sustainable fishing with unsustainable practices, then MSC certification has not provided the incentive it set out to.

A holistic fishery

Millions of tonnes of tuna have been fished from the waters of the Western and Central Pacific fishery. But the countries controlling these waters have not benefited to a large extent, mostly due to a lack of cooperation in bargaining for benefits, which allowed distant nations to exploit the fishery.

In the past decade, these Pacific Island states have increased their bargaining power in regional negotiations by implementing a scheme that controls the number of boats that can enter their waters. Under the program, called the vessel day scheme (VDS), these countries can now charge higher fees to boats that want access.

For example, PNA countries used to extract between three per cent and six per cent of the value of tuna fishery in their waters. Since their bargaining power has increased, they can now extract more than 14 per cent of the value, and this number is likely to continue to rise.

This is no small accomplishment for these Pacific Island nations, and other coastal state collectives are now trying to emulate their success. But this does not mean that all of the practices they allow are commendable, including those that are not representative of the “best environmental choice” in seafood.

On my Facebook feed, a colleague recently commented: “A Pacific Islander owned sustainably certified fishery is the wrong target.”

Let me clear up this misconception. The On the Hook campaign is not targeting the PNA, but the MSC. It would like the MSC to delay the recertification — authorized by the accreditation body in September — of the PNA fishery until the compartmentalization practice has been addressed. The fishery needs to be considered holistically.

A school of tuna.
(United Nations Food and Agriculture Organization/Danilo Cedrone), CC BY

For example, the MSC could specify that to earn a certification, a boat cannot fish sustainably and unsustainably on the same fishing trip. Consumer dollars should not be supporting the very practices the MSC condemns.

Another colleague remarked that because the PNA is challenging big industry, the On the Hook campaign might benefit big industry and hurt the PNA. In fact, it is the same boats, the same fleet, the same companies that are fishing MSC-certified tuna and on FADs.

Muddy waters

My colleagues also worry that the campaign calls into question the credibility of the MSC label. But this has actually become commonplace, with many groups pointing at examples of certified fisheries that are not sustainable. For example, the WWF has recommended that seafood buyers should stay away from MSC-certified Mexican tuna.

I would argue that the MSC is tarnishing itself by normalizing the practice of compartmentalization. It is no longer clear that fish carrying the MSC label offer the best environmental choice. Many Canadian fisheries, like lobster, herring, and Atlantic redfish, are MSC-certified. The faltering credibility of the MSC is a major risk for Canadian fish harvesters who rely on the MSC label to communicate their good fishing practices.

Additionally, Canadian consumers who are used to searching for the blue MSC check mark when they shop for seafood can no longer do so thinking that the logo conveys accurate information. Consumers need to know that the waters are muddy, that seafood sustainability is a moving target, and that it is not easy to make the right choice when standing in the aisle at the supermarket.

Governments and businesses need to make that choice easier for consumers. And they could start by dealing with compartmentalization in the PNA fishery — and elsewhere.

The PNA countries could also make demands. They could allow access rights only to vessels that agree to drop the practice of compartmentalization and that are transparent about their fishing practices.

The ConversationMore than anything, the MSC needs to take a good look at itself and remember what it is supposed to represent — the best environmental choice — not consumer confusion.

Megan Bailey, Assistant Professor, Canada Research Chair, Integrated Ocean and Coastal Governance, Dalhousie University

This article was originally published on The Conversation. Read the original article.

The murky issue of whether the public supports assisted dying

Katherine Sleeman, King’s College London

The High Court has rejected a judicial review challenging the current law which prohibits assisted dying in the UK. Noel Conway, a 67-year-old retired lecturer who was diagnosed with Motor Neurone Disease in 2014, was fighting for the right to have medical assistance to bring about his death. Commenting after the judgement on October 5, his solicitor indicated that permission will now be sought to take the case to the appeal courts.

Campaigners are often quick to highlight the strength of public support in favour of assisted dying, arguing that the current law is undemocratic. But there are reasons to question the results of polls on this sensitive and emotional issue.

