HAP Final Notes

List of Lectures

 Medical help-seeking behaviour (Week 1)

 Behaviour, personality, behaviour genetics and health risk factors (Week 1)
 Heart of the matter: Living with uncertainty associated with illness (Week 2)
 It wont happen to me Predicting and modifying behaviour leading to CAD (Week 3)
 Rheumatic fever and rheumatic heart disease in Indigenous communities (Week 4)
 Microbiome reconstitution and public health (Week 5)
 Key concepts and definitions in population, public, global, and planetary health (Week 6 Self-study)
 Genethics (Week 7)
 Research ethics (Week 9)
 Grief, loss, and mourning: Behavioural processes of bereavement (Week 10)
 Role of remotely located medical services in the management of renal dialysis (Week 11)
 Exploring the casual pathways between socioeconomic status and health (Week 11)
 Ethics and organ donation (Week 11)
 I am my choices? Applying self-regulation theory (Week 12)
 Demystifying obesity (Week 12)
 Stigma, fat shaming and justice (Week 12)
Medical Help-seeking Behaviour

 Factors that lead to individuals seeking medical care – presence of pain/discomfort, changes in appearance or functioning, injury; others
 Mistrust of healthcare – vaccination (fear of autism) – importance of consultation skills
 Both sexes require common forms of medical care (e.g. pain relief)
o Men – silent sufferers – less likely to visit physician relative to females with increasing age (difference emerges in adolescence)
 Take more risks and have more accidents, lower immunocompetence (testosterone)
 Male machismo
o Women – greater need of care and care-seeking
 More autoimmune problems (oestrogen, prolactin), more reproductive system-related care (pregnancy birth)
o Sex differences in pain perception – males respond less to pain than females (testosterone – higher pain tolerance, oestradiol, and
progesterone – lower pain tolerance)

Behaviour Genetics

 Genes underlie some difference in risk-taking

 Genes can make you prone to disease regardless of lifestyle
 Gene-environment interactions
 Genes underlie our general behaviour propensities or define the option set of possible behaviours
 Environment (and culture) determine the specifics
 Gene x environment interaction – being raised with uncertainty about the future → accelerates reproductive development
 Epigenetics – studying how the genome can produce different phenotypes (expressions of genotype) through exposure to environment
o Genes can be on, off or between – DNA methylation – prevents expression of genes in gene transcription process
 Big 5 model – openness, conscientiousness, extraversion, agreeableness, neuroticism (OCEAN)
Uncertainty in Illness Theory

 Antecedents of uncertainty → appraisal of uncertainty → coping of uncertainty

 Antecedents of uncertainty
o Stimuli
 Symptom pattern – the degree to which symptoms are present with sufficient consistency to be perceived as having a pattern or
configuration
 Event familiarity – the degree to which the situation is habitual, repetitive, or contains recognised cues
 Event congruence – the consistency between the expected and the experienced illness-related events
o Cognitive capacity – information processing ability of the individual
o Structure providers – resources available to assist the person in the interpretation of the stimuli – e.g. education, social support, credible
authority
 Appraisal of uncertainty
o Process of placing a value on the uncertain event or situation
o Influence – using related examples – personality dispositions, general experience, knowledge, contextual cues
o Illusion – positive outlook
o Uncertainty → danger or opportunity
 Coping with uncertainty
o Danger – possibility of a harmful outcome – reducing uncertainty, managing the emotion generated
o Opportunity – possibility of a positive outcome – maintaining uncertainty
o Adaptation – biopsychosocial behaviour occurring within the persons individually defined range of usual behaviour

Reconceptualised Uncertainty in Illness Theory

 Self-organisation – reformulation of a new sense of order (integration of continuous uncertainty into one’s self structure in which uncertainty is
accepted as the natural rhythm of life)
 Probabilistic thinking – belief in a conditional world in which the expectation of certainty and predictability is abandoned
 Formation of new life perspective – prior life experience, physiological status, social resources, healthcare providers
Uncertainty Management Strategies

