No. 29 (2/00) PSYCHIATRIC MEDICATION FOR CHILDREN AND ADOLESCENTS PART II: TYPES OF MEDICATIONS Psychiatric medications can be an effective part of the treatment for psychiatric disorders of childhood and adolescence. In recent years there have been an increasing number of new and different psychiatric medications used with children and adolescents. Research studies are underway
Microsoft word - joaoxxi_mencaohonrosa_.docBioethical reflections about the situation of the elderly Adjunct Professor of Ethics in the Superior School of Health of the University of Aveiro Correspondence to José Augusto R. Simões, Escola Superior de Saúde, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal, firstname.lastname@example.org The progresses of medicine, by increasing longevity, as well as in geriatrics, by improving the elderly’s quality of life led, according to Junges (1), to an understanding of old age based on the therapeutic metaphor. This fact, imbued with positive consequences, yet culturally reinforced by the ideology of perfect health, caused an increasing medicalization of old age, considered a disease to be cured. Thus, as Stepke (2) mentions, old age has become a predominantly biological fact, and its existential dimension is often neglected. However, the biological aspect only acquires human meaning when integrated in that ampler horizon of the elderly’s historical and existential itinerary. Therefore, we need to redefine old age as a personal event and explain the meaning of this process. Old age reminds and expresses aspects, such as vulnerability and temporality, typical of the human being and that go by unnoticed due to the vitality experienced during the juvenile years. As Junges (1) notices, one of the first perceptions of the human beings’ ageing process is gaining awareness of their vulnerability. Individuals start to realize that they no longer have the energy and vitality they once had and, therefore, are more vulnerable and fragile in face of biological or psychological factors tending towards the imbalance. And, if they have always considered themselves strong and independent people, without accepting in themselves the effects of frailty, that conscience of vulnerability will be a reason for discomfort and reaction. Nevertheless, the ageing process is inexorable, showing its effects little by little. If the elderly do not learn to integrate these inevitable effects, and thus reaching a vital and psychological equilibrium suitable for their new existential situation, they will experience great difficulties accepting old age, which is commonly considered hard and burdensome. Hence the need to integrate vulnerability as something that makes part of human existence. Living humanely is living in vulnerability, according to Roselló (3). By being multidimensional and inter-relational, human beings are not self-sufficient, as they need to build their structural and relational unit in an open way to others and to the surrounding reality. This unit is never finished and, on the other hand, it is constantly threatened by individual and foreign elements that disrupt it. Human beings are vulnerable, not only in the biological aspect, but also in the psychological, social and spiritual aspects. Nowadays, the biological effects of vulnerability are less felt due to the progresses in health sciences. However, as Junges (1) realizes, vulnerability is more visible in its social, psychic and spiritual aspects, being a reason for increasing pain and suffering. Cultural references do not help to integrate this vulnerability, on the contrary, they deny it by offering sensorial Human beings, who are more vulnerable than other living things due to their multidimensionality, are, however, more capable of protecting themselves thanks to their cultural condition. They are not only more vulnerable, but may also become aware of that vulnerability. They may still think about it, thus creating cultural references in order to integrate or to contest it. Human newborns’ frailty, which is different from other animals, is the exact expression of that vulnerability. But it is a frailty that will be overcome in due course. In the elderly’s case, on the contrary, their own face shows the inevitable vulnerability. Therefore, as Simone de Beauvoir (4) notices, modern culture has difficulty approaching elderly related issues, because it denies and rejects the meaning and the effects of the human being’s vulnerability making the apology of juvenile vitality. This makes young peolple, as Braga da Cruz (5) says, the main social protagonists and modellers of social behaviors. Illness is the exact metaphor of vulnerability and suffering is the bitter face of that experience. It is a reality that may appear during a human being’s life but, normally, it is not permanent. Only when the elderly realize time elapsing and the proximity towards death, conscience of vulnerability appears. Temporality and death are part of the human’s condition as a vulnerable being. As Junges (1) says, these two conditions Temporality expresses, at the same time, fugacity and opportunity. Time, on one hand, makes everything sift through caducity’s chronological process, leading to consumption and destruction. But, on the other hand, it is an opportunity for the new to appear, by the creation and innovation of the identity. Evolution, pierced through by time’s arrow, is, at the same time, life and death, as two sides of the same coin. In old age, human time is chronologically experienced as elapsed time that will not return; in