Mark Corson

By A. Mezir. Loma Linda University.

A key piece None noted apart from caution regarding rate and of apparatus is the Reformer which comprises a single amplitude of rhythmic movements imposed on tissues bed frame equipped with a sliding carriage that uses under repair cefaclor 250 mg low cost. Cables order cefaclor 250 mg on-line, bars quality cefaclor 500mg, straps and pulleys are features of a variety of Naturopathic perspectives Pilates-based exercises, performed in multiple posi- There is something inherently naturopathic about tions. Strength, endurance and flexibility of the major bodily rhythms being employed to gently coax postural muscles involved in trunk (core) stability, enhanced circulatory and drainage efficiency as well particularly the abdominal group, receive focused as neurological coordination and integration in dis- attention (Mullhearn & George 1999). Comeaux Z 2002 Robert Fulford and the elderly (Hall et al 1999, Hutchinson et al 1998, Segal philosopher physician. Juhan D 1989 An introduction to Trager Pilates has also been described as a mind–body psychophysical integration and mentastics fitness program (Pilates 1934, 1945). The movements happen within the safe proceeds the practitioner adjusts the parameters of confines of conditioned reflexes, creating a playful movement in response to changes in resistance, sense of letting go and trust in the client. The rhythmical movement in Trager® creates a Comeaux (2004) suggests: lulling relaxation, like floating on the sea, or swaying The stretch, cyclic afferent input, and articulatory in a hammock. The practitioner can vary different movements associated with natural gait is a useful parameters: frequency, amplitude, direction, hand way of mobilizing restricted segments of the central contact, pattern, pause, position, stretch, or axis. The Facilitated Oscillatory Release approach to compression, while initiating movement from his/her the spine and sacrum attempts to replicate the gait feet, as the hands catch, nudge and anchor the cycle. Like a ballroom dancer, the practitioner can take advantage of gravity, momentum, tensegrity, and • Beginning with the patient in a prone position, tonus, while feeling for signs of impedance and flow. When resistance is felt, even a slight • This hand is then set into motion rhythmically 180 degrees out of phase with the motion of the pelvis, creating torsion of the torso. Reproduced with permission from by one of three strategies of application of rhythmic Blackburn J. Journal of Bodywork and Movement Therapies force: 2004;8(3):178–188 Chapter 7 • Modalities, Methods and Techniques 253 Box 7. In this application the intent would be to induce a relaxation pattern of baseline neuromuscular coordination and to entrain a more harmonic pattern. Comeaux (2004) makes clear: If a practitioner is applying these strategies to the spine, it is wise to begin with the patient in as gravity neutral a posture as possible, with access to the spine. Journal stimulation is reproduced that is equivalent to that of Bodywork and Movement Therapies 2004;9(2):88–98 during active walking, with its alternating pelvic rotation and counter torsion through the trunk. One strategy is to induce a stretch or articulation the strategies are assimilated, it is possible to mobilization with a rapid exaggeration of the transfer most of these strategies to the seated rotation of the segment in phase with the position. A second more forceful strategy is to add the trunk, with localization as is necessary. To diagnose exaggerated rotation out of phase with the in the pelvis and more particularly the sacrum, a developed rhythm. This applies a destructive reciprocal role of the two hands is used by rotating interference pattern to the established wave in the trunk to generate momentum, and letting the the tissue by introducing more energy. A third intervention strategy is to gently persist resonant tissue compliance, and to then making with the established wave pattern to soften tissue corrective suggestion. The tissues are then held in this of time (see below) offers restrictions a chance to position for variable periods (90 seconds is a ‘unlatch’, release, normalize. Functional approaches Safety therefore rely on a skilled palpation sense The nature of indirect approaches is essentially safe, (Johnstone 1997, Schiowitz 1990). Physical therapy has evolved methods such as are safe as well as being effective (Cislo et al 1991, ‘mobilization with movement’ and ‘unloading’ Ramirez 1989, Wong et al 2004a,b). Hospital studies involving treatment of recently sur- McKenzie exercise methods incorporate gically traumatized tissue validate