[End-of-life practices and advance directives: a bioethical analysis based on discussions in the Brazilian Federal Legislative Branch].

There is increasing interest in the nascent field of ‘nutritional psychology’, which can be broadly defined as the examination of relationships between nutritional intake and psychological health and well‐being. At a general level, reviews have argued that diet plays a significant role in mental health functioning (Grajek et al., ). At a more specific level, it has been argued that micronutrients play a foundational role in maintaining good mental health functioning (Rucklidge, Johnstone, & Kaplan, ). Omega‐3 is another component of the diet which has been argued to play a significant role in mental health (Bozzatello, De Rosa, Rocca, & Bellino, ). Some randomized controlled trials (RCTs) have suggested that dietary supplementation with this long‐chain fatty acid may help reduce psychopathology. One pioneering RCT that gave omega‐3 supplements to teenagers with subthreshold psychosis documented a reduced transition to psychosis (Amminger et al., ). While a later study failed to replicate this finding in ultra‐high‐risk teenagers (McGorry et al., ), another RCT found that omega‐3 supplementation reduces schizotypal personality in children (Raine et al., ). Reviews of other psychopathologies have been equally mixed, with some arguing for efficacy for depression (Liao et al., ), while others argue that the evidence to date is either conflicting (Deacon, Kettle, Hayes, Dennis, & Tucci, ) or insufficient (Appleton et al., ). Another condition which may benefit from omega‐3 supplementation consists of antisocial behavior. Poor nutritional status in the first 3 years of life in 1,206 children has been associated with later externalizing behavior at ages 8, 11, and 17 years (Liu, Raine, Venables, Dalais, & Mednick, ), suggesting that nutrition per se may play some role in this behavior problem. In this same sample, an experimental intervention that included better nutrition from ages 3–5 years was associated with reduced antisocial behavior at age 17 years and reduced criminal behavior at age 23 years (Raine, Mellingen, Liu, Venables, & Mednick, ). Beneficial effects of the intervention were significantly greater for children with malnutrition at age 3 which suggests, but does not prove, that the nutritional component of the intervention may account for some of the improvement. Because the children in the intervention received over two child portions of fish per week more than the control group (Venables & Raine, ), we had hypothesized that omega‐3 could be the active ingredient in the enrichment that helped to reduce later antisocial behavior (Raine et al., ). The strongest evidence for a causal relationship between omega‐3 supplementation and reduced antisocial behavior emanates from RCTs. A number of reviews have argued affirmatively for the potential beneficial effects of this intervention on this behavior problem, suggesting that the link between poor nutrition and antisocial behavior could be explained by omega‐3 (Choy & Raine, ; Cooper, Tye, Kuntsi, Vassos, & Asherson, ; Gow & Hibbeln, ). However, these reviews are either not systematic, or they are limited in scope to just eight studies. There appears to be variability in findings of RCTs, with some finding positive effects (Richardson & Montgomery, ), some finding null effects (Crippa et al., ), and some finding negative effects (Bos et al., ). As such, it remains unclear whether omega‐3 supplementation significantly reduces antisocial behavior. The importance of this issue lies in the major economic and health costs of antisocial behavior. One longitudinal study of antisocial children found that, compared with controls, those on the antisocial life‐course path had three times the level of emergency hospital visits, 3.6 times the number of prescription fills, twice the number of hospital bed nights, and 6.5 times the number of social welfare benefits (Rivenbark et al., ). While only accounting for 9% of the total sample, they accounted for 53.3% of all criminal convictions, an outcome which in turn evokes a high financial and health care cost to victims and society alike.