"Professor Morris is a man on a mission
to rid the world of the male foreskin."
-- Dr. Basil Donovan, Clinical Professor in the School of
Public Health and Community Medicine, University of Sydney, reviewing "In Favour of Circumcision" by Brian Morris.[1]
"I have some good friends who are obstetricians outside the military,
and they look at a foreskin and almost see a $125 price tag on it. Each
one is...
"Professor Morris is a man on a mission
to rid the world of the male foreskin."
-- Dr. Basil Donovan, Clinical Professor in the School of
Public Health and Community Medicine, University of Sydney, reviewing "In Favour of Circumcision" by Brian Morris.[1]
"I have some good friends who are obstetricians outside the military,
and they look at a foreskin and almost see a $125 price tag on it. Each
one is that much money. Heck, if you do 10 a week, that's over $1,000 a
week, and they don't take that much time."
-- Dr. Thomas Wiswell, co-author with Brian Morris of the
latest defense of the AAP's proposal for government
funding of circumcision.[2]
Infant male circumcision is one of the most divisive issues in
contemporary society. When the American Academy of Pediatrics (AAP) issued
its policy statement on circumcision in August 2012, it was met with
international criticism for its cultural bias and lack of academic rigor.
[3,4]. The AAP's response was disappointing. Rather than engage in debate,
the AAP reacted defensively and simply reiterated its position.[5,6] In
response to our own critique of the AAP[3], Professor Brian Morris--along
with his familiar team of co-authors, including Dr. Thomas Wiswell (quoted
above)[7]--takes the opportunity to rehearse his longstanding conviction
that circumcision is a "biomedical imperative" for the 21st century.[8]
The paper is nearly identical in content to a number of similar reviews
and op eds by Morris et al. [Morris REFS: 21, 24, 46, 47, 52 , 55, 78, 79,
82], offering the same anthology of misleading claims and self-citations.
We here call attention to a few of the most conspicuous.
Firstly, their description of the AAP as "a major, possibly the most pre-eminent, paediatric authority internationally" (p. 1, emphasis in
original) is an example of a well-known rhetological fallacy, the appeal
to authority. What is breathtaking about this particular example is that
Professor Morris has criticised others for committing the very same
fallacy--but only when such paediatric bodies failed to be as enthusiastic
about circumcision as he is[i]. As Morris writes on his personal pro-
circumcision website: "The policy statements of professional pediatric
bodies have been misused by others as part of an 'appeal to authority'
fallacy... Those who write the policy statements are often physicians with
little or no academic expertise."[9] Thus, medical organizations which
issue statements that are comparatively friendly toward circumcision (see
footnote 1) are "pre-eminent" in Morris' view; whereas when their
statements are less friendly, they are the work of mere "physicians" with
"little or no academic training." As Morris then goes on to say, "Not
surprisingly, [these statements] have been criticized by academic
experts."[9] Note that Morris is using the term "academic experts" here as
a covert , third-personal reference to himself, in conjunction primarily
with his regular collaborators and other well-known circumcision
promoters. This is a theme to which we will return.
At numerous points in his reply to our critique, Morris cites his own and
his co-authors' opinions and seeks to pass them off as orthodox medical
fact . This appears to be part of a larger strategy employed by Morris to
distort the body of research on infant circumcision. As has been noted by
others,[10] Morris scans the literature for any new published study that
does not conform to his pro-circumcision stance, and then writes an
article, letter, or blog post attacking it, enabling him later to claim
that it was "refuted by experts" (i.e., by himself and his co-authors).
One example of this is an attack on the statistical methods used by
Sorrells et al. in a study showing that circumcision reduces sensitivity
of the penis [Morris REF: 12]. The "numerous flaws exposed by experts" (p.
2) in this study were "exposed" by none other than Brian Morris himself,
along with Mr. Jake Waskett--a 34-year-old "computer software engineer"
and "web designer"[11] with no known academic expertise[ii]--in the form
of a non-peer-reviewed letter exhibiting a manifest lack of statistical
competence[iii]. This same self-citation tactic was employed multiple
other times in his critique of our article [Morris REFS: 10, 12, 14, 62,
75, 76, 77, 91] and has been documented by other scholars subjected to the
same abuse[iv]:
[As] in critical letters to the editor following other recent studies
that failed to support their agenda, Morris et al. air a series of harsh
criticisms against our study. As seen, however, the points raised are not
well founded. It seems that the main purpose, as with prior letters, is to
be able in future writings to refer to our study as an "outlier study" or
one that has been "debunked", "rejected by credible researchers" or "shown
wrong in subsequent proper statistical analysis." ... As these critics
repeatedly refer to Morris' pro-circumcision manifesto as their source of
knowledge, their objectivity must be questioned.[10]
Morris et al. are to be congratulated, of course, for their sheer
energy in producing these unwarranted attacks. In doing so, they have
managed to generate a sizable pro-circumcision canon, ready to be cited by
like-minded writers whenever needed [Morris REFS: 24, 46, 47, 52, 55, 58,
65, 78, 79, 82, 102]. In the current critique, no fewer than 31 of the
references are to other publications by Morris or his co-authors.