the essential safety concepts of movement towards ‘ease’ that of positional release methods (Dickey 1989). In chiropractic, aspects of the use of sacro- numerous alternatives, and the overall approach of occipital technique’s ‘blocking’ methods indirect methodology offers an alternative to direct incorporate placing tissues into an methods of treatment. In craniosacral techniques much of the Proprioception treatment involves indirect pressure, taking Walther (1988) summarizes a ‘strain’ situation as distortions into a ‘crowded’ state, so allowing follows: change to take place spontaneously (Sergueef et al 2002). When proprioceptors send conflicting information there may be simultaneous contraction of the Upledger & Vredevoogd (1983) give a practical antagonists. The idea of moving reflex pattern develops which causes muscle or other a restricted area in the direction of ease is, they say, tissue to maintain this continuing strain. Often in order to dysfunction] often relates to the inappropriate open a latch we must first exaggerate its closure’. Chapter 7 • Modalities, Methods and Techniques 255 We can recognize such a pattern in an acute setting sis relates to the presumed effects of slackening fascial in torticollis, as well as in acute lumbago. This is a time of intense neurological and proprio- The reduction in tension on the collagenous cross- ceptive ‘confusion’, and is the moment of ‘strain’. Used appropriately there appear to be no contraindi- cations to use of positional release methods of Nociception treatment. Bailey & Dick (1992) suggest that strain dysfunction is far more complex than the simple proprioceptive example: Naturopathic perspectives In the realm of bodywork few if any methods would Probably few dysfunctional states result from a purely seem to be closer to basic naturopathic concepts than proprioceptive or nociceptive response. Nociceptive responses would occur (which are to have philosophical and practical similarities to more powerful than proprioceptive influences) and deep relaxation, therapeutic fasting, neutral (body these multisegmental reflexes would produce a flexor temperature) bathing, and various psychotherapeutic withdrawal, dramatically increasing tone in the flexor approaches such as emotional experiencing and group. Korr’s (1976b) explanation for the physiological In all these there is a ‘detachment from barriers’, normalization of tissues brought about through posi- provision of a ‘safe place’ (‘position of ease’), a virtual tional release is that: ‘granting of permission’ or offering of an opportunity for self-regulation to operate. D’Ambrogio K, Roth G 1997 Positional release physician has led the patient through a repetition of therapy. Churchill Livingstone, Edinburgh with gentle muscular forces, and second there have 3. American Academy of Other hypotheses Osteopathy, Indianapolis, Indiana Jacobson et al (1989) have suggested a circulatory 5. Locate an area of skin somewhere between your Horizontal reference elbow and wrist, on the flexor surface. Place two or three finger pads onto the skin and slide it 10˚ superiorly and then inferiorly on the underlying 36˚ 19. Slide the skin in that direction and, holding it there, test the preference of the skin to slide medially and laterally.

Early systolic data are more accurate with forward gating trusted cefaclor 500 mg, while end-diastolic data are preserved with reverse gating discount 250mg cefaclor overnight delivery. A narrow window means more homogeneous beats cefaclor 250mg low price, making the study more accurate but with a prolonged acquisition time if some arrhythmia is present. Increasing the window will reduce the acquisition time at the expense of the diastolic portion of the time–activity curve. Frame mode is the typical acquisition method but list mode is the more memory demanding one. List mode is particularly appropriate for studies of diastolic function and is more flexible in adjusting the beat length window, 184 5. The number of frames depends on the clinical problem, software capabil- ities and acquisition time available. A higher number of frames improves the temporal resolution, making the image more representative of the variations in chamber volume. Sixteen frames per cycle are enough to assess the systolic phase, while 32–48 frames per cycle are ideal in studying the diastolic phase but longer acquisition times are required to achieve good frame statistics. Bicycle exercise is preferred and can be performed in both the upright and supine positions: both place similar overall stress on the heart at any given workload. Exercise in the supine position, however, places more strain on the legs