 Patients/families, support groups, clinicians

9 Strategies – Deductive Management in Communication Skills

 Defines context of diagnosis and explains the signs and symptoms as part of the expected spectrum of the disease
 Eliminates alternative diagnoses by dealing with patient fears, giving reasons in the context of the patient’s belief system
 Describes the prognosis in terms of the likely course of the disease and expectations of treatment
 Negotiates key problems or issues that are important to both patient and physician
 Negotiates the plan and ensures patient understands, and is willing and able to comply, given his/her particular context
 Keeps diagnostic options open by making provisional diagnoses while keeping alternatives in mind
 Is circumspect and takes action to minimise the possibility of missing other critical diagnoses
 Plays for time by allowing signs and symptoms to develop to help clarify the diagnosis
 Plans for contingencies by providing appropriate if/then statements concerning situations requiring further action
It won’t happen to me: Predicting and Modifying Behaviour Leading to Cardiovascular Disease

 Specificity – personality is a causal factor in disease

 Generality – personality factors mediate/moderate effects of casual factor on illness – e.g. conscientiousness related to better health via the careful
observation of health advice
 Type A behaviour pattern – strenuous worker, compulsive tendencies, depressive/neurotic, impatience, anxious, little time for relaxation, poor
sleep pattern, aggressiveness, low introspection
 Shock tactics
 Personality and individual differences – personalised behaviour change at individual level – communication – motivation interviewing, awareness of
and referral to support groups, stress management

Health Promotion

 Medical/preventive
o Reducing premature deaths (mortality) and avoidable diseases (morbidity)
o Targeted at whole populations or high risk groups
o Increase the use of medical interventions to promote health
o Primary prevention – prevention of the onset of disease through risk education, smoking cessation, cholesterol reduction
o Secondary prevention – preventing the progression of disease through screening and other methods of early diagnosis
o Tertiary prevention – reducing further disability or preventing the recurrence of illness, patient education, palliative care
 Behaviour change
o Encourage individuals to adopt healthy behaviours
o Multimedia campaigns
 Educational
o Health education
o Provide knowledge and information and to develop the necessary skills so that people can make informed decisions about their behaviour
 Empowerment
o Helping people or communities to identify their own health concerns, gain skills and make changes to their lives accordingly
 Social change
o Targets groups and populations
 o Socio-economic circumstances determine health status
o Bring about physical, social, economic, legislative, and environmental changes

Rheumatic Fever and Rheumatic Heart Disease in Indigenous Communities

 Rheumatic heart disease – marker of socioeconomic deprivation

Rheumatic Fever and Rheumatic Heart Disease

 Acute rheumatic fever – multisystem immune mediated non-suppurative complication following infection with Gaβs
 Long term – fibrosis and scarring of cardiac valves → rheumatic heart disease
 M proteins on surface of Group A strep interact with collagen → immune mediated post infectious complications of rheumatic fever
o Heart – heart valves → mitral and aortic valve disease, carditis
o Brain → Sydenham’s chorea (inflammation in basal ganglia)
o Skin → Erythema Marginatum, sub-cutaneous nodules
o Joints → aseptic mono-arthritis, polyarthritis

Jones Criteria for Acute Rheumatic Fever

 Major criteria
o Carditis, polyarthritis or monoarticular aseptic arthritis, Sydenham’s chorea, subcutaneous nodules, erythema marginatum
 Minor criteria
o Fever, acute phase reactants (ESR, CRP), arthralgia, prolonged PR interval
 2 major, or 1 major and 2 minor and evidence of recent strep infection
Public, Global and Planetary Health Concepts and Definitions

Ottawa Charter for Health Promotion

 Caring, holism and ecology

 Socioecologic approach – to take care of each other, our communities and our natural environment

The Anthropocene

 Past – natural changes in temperature, climate, ecosystems, species

 Present – environment heavily influenced by human activity
o Refrigerators, aerosols → CFCs → ozone layer
o Burning fossil fuels → CO2 → global warming
o Wild forests and grasslands → grow crops, graze food animals

Public Health

 The art and science of preventing disease, prolonging life, and promoting health through the organised efforts of society
 Physical, mental, social well-being – not the absence of disease

Environmental Health

 Monitoring or mitigating factors in the environment that affect human health and disease

Population Health

 The health outcomes of a group of individuals, including the distribution of such outcomes within the group
 Improve the health of an entire human population – health outcomes, patterns of health determinants, policies and interventions

Rural and Remote Health

 Interdisciplinary – geography, midwifery, nursing, sociology, economics, telehealth, telemedicine