There have been numerous surveys and opinion polls on public attitudes towards assisted dying in recent years. The British Social Attitudes (BSA) Survey, which has asked this question sequentially since the 1980s, has shown slowly increasing public support. Asked: “Suppose a person has a painful incurable disease. Do you think that doctors should be allowed by law to end the patient’s life, if the patient requests it?” in 1984, 75% of people surveyed agreed. By 1989, 79% of people agreed with the statement, and in 1994 it had gone up to 82%.

Detail of the question matters

But not surprisingly, the acceptability of assisted dying varies according to the precise context. The 2005 BSA survey asked in more depth about attitudes towards assisted dying and end of life care. While 80% of respondents agreed with the original question, support fell to 45% for assisted dying for illnesses that were incurable and painful but not terminal.

A 2010 ComRes-BBC survey also found that the incurable nature of illness was critical. In this survey, while 74% of respondents supported assisted suicide if an illness was terminal, this fell to 45% if it was not.

Wording counts.
from http://www.shutterstock.com

It may not be surprising that support varies considerably according to the nature of the condition described, but it is important. First, because the neat tick boxes on polls belie the messy reality of determining prognosis for an individual patient. Second, because of the potential for drift in who might be eligible once assisted dying is legalised. This has happened in countries such as Belgium which became the first country to authorise euthanasia for children in 2014, and more recently in Canada where within months of the 2016 legalisation of medical assistance in dying, the possibility of extending the law to those with purely psychological suffering was announced.

It’s not just diagnosis or even prognosis that influences opinion. In the US, Gallup surveys carried out since the 1990s have shown that support for assisted dying hinges on the precise terminology used to describe it. In its 2013 poll, 70% of respondents supported “end the patient’s life by some painless means” whereas only 51% supported “assisting the patient to commit suicide”. This gap shrank considerably in 2015 – possibly as a result of the Brittany Maynard case. Maynard, a high-profile advocate of assisted dying who had terminal cancer, moved from California to Oregon to take advantage of the Oregon Death with Dignity law in 2014.

Even so, campaigning organisations for assisted dying tend to avoid the word “suicide”. Language is emotive, but if we want to truly gauge public opinion, we need to understand this issue, not gloss over it.

Information changes minds

Support for assisted dying is crucially known to drop-off simply when key information is provided. Back in the UK, a ComRes/CARE poll in 2014 showed 73% of people surveyed agreed with legalisation of a bill which enables: “Mentally competent adults in the UK who are terminally ill, and who have declared a clear and settled intention to end their own life, to be provided with assistance to commit suicide by self-administering lethal drugs.” But 42% of these same people subsequently changed their mind when some of the empirical arguments against assisted dying were highlighted to them – such as the risk of people feeling pressured to end their lives so as not to be a burden on loved ones.

This is not just a theoretical phenomenon. In 2012, a question over legalising assisted dying was put on the ballot paper in Massachusetts, one of the most liberal US states. Support for legalisation fell in the weeks prior to vote, as arguments against legalisation were aired, and complexities became apparent. In the end, the Massachusetts proposition was defeated by 51% to 49%. Public opinion polls, in the absence of public debate, may gather responses that are reflexive rather than informed.

The ConversationPolls are powerful tools for democratic change. While opinion polls do show the majority of people support legalisation of assisted dying, the same polls also show that the issue is far from clear. It is murky, and depends on the responder’s awareness of the complexities of assisted dying, the context of the question asked, and its precise language. If we can conclude anything from these polls, it is not the proportion of people who do or don’t support legislation, but how easily people can change their views.

Katherine Sleeman, NIHR Clinician Scientist and Honorary Consultant in Palliative Medicine, King’s College London

This article was originally published on The Conversation. Read the original article.

What you look like matters – but should it?

What our faces can tell other people about the state of our health

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Glowing with health.
Shutterstock/Luba V Nel

Alex Jones, Swansea University

Our facial appearance influences how we feel about ourselves – and other people’s faces influence who we choose to approach or avoid and who we’d like to form romantic relationships with. At a glance, a face reveals a wealth of information about how we are feeling, or the kinds of behaviours we might be about to engage in – but what does it say about us when we aren’t expressing emotion? As it turns out, it’s more than you could imagine.