and may cause patients, particularly the older or those out of condition, to stop exercising before an adequate cardiovascular stress is reached. Sufficient time should be allowed at each workload for the heart rate to stabilize and for enough image statistics to be acquired for reliable quantification. The period of peak exercise should be of sufficient length for superior image quality. However, prolonging the exercise by reducing the workload may lead to an immediate improvement of the ventricular function and to an underestimation of an eventual ischaemic reponse. An optional post-exercise image may be valuable in predicting functional recovery after revascularization in segments with severe wall motion abnormalities at rest. Alternatives for patients unable to exercise include atrial pacing, cold pressor testing, catecholamine infusion and coronary vasodilators such as dipyridamole or adenosine. It is recommended that the entire cycle be reviewed to obtain optimal information. Fourier transform analysis of the data and the first and third harmonics are used to filter the images and curve, to obtain functional parametric images such as those of phase or amplitude, or fit ventricular volume curves in order to determine systolic and diastolic function. The peak left ventricular filling rate is often a useful parameter to detect early dysfunction. Next, the morphology, orientation and sizes of the cardiac chambers and great vessels are evaluated and reported. Global left ventricular function is assessed qualitatively, followed by a segmental analysis of regional function using a cinematic display. Resting and stress images are displayed side by side to assess changes in chamber size, wall motion and ejection fraction. Quantitative measurements of ventricular systolic and diastolic functions are made. For patients with coronary artery disease, wall motion abnormalities can develop on exercise, with a fall in ejection fraction. Distortion of the left ventricular contour and paradoxical wall motion, usually in the anterior or anteroapical myocardium, are characteristic findings of ventricular aneurysm. Wall motion Visual assessment of cinematic display or analysis of phase and amplitude images. Principle Myocardial perfusion scintigraphy uses perfusion radiotracers that are distributed in the myocardium (primarily the left ventricle) in proportion to coronary blood flow. Areas of normal flow exhibit a relatively high level of tracer uptake, while ischaemic regions present a relatively low uptake. Regional coronary blood flow may be compared in conditions of rest, stress or pharmacologically induced vasodilation. In addition to evaluating relative regional blood flow these tracers are, therefore, also markers of myocardial viability. Myocardial perfusion scintigraphy may be performed using either single photon or positron emitting radionuclides. Among the commonly used single photon emitting 201 99m perfusion tracers are Tl and the various Tc labelled perfusion tracers (e. While having different physical and pharmaco- kinetic properties, these tracers have considerably overlapping clinical uses and will therefore be considered in parallel in this section. Clinical indications The clinical indications for myocardial perfusion tomography are summarized in Table 5. The presence of extensive ischaemia or myocardium at risk indicates the need for more invasive work-up, such as coronary angiography. Conversely, the absence of significant ischaemia or myocardium at risk generally rules out the need for intervention. Myocardial perfusion imaging can be performed in various settings: in patients with suspected coronary artery disease, after myocardial infarction or for the assessment of therapy. Myocardial perfusion imaging can also be used to evaluate the patho- logical significance of coronary lesions already detected by angiography. Angiographic coronary artery disease with a normal stress myocardial perfusion scan has little prognostic significance according to accumulated data. This helps clinicians to determine which patients to manage aggressively with invasive procedures and which ones to manage conservatively. As with detecting myocardium at risk, stratification using mycardial perfusion imaging can be done in various settings: in patients with suspected coronary artery disease, after myocardial infarction as well as before non- cardiac surgery (to determine the risk of perioperative cardiac events). The term ‘viable myocardium’, in its broadest sense, denotes any myocardium that is not infarcted. For the cardiologist, however, the search for myocardial viability is primarily a quest for myocardial hibernation.