Global Health

 Improving health and achieving equity in health for all people worldwide
 Transnational health issues, determinants, solutions
 Interdisciplinary collaboration – population-based prevention with individual level clinical care

One Health

 Resolve emergences of zoonotic disease – increased likelihood of human and animal contact
 Animals equally prone to the brunt of disease

Planetary Health

 Link between human health and health of planet

Life Expectancy

 Overall mortality level of a population

GNI

 Gross national income – total value of all the goods and services produced by people and businesses within a country
 GNI per capita
 High income (developed) countries, newly emerging economies (emerging), low-income countries (developing)

Three Key Transitions in Human Development

 Demographic transition
o High birth number, few surviving to old age → low birth number, most surviving to old age
 Epidemiological transition
o Deaths caused by infection, malnutrition and complications during childbirth (addressed by medical treatment) → deaths cause by non-
communicable diseases (cancer and heart disease) (living long lives in unhealthy environments)
 Ecological transition
o Living close to nature in sustainable natural systems → synthetic urban, industrialised, resource-depleting environments
Human Development Index

 People and their capabilities

 A long and healthy life, being knowledgeable, decent standard of living

Socio-demographic Index

 Per capita income, education attainment, total fertility rate

Mortality, Morbidity, and Co-morbidity

 Mortality – death
 Morbidity – illness or disease
 Co-morbidity – more than one disease or medical condition in a patient

Global Burden of Disease

 Gap between the ideal of living to old age in health and the current situation where healthy life is shortened by illness, injury, disability, and
premature death
 Disability adjusted life years (DALYs)
o Number of years of life lost due to premature mortality and the number of less than healthy years of life lived due to premature morbidity

Categories of Health Conditions

 Communicable, maternal, perinatal, and nutritional diseases – decreasing

 Non-communicable diseases – increasing
 Injuries (violence, conflict)

Years of Life Lost

 Frequency of deaths and the age at which it occurs

 Potential years the person would have lived if they did not die prematurely
Years Lived with Disability

 Number of years of what could have been a healthy life that were instead spent in state of less than full health
 Non-fatal burden
 Severity of a disability
 YLD = I x DW x L
o I – number of incident cases
o DW – disability weight
o L – average duration of disability (years)
 MSK disorders, mental health issues, substance use disorders (increasing), cardiovascular diseases, injuries

Epidemiology

 Study of disease and health-related events within populations → gain insight, relate possible causes, collate data for evaluation

Disease Prevalence

 Number of existing cases of a disease at one point in time

 Prevalence = number of individuals with disease/total number of individuals in the population x 100

Disease Incidence

 Number of new cases of a disease in a population in a given time period

Endemic

 Constant presence of a disease or infectious agent in a population within a specific geographic area
 Outbreak – sudden increase in cases in an area

Epidemic

 An elevated incidence of a particular disease in a specific geographical location

Pandemic

 An epidemic that has spread globally

Syndemic

 The clustering of two or more disease within a population, the biological, social, and psychological interaction of those disease, the large-scale
social forces that precipitate disease clustering in the first place
 A set of linked health problems involving two or more afflictions, interacting synergistically, and contributing to excess burden of disease in
population

2015 United Nations Millennium Development Goals

 Eradicate extreme poverty and hunger

 Achieve universal primary education
 Promote gender equality and empower women
 Reduce child mortality
 Improve maternal health
 Combat HIV/AIDS, malaria, and other diseases
 Ensure environmental sustainability
 Develop a global partnership for development
2030 UN Sustainable Development Goals

 No poverty
 Zero hunger
 Good health and well being
 Quality education
 Gender equality
 Clean water and sanitation
 Affordable and clean energy
 Decent work and economic growth
 Industry, innovation, and infrastructure
 Reduced inequalities
 Sustainable cities and communities
 Responsible consumption and production
 Climate action
 Life below water
 Life on land
 Peace, justice, and strong institutions
 Partnerships for the goals

Leave No-One Behind

 Eradicate poverty in all its forms, end discrimination and exclusion, reduce the inequalities and vulnerabilities that leave people behind and
undermine the potential of individuals and of humanity as a whole

SDG Spill-over Index

 Environmental and social impacts embodied into trade, economy and finance, and security
Genethics