other words, it is experienced as ageing that expresses itself through the appearance of face wrinkles, body feebleness and the certainty of death. However, it also means the build-up of personal experiences and the creation of individual, familiar and social histories, which are opportunities that will help face the future. Chronological time embraces the present reflected in the past, that is, it looks back to realize, in the present moment, the time that has elapsed; whereas, time as an opportunity, looks ahead, towards future chances for the new that may sprout. Current culture only encourages and values the immediacy of the present, with no reference to the past or projection towards the future. What matters is the present moment with its moments of pleasure and happiness. The past reminds us of how brief time is, with its signs that are best forgotten, offering nothing as a reference. The future is the uncertainty still in progress, needing effort and interest that are not worth employing. This being the case, current mentality reduces temporality to the chronological present, trying to forget and denying the fugacity of time, expressed in the past, and its opportunity, portrayed in the openness to the future. However, the ageing process compels us to face the condition of human temporality. Temporality points out to another feature of the human condition, mortality. The human being is a being destined to die. The death process is part of the life event. For life to be possible, it is necessary for death to take place continuously. In humans, this has a biological meaning, as well as a psycho-spiritual one. The body is in continuous reorganization through death and renewal of cells until autopoiesis is no longer viable, then culminating in complete death. In order to become aware of their mortal condition, human beings need to engage in an existential confrontation with it. Death is a psycho- spiritual challenge for which one needs to find a purpose. Every culture has stored, through their religions, references in this sense, enabling human beings to face the Modern culture, more secularized, tries to avoid the question, making death a taboo. Before, sex was a cultural taboo. Nowadays, death occupies its place. On the contrary, sex today is an issue publicly exposed with the greatest normality, without taboos. Before, there was a daily acquaintance with death, because it was part of people’s everyday life and it was looked at with normality. The moment of death took place in the person’s own home, in the company of family, where the mourning rites took place. Today, death happens, in general, in the hospital’s solitude. As Maria do Céu Patrão Neves and Walter Osswald (6) say, its expression is considered inappropriate, being concealed and veiled in appropriate places to reduce its manifestation. Death has become a taboo of which it is more and more difficult to talk about. The mourning rites themselves accompany this transformation of death into a The ageing process cannot avoid the death issue, since it is an inherent condition of human beings, who start to notice and confront it more clearly once old age begins. Part of the art of ageing with dignity is knowing how to include, with peace and meaning, death in the more immediate horizon of life. But the current mentality and culture do not offer references to integrate this reality, precisely because death is a taboo. This flaw points out to the exact meaning crisis in which actual society lives. The presence of the elderly reminds us all of this condition that cannot be discarded because it is a part of life, but which we try to avoid. As mentioned by João César das Neves (7), today, being old is a problem! In the course of time, people reached naturally old age, for ageing is a part of life. But, in our days, for the first time in History, being old has become a problem. Furthermore, we avoid using the word “old” because we find it offensive. We use detours and euphemisms like “elder”, “senior” or “third age”, to conceal reality. So how can human beings become prepared, throughout their lives, to make the most out of their old age? Learning how to age with dignity is each individual’s responsibility. The way each person deals with old age depends on how they dealt with life. Therefore it is more and more a job of exclusively each individual’s responsibility. In modern society, it is generally during retirement that individuals confront themselves with the task of repositioning their lives and thinking about what they are going to do from then onwards. This fact compels them to meditate about this new phase in life now beginning: third age. In traditional cultures, this task was facilitated, because a brisk cut-off of the daily life didn’t exist as it exists today with retirement. On the other hand, the role of the elderly was socially acknowledged and appreciated in its communitarian sense. Today, that no longer is seen. We can thus see a cultural and social void concerning the elder’s role in actual society, urging to rethink public policies that facilitate the integration of the elderly and that acknowledge what they’re worth. To reflect upon the existential task of confronting with old age, it is important to bear in mind the dimensions of the ageing process, which, as a matter of fact, correspond to those of any other human experience. Human beings consist of biological, psychological and spiritual structures, being these the different dimensions of their existential unity always placed in a socio-cultural