A patient (or solicitor ) can appeal the findings of a Tribunal to the Circuit Court buy cefaclor 250mg overnight delivery. A medical or nursing member of staff can hold a voluntary patient for up to 24 hours if deemed necessary (S order cefaclor 500 mg with mastercard. The fact that a patient must indicate a wish to leave the approved centre before 226 S buy 250mg cefaclor fast delivery. That decision confirmed that a Renewal Order takes effect on the expiration of the previous Order and not the date on 229 which the Order is signed. If a defect in an Order is not complained of at the relevant Tribunal it cannot subsequently be used in argument at a later Tribunal. Under the Act, an involuntary person suffering from a mental disorder who has been admitted to an approved centre shall not be a participant in a clinical trial. The treating psychiatrist should normally ensure that his/her patients give free and informed consent to treatment. However, treatment can be given without consent if the patient is incapable of giving consent. Following 3 consecutive months of drug therapy, written consent from the patient for further such treatment is required, or such treatment can be authorised by 2 consultant psychiatrists, one being the treating consultant (3-monthly renewal thereafter). Mental Health Act, 2001 (a) Definition of ‘mental disorder’: mental illness (abnormal thinking, perceiving, emotions, or judgement seriously impair mental function and necessitating intervention for sake of self and/or others), severe dementia (intellectual, psychotic, and behavioural manifestations) or significant intellectual disability 231 where – 1. Judgement is so impaired that without admission significant deterioration is likely or appropriate treatment would not be possible 3. Admission would materially help the patient or alleviate the disorder 222 Such an adjournment extends the review of the existing Order but not the life of the Order: the responsible consultant must still complete an Extension Order in order to hold the patient in the approved centre. Where the latter is not forthcoming permission has to be sought from the Tribunal. Doctor making recommendation must examine patient within 24 hours of receiving application 3. Decision to detain at approved centre to be made within 24 hours (was 72 hours in the 1945 Act) 232 The Mental Health Act, 2008 was rushed through the Dáil at the end of October 2008 because extensions of detention as stated on Form 7 (renewals) were deemed to be too imprecise (e. Mental health tribunals during 2008 Cost for tribunals €9,755,433 (per notification €2,922) 2,004 involuntary admissions, 2,096 hearings (241 revocations at hearings) 1,324 renewal orders 1,290 orders revoked by psychiatrists before tribunal hearings Findings of a postal survey of 238 consultant psychiatrists in Republic of Ireland (O’Donoghue & Moran, 2009) Subject: experiences and attitudes post-Mental Health Act 2001 introduction 70% response rate 48% felt care of voluntary patients deteriorated 32% felt care of involuntary patients improved 69% stated involuntary patient status was being changed to avoid a tribunal 14% re-admit patients involuntarily just after a tribunal revocation 57% of placements saw reduced training of junior doctors 87% report increase in on-call service workload 23% report increase in service consultant complement A majority worry about not admitting patients with personality disorders or substance abuse per se as involuntary patients Waterford Mental Health Services November 2006-October 2009 (Umedi ea, 2010) 2,254 admissions (130 or 5. Her legal team stated that the period of renewal was too imprecise: ‘not in excess of 12 months’. The Act introduced diminished responsibility and (re- )introduced the verdict of ‘not guilty by reason of insanity’ into Irish law. The Minister designates psychiatric centres to receive persons diverted from the courts. The donor gives an attorney power to make personal welfare decisions on his/her behalf: such power has to be in a form prescribed by the Minister for Justice, the attorney must apply for the power to be registered with the Office of Wards of Court when the donor is/is becoming mentally incapable, certain people must be notified of the intention to register such power, and there are certain grounds for upholding objections to registration. Non-medical 235235235235 The Mental Health Act 2007 amends the the Mental Health Act, 1983 and the Mental Capacity Act 2005. Mental Capacity Act 2005 in England and Wales, (Jones, 2005; Church & Watts, 2007; Church & Jones, 2008; Nicholson ea, 2008) states that a person lacks capacity if at a relevant time he is unable to decide in relation to a particular matter due to an impairment/disturbance of mind/brain. People with capacity can appoint others to make decisions for them if/when capacity is lost (lasting power of attorney). They can also state what