Conditions of an Informed Consent

 Patient needs to understand the purpose of the intervention

 Need to understand the reasonably foreseeable risks and benefits of the intervention
 Physicians required to do what is reasonable to ensure that patient understand this, and are required to respect the decisions of the patient even
when they are at odds with the physicians judgement

Best Interests Standard

 Unresolvable moral conflict, patient incapable of making a decision for themselves, no empowered substitute decision maker – physicians
obligation is to act in the best interests of the patient

Involuntary Disclosure

 Whether and under what conditions we should ignore the consent of an individual to share genetic information
 Supporting disclosure
o Medical necessity – prevent a serious threat to life, health, or safety
o Adult children and other genetic relatives may wish to undergo their own testing, but may not be able to unless information is disclosed →
planning for disease onset, anticipate predictable depressions or other cognitive disorders
 Against disclosure
o Damage relationships within the family
o Treats judgement of the patient with disrespect → damages therapeutic relationship
o Cause undue distress among children and relatives → violate non-maleficence
o Expose patient to risks of domestic violence, social stigmatisations of various kinds and economic loss
NHMRC Recommendation

 Do not involuntarily disclose

 Provide competent genetic counselling prior to any testing – continue counselling through the procedure, the reception of results, and where
necessary, into the future
 Ensure that the individual has all relevant information necessary to make an informed judgement about disclosure – this must include all relevant
implications for children and family
 Invite the patient to consider the wishes of others – without being coercive
 If you make a judgement that there is a reasonable probability of harm to the life, health, and safety of others, then consult colleagues to get their
assessment
 Do not act alone unless there is absolutely no alternative
 The default is always to respect the choice of the empowered individual unless there are medically compelling reasons to override

Conditions for Involuntary Disclosure of Genetic Information

 Efforts to get a voluntary disclosure have failed

 There is a high probability that harm will occur if the disclosure is not made
 The harm must be serious
 Efforts must be made to limit the information shared to those genetic results necessary for diagnosis and treatment

Genetics and Children

 Physicians may have to balance the right of the parent to know about their child’s health with the best interests of the child
 A test may determine that a child is at risk for some future harmful clinical event, but there may be no available practice intervention with which to
mitigate it
 Provide access to genetic counselling → assess the potential benefits and harms of the test → determine the decision making capacity of the child
→ advocacy on behalf of the best interests of the child → if the medical benefits will not accrue until adulthood, then defer the test → discourage
testing when the results of the test are more likely to produce a harm for the child
Beneficence, Non-maleficence and Informed Consent and Genetic Testing

 Aimed at understanding of the possible test results

 Net benefit of the test may be highly dependent on how much the patient values the information and what they want to do with it
 Needs careful consideration of the social and psychological risks of genetic testing
 Evolving social contexts such as the workplace, the insurance industry and the family determine whether and how the risks materialise
 Genetic information affects other family members as well as any of those who either share or are perceived to share the information

Clinical Benefits

 There are cases where there are clear clinical benefits to testing, such as the provision of abortion as an option in prenatal testing, or the
identification of a family history of colon cancer as a condition for avoiding the invasive monitoring and testing that normally occurs
 But in many cases the benefits are simply the information itself along with the choices that it provides
 Under most clinical circumstances, there needs to be some measurable difference in clinical outcomes or in the adoption of population health
measures before a given test, screen or intervention is adopted
 But most genetic tests do not offer this improved outcome – they just provide accurate information
 The tests do not protect patients from any of the risks, and the patients become responsible for evaluating whether the social and psychological
risks justify the benefits

Risks

 One family member may have to devote their life to caring for another
o For some this is rewarding, but others it is stifling
o Some may lack the financial resources to provide the care for another
 The same information can be a benefit for one person and a harm for another, unlike an undesired chemotherapy side effect
o Informed consent demands a great deal of close involvement between the genetic counsellor and the patient and their family
o Unlike other healthcare interventions, the genetic counsellor is not informed in the way in which the normal doctor is
 Genetic tests can result in employee discrimination in order to reduce financial or insurance costs as well as to avoid legal risks
 Depending on the medico-legal environment, individuals may be required to provide the results of any genetic tests to insurance companies as part
of the contract
 Such information may increase the cost of insurance or result in complete denial of access
Direct to Consumer Genetic Testing