context. Hence, any experience to be defined as human must contain these three dimensions, inserted and lived in a determined context, as said by Henrique Vaz (8, 9). The first manifestations of old age appear on the body: face wrinkles, muscle flabbiness, whitening and/or loss of hair, decrease of physical energy, etc. There are several theories that try to explain this biological transformation. The environmental theory explains that ageing is due to damage caused by toxics present in the organism and in the environment. The most mentioned of these toxics are oxygen free radicals, which cause deep changes in the metabolism of mitochondria. Other theories have a more genetic character, blaming ageing on the genes, especially on the chromosomes’ telomeres. According to Martin, Baker (10) and Petrini (11), the key factor to survival and, consequentially to the organism’s longevity, lies in the cells’ ability to resist, adapt and repair the altered molecules. These molecular changes have repercussions at the level of the cells that are structurally modified. And, as said by Macieira-Coelho (12), this restructuration progresses reducing the probability of further restructurations, i.e., it tends to a limit. The ageing process follows the tendency to reach that limit. The basic feature of life is autopoiesis, which allows living beings to continuously self-organize themselves in order to survive. The ageing process will mean a gradual reduction of autopoiesis and death, the definitive loss of that ability. In human beings, autopoiesis gains greater complexity because of cultural elements. The body isn’t just a biological reality; it is a personal and cultural event. The bodily dimension of human beings isn’t restricted to its physical and material structure, for it expresses itself, fundamentally, as self’s-body, which understands the appropriation of the bodily reality as an expression of itself. In this sense, the self’s body is the personal configuration of the biological structure assumed as the subject. People have self-consciences and reveal themselves to others through their appropriated body as a manifestation of themselves. According to Junges (1), this appropriation depends on cultural forms that give meaning to the body in a certain context. This reflection about the self’s body has a transcendental meaning to the ageing process. If the biological body suffers from increased frailty, the self’s body is something acquired that is part of the individual’s identity, depending more on the personal experience with the biological structure than on physiology. Furthermore, the body is enriched by the marks left by an existential history that identifies the elderly. There is a paradoxical beauty and enchantment in a face wrinkled by time, in a hand crumpled by labour, in a body hardened by life’s collisions. Hence the importance of training the conscience of the bodily self in order to face the increasing physical debilitation. A healthy appropriation of the body as an expression of one’s self, helps to take care and assume needed dietetic and physiotherapeutic attitudes towards good Human beings aren’t just about biological exteriority, but also about psychic interiority. The inner self shapes itself with imagination and affections. It is made of representations and desires that shape its contents. Imagination is a host to exterior representations and, affectionately, emerge desires that shape the psyche and that include conscious and unconscious elements, tracing out the person’s inner psychology. The body is an immediate reality, to which other individuals have unmediated access. Interiority, on the contrary, isn’t immediate, because the others can only access the inner self through the individual’s mediation. The others can only know someone’s psychic experience if the individual opens his interiority to them. Opening to reality arouses the representations and desires that are the contents and the fuel of the interiority. The inner self shapes itself essentially through the relationship with others. Hence the importance of inter-subjectivity for healthy shaping of the psyche, pointing out towards psychological disorders exhibited in autism and narcissism. This way, through relationships, people adapt themselves and assume their psychic structures as If this is the structure of the human psyche, we can easily imagine its deep meaning in the ageing process. Due to the lack of physical energy and more idle time available, the elderly will live their interiority more intensely, giving rise to representations and desires. Therefore, old age is charged with greater affective sensibility and representative memory. In old age, people are more prone to show feelings and to reminisce the past. Psychic interiority is more shown, due to control weakness and to less concern about the already debilitated masks of bodily exteriority. With a greater exposure of their interiority, the elderly show the lights and the shadows that linger in their hearts. Those interior realities, positive or negative, which used to be taken with certain conscience and control, dissolving themselves in life’s daily affairs, now emerge in their spontaneity with less resource to rationalizations. Both the elderly and children live with less masks, because they are less worried about their image, thus revealing who they really are. In old age, what a person lived, whether it was good or bad, shows. This way, in the ageing process there is a reduction in privacy as a consequence of the bigger vulnerability and the need