Christine Gee: Courting controversy

CONTROVERSY seems to follow some areas of medicine and this week’s stories in MJA InSight highlight just that.

The recent amendment to the Australian Diabetes in Pregnancy Society’s (ADIPS) guidelines, which suggested a lowering of the diagnostic thresholds for gestational diabetes, has divided experts on what the optimal cut-offs should be. We report on two articles in this week’s MJA that have challenged these revised guidelines, suggesting that the statistical basis for this change was uncertain and that the premature adoption of these lower thresholds could result in unnecessary patient harm.
    
The Royal Australian College of General Practitioners has decided not to endorse the guidelines, leaving clinicians in the dark as to how best to serve their patients. However, the medicolegal implications for those choosing to ignore the new recommendations are unclear.

In our “News in brief”, we report on a similar new dilemma that seems to have beset those treating post-traumatic stress disorder (PTSD).

In a group of US soldiers, PTSD-screening questionnaires using the DSM-5 (released mid 2013) criteria were compared with those using the older DSM-IV. While overall prevalence of PTSD differed minimally between the two tests, a considerable proportion of soldiers who received a diagnosis of PTSD using the older version were not diagnosed with the new one, and vice versa. At the individual patient level, the effects of such a change could be profound.

In the battle against obesity, bariatric surgery is one of the few interventions that has demonstrated clear evidence of success. But here, too, we see a lack of consensus over exactly which type of procedure is preferred. In this week’s InSight news story, experts diverged widely on their views of gastric banding versus sleeve gastrectomy.

Regardless of procedure type, this is an intervention which has largely been restricted to those who can afford to be treated within the private hospital system, creating an access barrier for many potential candidates. New research in the MJA evaluating bariatric surgery performed in the public setting suggests that it may be performed safely and effectively. While not resolving the banding versus gastrectomy debate, these data could lend support to policy changes enabling future access to bariatric surgery for less-well-off patients within the public system.

A discussion of medical controversies would not be complete without mention of voluntary euthanasia, or assisted dying. In a “Comment” article in MJA InSight, Dr Rodney Syme discusses the current moral and ethical landscape surrounding this issue in Australian palliative care. He brings attention to the government’s recent call for submissions to the “Dying with Dignity” Bill, arguing: “I can find no logical reason why a person, dying with unrelievable suffering, loss of meaning and control, should, by law, go to the very end of the line”.

Rarely a day goes by when the lay media do not cover stories on various scandals involving performance-enhancing substances used by professional athletes. But this week in MJA InSight, Dr Brad Partridge broadens this debate with a discussion including the issues of voluntariness and conflict of interest in athletes who experience extreme pressure to succeed and feel compelled to use such substances. He questions whether there is an ethical justifiability for clinical trials of these performance enhancers so that those using them, legally or not, would at least be better informed of the risks and benefits they may carry.

There would appear to be little controversy in blaming our parents for our various foibles and chronic conditions. It is a habit that is unlikely to change across the generations. But, as MJA InSight columnist Jane McCredie cautions, advances in knowledge of epigenetics could lead to such an extreme culture of blame that the freedoms of pregnant women in particular could be curtailed.

She says that this new science should be viewed in the context of the many social and environmental factors that affect children’s development, not just chemical markers in the mother.

English author William Hazlitt said that when something was no longer a subject of controversy, it ceased to be a subject of interest. If that be the case, this week’s MJA InSight should provide more than enough interest for readers.

Dr Christine Gee is a deputy medical editor of the MJA and acting medical editor of MJA InSight. Dr Ruth Armstrong is on leave.