 Increasingly easier to pay for genetic testing

 Problems
o Privacy and confidentiality cannot be guaranteed with DTC genetic testing
o Protections guaranteed to Australians under Australian law may not be enforceable in the jurisdiction from which the test is sold
o The DTC market can increase the number of worried well people and indirectly increase the strain on the Australian healthcare system
Research Ethics

Human Research Ethics Committees

 Responsible for ensuring that any human subject research at universities in Australia conforms to national ethical standards
 Responsible for assessing proposals on grounds of justice, beneficence/non-maleficence, and respect
 Assess the project to ensure that any risks involved in the project are outweighed by the potential benefits from it
 Ensure that researches consider all of the morally relevant considerations as they plan their projects
 Play a support role to ensure that researches meet high ethical standards – ensures that abuses (deliberate or inadvertent) are not ignored

Justice

 Fair criteria for inclusion or exclusion of research subjects

o Pregnant women have been excluded from studies even though there is no real risk to either them or the foetus, and even though both
might have benefit from the study
o Marginalised populations may be unfairly included (e.g. where coercion is not sufficiently accounted for) or excluded (because of over-
weighting of fears of possible coercion)
 Recruitment process has to be fair and free of conflicts of interest or of role conflicts
 The burden of participating in research must not be unfairly imposed on specific groups
 Benefits of the research have to be fairly distributed
 There must be no exploitation of research subjects
 There must be fair access to the benefits of research

Beneficence/Non-maleficence

 The benefits of the research must be sufficient to justify any risks of harm or discomfort to patients
 The study must be designed to minimise risk to participants
 The risk and benefits must be clearly communicated to participants
 The researches must consider the welfare of the participants as they do their research
Respect

 Researches must pay due regard to the welfare, beliefs, perceptions, customs, and cultural heritage (individually and collectively) of research
participants
 Researches must respect privacy, confidentiality, and the cultural sensitivities of participants and, where relevant, their communities
 The consent and capacity of research participants must be respected, including their right to withdraw from the study at any time without any
harms imposed upon them
 Where capacity is diminished or absent, the researcher must find ways to empower them and provide fro their protection

Risk, Low Risk and Negligible Risk Research

 Physical harms, psychological harms, damage to personal worth, social harms, economic harms, legal harms
 Negligible risk – no foreseeable harms or discomfort to it
 Low risk – only foreseeable risks are of discomfort
 Minimal review

Cautions about HRECs

 More or less strong in their capacity to evaluate different forms of research – those that are good at randomised clinical trials may be ill informed
about participatory action or ethnographic research
 Vulnerable to financial conflicts of interest – depends on where their sources of funding originate – twisted into supporting illicit research
 Problems of waste arising from the time burdens imposed unnecessarily on researchers
Grief, Loss, and Mourning: Behavioural Processes of Bereavement

 Grief – a normal reaction or response to loss

 Loss – felt or experienced when something or someone to which we are emotionally attached to becomes permanently unavailable
 Mourning – process by which people adapt to loss
 Bereavement – encompasses all of the above terms
5 Stages of Grief

 Denial → anger → bargaining → depression → acceptance

 Denial – not me
o Buffer to unexpected or shocking news
o Allows individuals to collect self and use less radical defence mechanisms
o Temporary – individual recuperates gradually
o Can move in and out of denial
 Anger – why me
o When denial can no longer be maintained – replaced by anger, rage, envy and resentment
o Anger is displaced and projected
o Health professionals may be target
o Tries to give person more control
o Can provoke rejection and anger in others
o Careers may exhibit avoidance behaviour
 Bargaining – yes me, but
o Attempt to postpone the inevitable
o Includes some prize/reward (e.g. more time/less pain or discomfort) for good behaviour
o Person sets a self-imposed deadline and promises he/she will not ask for more if the postponement is granted
o Most made with divine being and kept secret
 Depression – yes me
o Experiencing a great sense of loss associated with body image, roles, hospitalisation, financial, dreams or plans for the future
o Reactive vs preparatory
  Acceptance – its ok
o Individual neither depressed nor angry about impending death/loss
o Able to express previous feelings
o Has mourned impending loss
o Ponders end with quiet expectation
o Tired, weak, sleeps often to gain relief from pain/discomfort
o As if the pain has dissipated and individual taking their final rest before journey ahead
o Family may need more support than dying person
o Circle of interest diminishes – disengagement
o Communication becomes nonverbal rather than verbal – silence