for the presence and Human beings go beyond their biologic bodies, as well as their inner psyches. Human beings also carry a spiritual dimension that lies beyond the psychic reality. As far as the spirit is concerned, human beings seek a meaning for their actions, for their existence, one that explains the search for self-fulfilment and happiness. That meaning materializes as a horizon of meaning that transcends the pure factuality of the existence and the inner psyche itself. The meaning reveals itself as something that drags and inspires the subjects, giving them new eyes to behold the surrounding reality as well as renewed energy to face the obstacles of life. Humanity has always managed to respond, in its culture, to the appeals of the human spirit. The different religions were the climax of that search for the meaning in life. History shows the central role of religion in different cultures, and it embodies the symbolic core itself of the culture. The pro-secular trend of contemporary culture has promoted a current of materialism that reduces human beings to their biologic and psychic culture, thus denying them of their spiritual dimension. The current crisis of civilization has to do with the impossibility by the current culture to define absolute references that give meaning to life. Technology and the immediate appeals of the present are, in a way, making up for it. Today people can’t seem to find many symbolic resources to respond to their quest for meaning that reveals itself through the spirit. If the development of the spiritual dimension is a need for any human being, it becomes a priority for the elderly, since they need to find a meaning for the new step of their existence, since the foundations which once supported it have now become more fragile. The challenge is to find more consistent references that can counter the vulnerability and the perspective of death. That could explain why the elderly, in general, are people with a greater religious sensibility. According to Bianchi (13), many elderly individuals rediscover religious practices again or seek paths of spirituality. During the ageing process, the human being is confronted with other dimensions that may have already been forgotten, due to the feeling of power and independence experienced during youth and adult life. The elderly expose, show and remind everyone of typical human realities such as the self-body apprehension as an expression of themselves before the debilitated biological body, greater conscience of contents of psychic innerness and the strength of the experience of meaning at a spiritual level. During ageing, the individual captures with more intensity the importance of these realities, in order to lead a happy and sane existence. The ageing process makes human beings confront themselves with their own bodies, with their inner psyches and their horizon of meaning for existence, since they can no longer rely on the exteriorities that previously used to fill and sustain their lives. They are thus confronted before the nudity of their existence and maybe because of that, like Junges (1) stresses, the elderly in the pre-modern cultures were respected and considered a source of wisdom and teaching. The ethical issues have to do with the schizophrenia that is the situation of the elderly in contemporary culture: on one hand, treasured by medicine, which grants them greater longevity; on the other, socially marginalized, because society is unaware of what to do with increasingly older individuals. Without a place and a role for themselves, the elderly are bound to feel useless and isolated. This situation of isolation is worsened with the increasing difficulty and the lack of inter-generational socialisation, and it actually becomes a paradox in first world countries, with the loss of the conscience of inter-generational solidarity. This is not just about the generational conflict of cultural tastes or moral values, but an emptying of the cross-generational family interdependence. According to Paula Guimarães (14), what we find now is a multiplicity of aggregates that change in function of the dynamics of its elements. In Northern European culture, which is spreading South, parents don’t tend to invest much in their children, and push them precociously towards independence, because children will not look after their elderly parents, which forces them to save money in order to have a good provision during ageing. There is a family independence here in which each one has to fight for him/herself. The affective bonds in the family become much more fragile, and they can’t be a support for troubling moments. This trend leads to isolation and to a progressive marginalization of the elderly in nursing homes, far from the inter-generational socialisation. All this is a sign, according to Roudinesco (15), of a family model in crisis, of a changing institution. The bottom-line ethical issue is, therefore, socio-cultural. And this because, on one hand, there isn’t a place for the elderly in the contemporary society as it used to happen in pre-modern social contexts, and on the other hand, the culture itself does no longer supply (as before) additional symbolic references to help them face this new step of their lives. The elderly are thus doubly hampered, and that is why it is urgent to consider ethical demands that may be useful as guidelines for public policies for the As such, the famous principles of Bioethics, defined by Tom Beauchamp and James Childress (16) – autonomy, beneficence, nonmaleficence