treatments they would wish to refuseshould they become incapacitated in the future (advance directives). Should a person lose capacity without having appointed a lasting power of attorney, the Court of Protection may be involved in deciding on capacity and in handling financial/health/welfare decisions. Doctors are able to make decisions based on the Act and will not have to rely on common law. Principles of Mental Capacity Act 2005, England and Wales (Bartlett, 2006) A person is presumed to have capacity if there is no evidence to the contrary A person does not lack capacity just because of an unwise decision Decisions made on a person’s behalf must be made in his/her best interests Such decisions should intrude as little as possible into rights/freedom of action A person must be helped to make a decision before he/she can be treated as lacking capacity The Mental Health Act, 1983 (England & Wales) replaced the Mental Health Act 1959 and was itself amended in 2008. Many experts felt that it errred too much on the side of rights to freedom as distinct from rights to treatment (‘Rotting with your rights on’. Nevertheless, it was followed by almost doubling of the numbers of compulsory admissions during first 12 years of its existence (Wall ea, 1999) Part I dealt with definitions of mental disorder, severe mental impairment, mental impairment and psychopathic disorders. Guardianship is not commonly used in practice, perhaps because of resource implications. If a detained patient does not want treatment, including medications, after 3 months one must arrange for a second opinion. The patient can be recalled to hospital if deterioration occurs or certain conditions are not kept. In respect of the admission of a child to an approved centre for adults, the following applies: no child under 16 years is to be admitted to an adult unit in an approved centre from 1st July 2009; no child under 17 years is to be admitted to an adult unit in an approved centre from 1st December 2010; and no child under 18 years is to be admitted to an adult unit in an approved centre from 1st December 2011. Hall and Ali (2009) expressed concerns about the changes in the Responsible Clinician role and about the effect this might have on relationships between professions as well as on the role of the psychiatrist. Parental permission does not override the decision of patients aged 16-17 who have capacity. Whilst treatment cannot be forced on a person in his/her own home, that person may be removed to a specified place for 6 hours so that treatment may be administered. Owen ea (2009a) examined consecutive admissions to a London psychiatric hospital (Maudsley) and found that psychotic disorders and the manic phase of bipolar affective disorder were most strongly associated with lack of capacity; in non-psychotic cases, unlike in psychosis, depressed mood was associated with capacity status; insight was the best discriminator of capacity status in psychosis and mania but is less discriminating in non-psychotic cases; and cognitive performance did not predict capacity status in cases with psychosis. In a further publication, Owen ea (2009b) examined 200 psychiatric inpatients using the MacArthur Competence Assessment Tool for Treatment: a quarter were informal (voluntary) but lacked capacity and these people felt more coerced and were more likely to refuse treatment than voluntary patients with capacity; a small number of detained (involuntary) cases had capacity and were difficult to characterise. Adults with Incapacity (Scotland) Act 2000 establishes statutory authority to treat adults who are not able to consent for themselves.

Nature Cure Publishing cefaclor 500mg with visa, Chicago Rheumatology 21:2341–2343 Linton S 2000 Review of psychological risk factors in George S 1964 Changes in serum calcium order 500 mg cefaclor with amex, serum back and neck pain cefaclor 250mg overnight delivery. Scandinavian Heyman M 2005 Gut barrier dysfunction in food Journal of Rheumatology 28:47–53 allergy. European Journal of Gastroenterology and Lust B 1918 Universal naturopathic encyclopedia, Hepatology 17(12):1279–1285 directory and buyers’ guide: year book of drugless therapy for 1918–1919. Naturopathic News Animal Practice 13(4):211–216 30:368 22 Naturopathic Physical Medicine Lutgendorf S, Costanzo E 2003 introduction to complementary medicine. Allen & Psychoneuroimmunology and health psychology: Unwin, Sydney an integrative model. Macefield G, Burke D 1991 Paraesthesiae and tetany Chest 80(2):149–153 induced by voluntary hyperventilation. Journal of the Butterworth-Heinemann, Oxford American Osteopathic Association 100(12):776–782 Mannerkorpi K, Nyberg B, Ahlmen M, Ekdahl C 2000 Ott H et al 2006 Symptoms of premenstrual syndrome Pool exercise combined with an education program for may be caused by hyperventilation. Journal of the American Osteopathic McKenzie R 1981 The lumbar spine: mechanical Association 105(10):475–481 diagnosis and therapy. Spinal Publications, Waikanae, Pellegrino E 1979 Medicine, science, art: an old New Zealand controversy revisited. Man and Medicine 4(1):43–52 McMakin C 1998 Microcurrent treatment of myofascial Peltonen R, Kjeldsen-Kragh J, Haugen M et al 1994 pain in the head, neck and face. Topics in Clinical Changes of faecal flora in rheumatoid arthritis during Chiropractic 5(1):29–35 fasting and one-year vegetarian diet. British Journal of McMakin C 2004 Microcurrent therapy: a novel Rheumatology 33:638–643 treatment method for chronic low back myofascial pain. Perdigon G, Alvarez S, Nader M et al 1990 The oral Journal of Bodywork and Movement Therapies administration of lactic acid bacteria increases the 8:143–153 mucosal intestinal immunity in response to McPartland J, Brodeur R, Hallgren R 1997 Chronic neck enteropathogens. Journal of Food Protection pain, standing balance and suboccipital muscle atrophy 53:404–410 – a pilot study. British Journal of Edinburgh, p 81 Rheumatology 35:874–878 Radjieski J, Lumley M, Cantieri M 1998 Effect of Mosby’s medical, nursing and allied health dictionary, osteopathic manipulative treatment on length of stay 5th edn, 1998. In: Robson T (ed) An Churchill Livingstone, Edinburgh Chapter 1 • Physical Medicine in a Naturopathic Context 23 Rich G 2002 Massage therapy: the evidence for practice. Timmons B, Ley R (eds) 1994 Behavioural and Braumueller, Vienna psychological approaches to breathing disorders. Roithmann R, Demeneghi P, Faggiano R, Cury A 2005 Plenum Press, New York, p 118–119 Effects of posture change on nasal patency. Revista Tortora G, Grabowski S 1993 Principles of anatomy Brasileira de Otorrinolaringologia (English ed. HarperCollins, New York, 71(4):478 p 69 Selye H 1946 The general adaptation syndrome and the diseases of adaptation. Journal of Oral Rehabilitation research study on the use of complementary therapies 10:957–962 among patients with inflammatory bowel disease. Select Committee Vlaeyen J, Crombez G 1999 Fear of movement, on the Definition of Naturopathic Medicine. Churchill Livingstone, Edinburgh, p 457–459 American Naturopathic Association Ward R (ed) 1996 Foundations for osteopathic medicine. Standish L, Calabrese C, Snider P et al 2005 The future Williams & Wilkins, Baltimore and foundations of naturopathic medical science. The Wendel P 1951 Standardized naturopathy (published by naturopathic medical research agenda. Stress-related alterations of Zeff J, Snider P, Myers S 2006 A hierarchy of healing: gut motor function: role of brain corticotropin-releasing the therapeutic order. In: Pizzorno J, Murray M (eds) Gastrointestinal and Liver Physiology 280(2): Textbook of natural medicine, 3rd edn. Selye described stages in which an initial defensive/protective (‘fight/ Schamberger’s malalignment model 42 flight’) alarm phase occurs in response to a stressor Beyond dysfunction towards pathology 43 (Rosch 1999) (see Fig. Rosch apparently expressed the view that had his knowledge of attempts to explain the choice by Selye of the word English been better he would have gone down in history ‘stress’ that he used to describe the background to as the father of the ‘strain’ concept. Finding an acceptable definition of stress was a Rosch points out that although Selye was fluent in many problem that exercised Selye for the rest of his life. He languages, including English, his choice of the word noted to Rosch that 24 centuries previously Hippocrates ‘stress’ to describe the non-specific response syndrome had written that disease was not only pathos (suffering), he discovered was probably an error of judgment. He but also ponos (toil), as the body fought to restore had used the word ‘stress’ in his initial letter to the normalcy. Editor of Nature in 1936, who suggested that it be Ultimately, because many people viewed stress as an deleted since this word implied nervous strain, unpleasant threat, Selye created a new word, ‘stressor’, recommending that he use the term ‘alarm reaction’ in order to distinguish between stimulus and response. Even Selye had difficulties when he tried to extrapolate Selye was unaware that the word ‘stress’ had been his laboratory research to humans. In helping to prepare used for centuries in physics to explain elasticity, the the First Annual Report on Stress in 1951, Rosch property of a material that allows it to resume its original included the comments of one critic, who, using size and shape after being compressed or stretched by verbatim citations from Selye’s own writings concluded: an external force. As expressed in Hooke’s Law, the ‘Stress, in addition to being itself, was also the cause of magnitude of an external force, or stress, produces a itself, and the result of itself. An evolution of these models has included recogni- tion of an altered version of homeostasis – Stress is defined by Selye in his writings (1976) as the allostasis – that produces exaggerated, or insufficient, non-specific response of the body to any demand, responses to stressors (Fig. Chapter 2 • Adaptation and the Evolution of Disease and Dysfunction 27 Infections Genetic predisposition Psychosocial Early intense stress Intact psychosocial homeostatic Health stress (abuse, Toxins etc. Appropriate treatment to C improve immune defense and Recovery, repair functions or to improvement reduce adaptive demands: drugs, manual methods, acupuncture, exercise, psychotherapy, dietary changes, etc. Reproduced with permission from B Chaitow (2003a) Many of Selye’s findings and concepts fit intimately In this model, a spectrum of adaptive changes – many with naturopathic thought, as outlined in Chapter 1 of which produce symptoms, some benign and others (Selye 1976): serious or sinister – is seen to emerge from a back- ground of the interaction of variable (in degree, variety The fact that the state of stress, even if due to the same and chronicity) idiosyncratic adaptive demands, agent, can cause different effects in different superimposed on the individual’s unique acquired individuals, has been traced to ‘conditioning factors’ and inherited biochemical, biomechanical and psy- that can selectively enhance or inhibit one or the other chosocial characteristics, qualities and attributes – stress effect. This conditioning may be endogenous sometimes called polymorphism (Williams 1956).

Whilst images of crack babies and irresponsible mothers prevail in stories about maternal exposures to drugs buy cefaclor 250 mg mastercard, visual images in popular science magazines and news stories about male reproduction place sperm in the centre of focus as the tiniest victims of toxicity purchase cefaclor 250mg without a prescription. Even in newspaper stories that address the connection between paternal exposures and fetal health order cefaclor 500 mg amex, certain patterns of reporting emerge that function to reduce male culpability for fetal harm. In all of the stories that draw connections between paternal exposures and fetal harm, maternal exposure was also mentioned as a possible source of harm. Evidence of male-mediated risks are often prefaced with statements such as, ‘While doctors are well aware of the eVects that maternal smoking, drinking and exposure to certain drugs can have on the fetus, far less is known about the father’s role in producing healthy oVspring’ (Merewood, 1992: p. News and World Report began an article on paternal–fetal harm in these terms, ‘It is common wisdom that mothers-to-be should steer clear of toxic chemicals that could cause birth defects. Between fathers and fetuses 125 Fourth, paternal exposures to illegal drugs are always contextualized by reference to ‘involuntary’ environmental and workplace exposures, thereby reducing men’s culpability for harm. After reporting that children of fathers who smoke have been found to be at increased risk for leukaemia and lymphoma, the article ends with the recom- mendation of a physician that men who smoke ‘either modify their diets to include fruits and vegetables or take a vitamin C supplement each day’. While sperm ‘delivers’, ‘transports’ or ‘carries’ the drug to the egg in such stories, it never ‘assaults’ the fetus, as stories on drug use and women imply. When the sperm is not presented as itself a victim, it acts as a shield for men – deXecting or capturing the blame that might otherwise be placed on the father. One news story entitled ‘Sperm Under Siege’, presented an image of sperm at the centre of a target, menaced by bottles of alcohol and chemicals (Merewood, 1991). Another presented a cartoon image of a man and his sperm huddled under an umbrella whilst packets of cigarettes, martini glasses and canisters of toxins rained down upon them (Black and Moore, 1992). Yet of the 853 column inches dedicated to pregnancy, alcohol and drug abuse by the New York Times in one two-year period, almost 200 column inches were taken up by photographic images of crack babies and their drug-addicted mothers (Schroedel and Peretz, 1993). The biological mechanism of paternal–fetal harm have been made invisible not by science itself, but by the lens through which scientiWc evidence is perceived. As Evelyn Fox Keller has observed, un- articulated gender assumptions aVect not only the questions and methodolo- gies of scientiWc research but also ‘what counts as an acceptable answer or a satisfying explanation’ (Keller, 1992: p. For this reason, scientists who have engaged in research on paternal–fetal hazards have met with scepticism from colleagues, editors and newspaper reporters alike. Daniels Paternal effects and ‘political correctness’ Evidence of paternal–fetal harm has generated, at best, virtual silence from public health authorities and the courts, or, at worst, active hostility. An editorial in Reproductive Toxicology (Scialli, 1993) argued