Anticipatory Grieving

 Takes place before expected loss has actually occurred

Morbid Grief (Complicated Grief)

 Long continuation of grieving period

 Accompanied by maladaptive behaviours – possible suicidal ideation

Responses to Loss

 Physical – fatigue, disturbed sleep, changes in appetite, palpitations, increased vulnerability to illness
 Behavioural – social withdrawal, inability to perform normal activities, crying, restlessness
 Emotional – depression, anxiety, hostility, guilt, hypervigilance
 Cognitive – memory loss, short attention span, inability to concentrate, confusion, preoccupation

What is Normal?

 Work theories – bereavement rationalised as series of activities or time period that people work through
 Stress theories – seen as dynamic process in reorienting towards loss (moving from preoccupation to appropriate attention)
 Stage theories – assume linear process
Is Grief an Illness?

 Confused with depression

 Complicated, intense prolonged grief – persistent yearning and preoccupation with the deceased
 Depression – pervasive, free floating sadness and loss of interest and pleasure
 Persistent complex bereavement disorder
o 12 months (adults), 6 months (children)
o Intense sadness or distress that does not improve as time passes, continual yearning for the deceased person, difficulty trusting other
people, digestive issues, constantly ruminating on the death, emptiness, inability to perform daily activities, loss of interest in hobbies,
fatigue, hallucinations of the deceased, loneliness, suicidal ideation
 Prolonged grief disorder
o Persisted for an atypically long period of time (> 6 months)
o Longing for the deceased or persistent preoccupation with the deceased
o Intense emotional pain – sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, an
inability to experience positive mood, emotional numbness, difficulty in engaging with social or other activities
o Causes significant impairment
Renal Disease in Remote Indigenous NT Populations

Impact of Dialysis
  Dislocation from family, disruption of family life, dislocation from community and work, loss of job, financial impact on family and community,
travel implications, loss of community leadership, impact on hope, rite of passage

Socioeconomic Class and Health: Untangling the Casual Pathways

Socio-economic Classification

 Higher professional and managerial workers

 Lower managerial and professional workers
 Intermediate occupations
 Small employers and non-professional self employed
 Lower supervisory and technical
 Semi routine occupations
 Routine occupations
 Long term unemployed

SES Incorporating Estimated Living Standards

 Equivalenced scales correct the context

 McClement’s scale – size of household, ages of children in household
 OECD – household size
 Other factors – geographic area, transport costs

Definitions of Poverty

 Absolute poverty measures – fixed definition (e.g. daily wage, ability to purchase a fixed bundle of goods, child mortality level)
 Relative poverty measures – applied within nations or groups, based on income distribution patters – e.g. being below a particular percentile for
income
 Poverty

Some Stuff

 Social class → risky lifestyle → early mortality

 Cognitive development → poor lifestyle → mortality
 Being raised in poverty is associated with differences in brain development in childhood
Ethics and Organ Donation

The Problem

 The need for organs from deceased donors exceeds their availability
 At any time, there are around 1500 Australians who have been assessed as eligible and are waiting for a transplant, a number of whom die before
receiving a transplant as their disease progresses beyond the point at which transplantation is possible

Types of Organ Donation

 Deceased organ donation, living donor transplantation

Core Ethics Principles

 Decision-making regarding allocation must involve explicit evaluation of the risk and benefits to the potential recipient as well as the need to ensure
the appropriate use of scarce health resources
o Utilitarian assessment of the benefits and harms, justice evaluation as to how best to allocate resources
 Organ transplantation is highly successful and, in some environments, the only available treatment for a range of health problems
 Demand always exceeds the available supply of organs
 The result is that some people sicken and die who would otherwise benefit from an organ transplantation
 Some eligible people become ineligible for a transplant if it takes too long for an appropriate organ to become available
 There must be no unlawful or unreasonable discrimination against potential recipients on the basis of
o Race, religious belief, gender, marital status, sexual orientation, social or other status, disability, or age
o The need for a transplant arising from the medical consequences of past lifestyle
o Capacity to pay for treatment
o Location or residence (e.g. remote, rural, regional, or metropolitan)
o Previous refusal of an offer of an organ for transplantation
o Refusal to participate in research
Ethically Relevant Factors in Providing an Organ