and justice – could pave the way towards ethical guidelines that could help third age. Incentives to the autonomy of elderly individuals Autonomy could assume two perspectives: one of ethical task for the elderly and one of moral demand for the caregivers. Third age is, more than anything, a phase in life that the elderly themselves readily assume. How can the elderly be prepared to live with peace and serenity the ageing years, without becoming isolated or depressed, and rather reacting with new initiatives and activities. This means, on one hand, to learn to deal with the limitations and changes imposed by the ageing process, and on the other hand, to learn to reposition oneself in life, in an autonomous way. Some elderly individuals assume this task spontaneously; others need to be induced towards that learning process. The goal is to enable the person, upon entering third age, rather than succumbing to dependence, to try to maintain the maximum possible level of autonomy. The third age clubs may become a space to help the elderly assume, with conscience and autonomy, their own ageing process, offering symbolic references that strengthen the sense of worthiness as a person and the search of a new meaning for life. The conscience of the elderly as autonomous individuals emerges and grows when they are treated as such. There is a tendency to patronize the elderly, treating them as dependent beings that can’t decide what is best for them. One of the important ethical demands for the professionals, or the relatives that are in daily contact with the elderly, is to help them develop autonomy, and to encourage them, as much as possible, to make decisions and take initiatives that concern them, particularly hygiene, health, activities The principle of beneficence defined by Tom Beauchamp and James Childress (16) demands the promotion of well-being of the elderly as a duty of the professionals that work with people of advanced age. It is, also, a demand of solidarity to the relatives that deal with an elderly individual in their home. The main issue is: what does it mean to promote benefits to the elderly or to promote their well-being? Is it just about offering good physical conditions in terms of accommodation, food, medication and If the human being is not just about the biological dimension, but also about the psychic and spiritual dimensions, the ageing process reaches and encompasses the three dimensions as we have seen previously. The well-being of the elderly should also consider, and in a special way, their psychic innerness and their spiritual horizons. It is necessary to consider the universe of affections and of the representations that fill the inner selves of the elderly and to bear in mind the values and the symbols that provide It is pointless to have the best housing material conditions, food and health, if the elderly individual ends up isolated and marginalized, suffering from solitude and uselessness, and not feeling treasured. That is why the affective presence of people is important, particularly relatives, to prevent the process of ageing to fall into a downward spiral of narcissistic isolation and concentration. Another important initiative is the reeducation of the elderly through occupational therapies, that enable them to discover healthy ways to spend time and to perform appropriate activities for their health, that are also useful to the group and even to society. These are some key aspects Negligence and maltreatment against the elderly The principle of non-maleficence defined by Tom Beauchamp and James Childress (16) includes the duty of not causing damage to people that are under someone’s responsibility. According to Lazaro Nogal and Ribera Casado (17), the elderly may suffer damage from neglect and lack of attention, or the violence of mistreatment, that could either be physical, psychological or moral. Negligence and mistreatment by the family are the result of worn down relationships, generational conflicts, economic problems, which lead to stress in the family environment and make the task of looking after the elderly individual painstaking and difficult. These abuses against the elderly carry a destructive effect to their quality of life, because they feel despised and mistreated by words and gestures that strike them deeply in their affective existence. In these cases, the family and the elderly individual require therapy and help in order to break the standstill. In institutions, mistreatments occur when professionals are not prepared to look after elderly individuals, and this may happen when they are not valued or there aren’t enough of them, for example. In order to overcome this situation it is necessary, on one hand, for public entities to carry out inspections and assessments of nursing homes, and on the other hand, to empower professionals, and thus raising awareness on the rights of the elderly and reflecting about the fundamental guidelines of their care. For that, it is necessary to raise the awareness of the civil society towards the rights of the elderly and for the accusation of abuses. Some authors defend the need to create caring committees of the rights of the elderly, not only to receive the accusations, but also to forward them, in a similar way to what already exists in terms of the defense of children’s rights. According to Junges (1), the guardianship of the child and of the elderly individual has particular nuances. While the child still doesn’t have autonomy to decide, the elderly individual is undergoing a process of