Over the past few years I’ve learned how aspects of our personality are present in our faces, how symptoms of depression cause faces to appear less socially desirable, and how wearing make-up changes perceptions of social traits – but the most important signals that our faces can give are of health.

The face is a biological billboard and we are expert readers, always interested in what it has to say. We are attracted to healthy-looking faces and avoid those who are unhealthy –- think of the sensation you might have had the last time you were on the train or a bus near someone who looked unwell – but it is the question of what makes a face look “healthy” in our eyes that is the most intriguing.

There are many historical examples of people altering their facial appearance to appear healthier. Things like the influence of body mass index (BMI) on face shape, or the smoothness of skin texture play a role in how healthy we are viewed to be, but it is actually facial colouration that seems to be the most important.

The lighter areas show where the skin of healthier looking faces are brighter (left), redder (middle), and yellower (right).

Early research has identified that faces with lighter, redder, and yellower skin were seen as the healthiest – and this was consistent across all ethnicities. There also seemed to be relevant biological processes associated with these colours: for example, lighter skin is associated with the ability to absorb more vitamin D. Greater redness, particularly when from oxygenated blood, may indicate more efficient circulation and blood supply to the skin.

But it is yellowness that seems to be particularly relevant for health, and for good reason: people with yellower skin tend to have healthier diets, rich in fruit and vegetables. The organic pigments in these foods, known as carotenoids, are hugely beneficial for health, and seem to be responsible for producing that desirable healthy glow. Intriguingly, tanning also increases skin yellowness and makes faces appear healthier, but the yellowness conferred by carotenoids (as a result, perhaps, of a healthy diet) is preferred to the yellowness brought about by tanning.

Healthy glow

The secret to a healthy appearance isn’t as simple as eating more fruit and vegetables, however, it’s a bit more complicated than that – and healthy face colouration may be more nuanced than previously thought. Skin conditions such as dark circles under the eyes or rosacea, a condition which causes the skin to flush and redden, cause great concern to sufferers – Google searches of treatments or remedies return millions of hits. Both these conditions are also localised to areas of the face, which suggests colours in certain areas of faces could be relevant for looking healthy. Might these patterns of colour in faces, rather than the colour of the entirety of facial skin, be more relevant for looking healthy?

To answer this questions, we asked observers to rate faces for how healthy they thought they were, and calculated the colour differences between faces seen as very healthy and very unhealthy. We used Caucasian faces for the comparison, but there is some evidence that suggests how the overall skin colours of yellowness, redness, and lightness are seen as healthy in non-Caucasian faces too: it seems that everyone, regardless of race, finds these tones to be healthy.

Our research found that while yellowness across the whole face was a contributor to looking healthy, confirming earlier findings, lighter skin under the eyes and redder skin on the cheeks seemed to play larger roles. That colouration, in those areas, seemed to account for a lot more variation in health ratings than skin yellowness.

We subtly changed photographed faces to have lighter under-eye skin and redder cheeks – and also the reverse effect: darker under-eye skin and greener cheeks. Asking people to pick which they found the healthiest revealed a strong preference for the former pattern.

One a picture of health, the other, not so much – which do you think looks healthier?

Interestingly, when we reversed the location of the colouration – lighter cheeks and redder under-eyes or darker cheeks and greener under-eyes – there was no clear preference. Given the wealth of research showing lighter skin and redder skin across the whole face is perceived as healthier this result was surprising. What this work suggests is that lightness and redness in our facial skin is seen as healthy, but only when it is under the eyes or in the cheeks, respectively.

Red cheeks are healthy, red eyes not – do you think one looks healthier than the other?

In a final study, I looked at which facial area and colour was seen as the healthiest. While having redder cheeks and light skin under the eyes came out as looking equally healthy, dark skin under the eyes made people think the faces looked quite unhealthy, even more so than sickly-looking greener cheeks.

The ConversationIt is no surprise that cosmetic products such as concealer and blusher are so popular, since they increase a healthy looking colouration in the areas that matter the most to health perception – but nothing could ever beat a good night’s sleep and regular exercise.

Alex Jones, Lecturer, Swansea University

This article was originally published on The Conversation. Read the original article.