 Relative urgency of need, medical factors which affect likelihood of success (e.g. comorbidities, tissue matching), relative severity of illness and
disability, relative length of time on the waiting list, likelihood that the recipient will be able to comply with the necessary ongoing treatment after
transplantation
Law Stuff

 Donation of organs is an act of altruism, solidarity and community reciprocity that provides significant benefits to those in medical need
o The donation must be consensual and an act of altruism, solidarity, and community reciprocity
o It must also provide significant benefits to those in medical need
o Solidarity and reciprocity are core moral norms driving the allocations
 Processes and policies for determining a person’s eligibility for transplantation and for allocating donated organs must be just, equitable and
respectful of the inherent dignity and of the equal and inalienable rights of all persons
 Decision making about transplantation must recognise and respect the autonomy of the recipient
o Informed consent must be sought, whether from the individual or, if incapable, from their surrogate decision maker
o All reasonably foreseeable risks and benefits must be communicated to the prospective recipient
o Their participation must not be coerced
 The allocation and transplantation of organs must be undertaken in a manner that protects recipients from harm
o Decisions should take into account – the condition of the organ, the general health of the patient, the medical need of the recipient, the
likelihood of a successful transplantation outcome balanced against the risk of not receiving a transplant
 The process of allocating and transplanting organs should acknowledge both the needs and wellbeing of the recipient and the necessity to achieve
the best outcome for the community as a whole
o Morally relevant considerations include
 The needs of the individual and the potential benefit to the individual
 The need to ensure the appropriate use of scarce health resources
 The risk of the transplantation process balanced against the benefits to the recipient
 Pretransplant quality of life, expected extended length and quality of life and duration of benefit
 Medically relevant criteria related to the recipient and the organ to be transplanted
 The organisation and implementation of transplantation activities, as well as their clinical results, must be transparent and open to scrutiny, while
ensuring that the personal anonymity and privacy of donors and recipients are always protected
o The transplant physicians and surgeons should not be involved about decisions about end of life care or determination of death of
individuals who may become organ donors
o Health care professionals should not be involved in decision making involving family members, friends or colleagues as prospective donors
or recipients
o The decisions about eligibility should be made by the multidisciplinary transplant team rather than the physician alone
o In some case, a clinical ethics committee should be involved
The Six Month Sobriety Rule

 Recipients must be able to demonstrate that they have been sober for six months prior to receiving the donation
 Alcohol recidivism – afraid that the recipient will waste the liver
 Problems
o Socially unjust in virtue of discriminating against a whole class of persons on the basis of their group membership
o Not enough evidence
I Am My Choices: Self-Regulation Theory

Self-Regulation

 The capacity of organisms to override and alter their responses

 The process by which people attempt to constrain unwanted urges in order to gain control of the incipient response
 Regulation → change (change to bring behaviour or other states into line with some standard such as an ideal or goal)
 Changing one’s behaviour so as to follow rules, match ideals, or pursue goals is thus a form of self-regulation
 Control of emotions, attention, and impulses, maintain appropriate response to the demands of the environment, inhibits undesirable behaviour,
controls short term gratification, associated with higher academic achievements, better mental health and social integration

Self-regulation Theory

 Integrates biopsychosocial factors around a patients common sense representations of health and illness arguing that an individual’s beliefs are
major determinants of health behaviour
 Postulates that illness representations determine a persons appraisal of an illness situation and health behaviour

Common Sense Model of Illness Representations

 Conceptual framework to examine perceptual, behavioural and cognitive processes involved in individuals self-management of ongoing and future
health threats
 Asserts that individuals are problem solvers dealing with 2 phenomena
o Perceived reality and emotional reactions to health threat
o Engage in parallel processing
 3 central tenants
o Individuals actively seeking information and acting to assess their somatic sensations (symptoms)
o Illness representation – central cognitive construct guiding coping and appraisal
Illness Representation