losing the ability to be autonomous. That lessening or even absence of autonomy would underlie the juridical basis for the guardianship. If the mistreatments in nursing homes are easier to discover and overcome, those which occur within the family environment are harder to be known and healed, as they involve affective connotations that make it harder to talk and say the Public policies for the defense and promotion of the rights of the elderly The principle of justice defined by Tom Beauchamp and James Childress (16) points out the obligations the State institutions and the society in general have towards ageing. The well-being of the elderly does not depend only on care based personal relationships on behalf of relatives or professionals. It is also based on public policies that aim to ensure the rights of the elderly and to create conditions for the promotion of their autonomy, integration and active participation in society. We must also point out, like Manuel Nazareth states (18), that the United Nations General Assembly hailed 1999 as the International Year of Older Persons, referring to it as the year that would pave the way towards a Society for all Ages, thus raising awareness towards people belonging to generations that were born before the Second World War, that embodied an enormous potential. The General Assembly also put forward a few principles regarding the improvement of the quality of life of the - The principle of dignity, which acknowledges that elderly citizens should be entitled to worthy conditions of existence, safety and justice, regardless of age, sex, race, ethnicity, economical status and any other circumstance; - The principle of personal development, which acknowledges that elderly citizens should be entitled to conditions that foster their personal development, namely in terms of education, culture, hobbies and of spiritual development itself. - The principle of participation, which acknowledges that elderly citizens should be entitled to conditions that contribute towards their active participation in society, namely the definition and application of policies that direct or indirectly contribute to their quality of life, the sharing of socially useful roles, according to their capabilities and interests, and the development of associations, among others. Let’s not forget that on the 8th of April (2008), the President of the Portuguese Republic, Aníbal Cavaco Silva, who spoke at the conference “The Time of Life”/Gulbenkian Health Forum, refused to accept that population ageing should be considered a “threat” or a “burden” to society, adding that “the fact that we’re talking about older people should not stop us from considering them as part of the solution as The improvement of the elderly’s situation relies more on a cultural mentality change rather than on the creation of laws to defend their rights. That improvement will not be effective unless society is able to overcome the cultural schizophrenia disclosed by the contradiction of, on one hand, there is a growing longevity fostered by medicine, and on the other, the manifest uselessness to which the elderly are reduced in As Mucznik (20) states, the more developed societies tend to grant a new status to aged individuals, the status of “the new aged”, or of “the old new”, which has triggered the rise of a whole market that encompasses travelling, plastic surgeries, or even Viagra®. This is all aimed at maintaining the illusion of eternal youth. But in reality, this new status underpins the self denial of old age as something of fecund. Our new modern societies tend to take away from the ageing phenomenon what is specific of it: the experience and the wisdom. For the contemporary culture, the elderly have nothing to give to society. They are reduced to the compulsive inactivity, and survive through a pension granted by society in order to remain still. That sort of inactivity isolates the elderly from social contact. As such, ageing is a bothersome reality to the contemporary cultural ideology. For me, this is the biggest ethical problem concerning the situation of the elderly and their families, these days. I conclude by quoting Cristina Galvão (21), who states that General Practice/Family Medicine, as a specialty based on globality and continuity of care, can and should represent an important factor of social integration of the elderly in the community, while fostering their autonomy and reducing their institutionalization in order to achieve a greater quality of life. And I finish off with two excerpts of poems, the first by António Gedeão (22): like a lost star that cools down. 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(ed.) Bioética. Un diálogo plural. Madrid: Universidad Pontificia 18. Nazareth, JM. A situação demográfica. In: CNECV. Colecção Bioética VI. A pessoa idosa e a sociedade. Perspectiva ética. Lisboa: Presidência do Conselho de Ministros, 19. Público. Notícia: Cavaco critica empresas que vivem obcecadas com o "contínuo rejuvenescimento dos seus trabalhadores". Edição de Lisboa, 09-04-2008, p. 14. 20. Mucznik, E. Vistas sobre a idade avançada. In: CNECV. Colecção Bioética VI. A pessoa idosa e a sociedade. Perspectiva ética. Lisboa: Presidência do Conselho de 21. Galvão, C. Habitação segura. Envelhecer com Qualidade. Dissertação de Mestrado apresentada à Universidade de Salamanca, 2000. 22. Gedeão, A. Teatro do Mundo. Coimbra: Of. da Atlântida, 1958. 23. Andresen, SMB. Obra poética I. Lisboa: Editorial Caminho, 1998.
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