that the impulse to link paternal exposures with fetal eVects is a result not of science but of ‘political correctness’, ‘There has been no quarrel that testicular toxicants can produce fertility impairment, but paternally mediated eVects on conceived pregnancies is [sic]adiVerent matter altogether’. The article concedes that ‘several’ studies on paternally mediated eVects have been ‘nicely performed and reported’, but taken as a whole they are ‘diYcult to interpret’ (Scialli, 1993: p. Of those who defend the evidence for paternal/fetal links, the editorial (Scialli, 1993) concludes: The people who make these accusations appear to believe that paternally mediated eVects must occur in humans, for the sake of fairness. It is argued that because father and mother make equal genetic contributions to the conceptus, they must have equal opportunity to transmit toxic eVects. Yet except for those rare and tragic cases where women are exposed to substances such as thalidomide which cause severe, visible deformities, the question of causality remains profoundly complicated for both women and men. The fact that even the chronic abuse of drugs and alcohol by men has been dismissed, whilst so much attention has focused on even the occasional use of drugs and alcohol by pregnant women, points to the clear ways in which gendered constructions shape both the science and policy of risk. Even in cases where men are exposed to known reproductive hazards, scientists have been remarkably reluctant to recommend the most simple restrictions on men. At the Wrst major medical meeting on male-mediated developmental toxins at the University of Pittsburgh in 1992, men were given ‘conXicting advice’ about whether to postpone procreation during cancer treatment (or ‘bank’ sperm before treat- ment). The journal Human Reproduction published a recommendation Between fathers and fetuses 127 stating that sperm saved in the early stages of chemotherapy was safe ‘based on the belief that since the drugs did not kill sperm. It is not just the nature of the risk but also the symbolic construction of the population targeted that has determined the public response to fetal risks. The evidence that does now exist suggests that men’s actions can have a profound eVect on fetal health – both before conception and throughout pregnancy. While the mechanisms of harm may not be identical, given the additional avenues of harm that can be delivered through the female body during gestation, it is clear that paternal exposures to toxins can aVect both male reproductive health and fetal health. Science and media representations shaped by gendered constructs of vulnerability and virility have led not just to the negative targeting of women, but also the systematic neglect of men’s health needs. Ultimately, talk about individual causality for either men or women, whilst important, directs attention away from the more profound social determinants of parental and fetal health – good nutrition, good health care and a clean and safe environment. The argument appears to be that pregnant drug addicts should stop, as it is wrong to harm fetuses (who will become babies who have a right to be born of sound mind and body). Examples include taking legal drugs (such as alcohol or cigarettes), failing to attend for ante- natal care, inhaling environmental pollutants or even skiing. Actions against pregnant drug takers are taking place within a wider programme of legal enforcement of women’s ethical obligations to their fetuses (Kolder et al, 1987; Nelson and Milliken, 1989; Re S, 1992). The moral relationship of mother and fetus A necessary condition before limiting a pregnant woman’s freedom is that a moral relationship exists between mother and fetus. The claims of those wishing to limit pregnant women’s freedom are Wrstly, that a fetus has full rights, and, secondly, that the right to life (Kluge, 1988) or prenatal care (Keyserlingk, 1984) overrides the mother’s right to autonomy or inviol- ability. Although counter-arguments may be made that the unborn fetus has no moral status (Harris, 1985), or that the right of a woman to control her body 131 132 S. Arealand seriousriskof harmto the fetusmustexist;as restrictionsonlibertyincrease,somustthe justification;thereshould beno less drastic methodforachievingthesame end;the harm prevented should be less than that caused; and compensation might have to be considered for limits on freedom. The moral status of the embryo (so important in the abortion debate) is irrelevant to the existence of obligations with respect to harming a future person who indisputably has moral status (Gillon, 1988). I assume: (1) A fetus has some, even full, moral status; (2) A woman does not have an absolute right to control her body; (3) In general, people have a basic human right not to be interfered with (Hart, 1955); and (4) If a mother has obligations to her fetus, then so has society.