 Beliefs and expectations about an illness or somatic symptom

 6 elements
o Identity – name or label of a threat (e.g. sore throat, arthritis)
o Timeline – threats believed time trajectory (e.g. acute, chronic, cyclical)
o Consequences – believed consequence of a threat (minor or major)
o Cause – threat’s casual mechanism (e.g. hereditary, external, internal)
o Control/cure – whether something can be don’t to control the threat
o Illness coherence – whether a person thinks about the threat in a coherent way

Assessment of Illness Representations

 History taking – stuff like how has this affected you etc, what the person thinks about the illness, patient perceptions of stuff
Obesity and Health Outcomes

Stupid lecture move on

Stigma, Fat Shaming and Justice

 Fat stigma – the moral discrediting or social death that people experience because of the negative social meanings attached to being overweight or
obese
 Weight stigma – the negative attitudes and beliefs attributed to an individual based on their body weight

The Problem of Individualism

 Individualisation – the belief that causes and effects of specific health conditions are to be found in the behavioural choices and character of the
individuals who have those conditions
 Health is a moral judgement, and ill health refers to judgements about the immorality of those afflicted by the health conditions
 Internalisation of messaging
How Stigmas May Cause Weight Gain

 Create disincentives to exercise and other weight loss measures – obese people are less likely to do public exercise because of external and internal
threats/shaming
 Obese and overweight individuals may avoid exercise because of the real self-judgements and the self-judgements of others
 Directly impacts what, how and when people eat – comfort eating in response to obesity stigma, more bingeing, more extreme forms of calorie
restriction → contribute to increasing weight gain likelihood, weaken the cues that suggest satiety
 People experience obesity stigma in health care tend to avoid health care, or to doctor shop and thereby limit their access to health care
 Stigma also predicts lower self-efficacy and self-esteem, which impacts confidence that weight loss efforts will work
 Indirect effects of psychosocial stress
o Being stigmatised is very stressful
 Predictor for weight gain in response to the stressors, especially among people who are already obese
 Developing metabolic systems (those of children) are most vulnerable and the impacts are lifelong
o Indirect effects of changes in social relationships – peers directly influence diet, exercise, and behaviour
o Obesity stigma can contribute to ostracism and exclusion – driven by both internal and external loathing
 Negative socioeconomic effects of weight stigma contribute to weight gain – weight bias
o Obese people receive fewer promotions, jobs, training, education, and career opportunities
o Obese people, especially overweight women, are paid less, receive a wage penalty for being overweight
o Obesity stigma also undermine the attempts of people, and especially women to transfer from welfare to working situation

Health Impacts of Weight Bias on Patients

 Isolation, rejection, high levels of shame, guilt and self-blame, depression, anxiety, low self-esteem, body image concerns, binge eating, avoidance
of physical activity, self-harm, suicide
Obesity Bias Among Healthcare Workers

 The constant bombardment of messages about individual responsibility and the capacity of the individual to change is a very harmful element of fat
shaming
 It comes from different parts of the public sphere – media, marketing/advertising, messaging from family members, friends, schools
 Health care professionals learn these attitudes just as much as do others
 Obesity is – a matter of choice, is controllable, that individuals are choosing to be fat, choosing to harm their own health (and thereby are foolish,
stupid, lazy etc)

Consequences for Patient Treatment

 Diminished patience, irritation with patients, diminished respect for patients, beliefs that patients are wasting their time (due to the belief that
weight is not a medical problem, and that it is purely a matter of choice for patients), failure to adequately intervene medically, ambivalent about
their management of patients, unlikely to refer patients to weight management programs, failure to discuss weight management options with
patients, belief that weight management counselling is inconvenient, failure to take patients seriously
 Health care students – derogatory and humiliating jokes and language
Access Barriers Arising from Weight Bias

 Doctors commonly net effectively trained in best practices for obesity treatment
 Doctors commonly identify a lack of time for weight loss counselling
 Doctors commonly are not reimbursed for weight loss counselling
 When weight bias is present, doctors spend less time with patients, they talk less with patients, they provide fewer interventions for patients, they
carry out fewer preventative health screenings of obese patients
 They fail to follow established best practice guidelines about managing obesity
 Refusal to public fund obesity related health care treatment such as bariatric surgeries on the grounds that the weight challenges are a matter of
personal choice and character
 Health insurance programs can be reluctant to reimburse patients and health care providers for obesity-related consultations, due to the belief that
being overweight is a choice