Unfortunately, well-meaning peer-reviewers do not have the time to go down
a "rabbit hole" of self-citations in order to properly evaluate each claim
for its veracity.
Morris points to a "policy statement" by the Circumcision Foundation of
Australia (CFA), implying that it operates with the approval of the Royal
Australasian College of Physicians (RACP) (p. 1). However, nothing could
be further from the truth. Morris fails to disclose[v] that he himself
established the CFA[vi] (as well as drafted its "policy statement") in
opposition to the RACP, which released a statement in October 2010 that
failed to endorse routine circumcision[vii].[14] So misleading were
Morris's claims that the RACP felt obliged to distance itself from him
when he insinuated that he had been engaged as a reviewer for their
College.[15] In a letter to Australian newspapers, Dr. David Forbes, Chair
of the RACP Paediatrics & Child Health Policy & Advocacy
Committee, stated: "Professor Morris ... is not a member of the RACP and
is not and has not been engaged as a reviewer for the College."[16] As the
CFA website now admits: "The Foundation is not aligned with any medical
body."[13]
While Morris seeks, in this reply, to defend the AAP against its critics,
even the AAP does not endorse the extreme conclusions that he and his co-
authors draw (see footnote 1 for further discussion). As Morris has
publicly insisted, circumcision "should be made compulsory ... [and] any
parents not wanting their child circumcised really need a good talking
to."[17] Morris's striking lack of objectivity concerning infant
circumcision was noted by a leading sexual health researcher in a review
of Morris's trade book, "In Favour of Circumcision"[18]: "Even the most
naive reader can see that [the book] is very unbalanced. ... He preys on
parental fears with his (unreferenced) claims. [Such claims are] so
dangerous that it provides sufficient grounds for the publishers to
withdraw the book."[1] As noted above, this same lack of objectivity is
apparent throughout his reply to our critique.
Medical issues aside, however, the real challenge is to establish the
ethical propriety of advocating, without qualification, the needless
removal of healthy and functional body parts from non-consenting
children. While the AAP at least recognizes the relevance of this basic
bioethical issue (but fails adequately to address it, along with the
actual anatomy and function of the tissue being removed)[3], Morris and
colleagues offer arguments that are quite a bit more extreme. They float
the idea that circumcision is less risky if performed in infancy, and then
cite an opinion piece as supportive evidence.[Morris REF: 4][viii] They
then repeat Morris' discredited analogy between circumcision and
vaccination,[24] ignoring the fact that vaccination does not remove
functional tissue, and is both the safest and most effective means of
achieving the desired health outcomes--neither of which can be said of
male circumcision. And they dismiss autonomy, the concept that is the very
basis of modern bioethics,[25] as "radical."
In the final analysis, Professor Morris' exhortations ring of the same
Victorian paternalism that held sway long before modern child protection
measures or foundational concepts in medical ethics had ever so much as
been proposed: "So great are the evils resulting not only from congenital
phimosis, but from an abnormally long, though not phimotic, prepuce,"
wrote Erichsen in the late 1800s, "that it is only humane and right from a
moral point of view, to practise early circumcision in all such
cases."[26]
Modern doctors know better--or at least they should.
End Notes
i. Note that while the AAP cannot actually bring itself to recommend
anything even approaching Professor Morris' stated ideal (i.e.,
"imperative" universal circumcision) it appears that Professor Morris has
recognized that their recent policy statement is about as close as any
respectable pediatric authority is ever going to get--hence, it would
seem, his obsequious defense of them against our critique.
ii. Waskett does, however, have a long history of pro-circumcision
activism, see Frisch[10]. Waskett has personally edited the Wikipedia
pages on circumcision several thousands of times to reflect a pro-
circumcision bias[11], leading it to become the 6th most "controversial"
Wikipedia page (as measured by edits, re-edits, and re-re-edits) of all
time.[12]
iii. In this and other "critiques," rather than provide reasoned
arguments, the authors typically reject well-established and conventional
statistical methods. Their ostensible lack of understanding of meta-
regression [Morris REF: 91], mixed-marginal models [Morris REF: 22],
representative cross-sectional survey sampling methods [Morris REF: 14],
and attributable risk [Morris REF: 62], does little to boost the reader's
confidence in their assessment of others' work.
iv. Morris does not limit himself to the tactics of letter-writing and
passively-phrased self-reference. Instead, as was recently documented in
the International Journal of Epidemiology, Morris also disregards the norm
of confidentiality in peer-review, exhorting journal editors to reject
well-conducted studies if they suggest that circumcision may be harmful.
Responding to one such episode, a Danish sexual health researcher reported
that Morris had been a "particularly discourteous and bullying reviewer
who went to extremes to prevent our study from being published. In an
email, Morris ... called people on his mailing list to arms against our
study, openly admitting that he was the reviewer and that he had tried to
get the paper rejected. ... Breaking unwritten confidentiality and
courtesy rules of the peer-review process, Morris distributed his
slandering criticism of our study to people working for the same
cause."[10]
v. Morris not only routinely fails to acknowledge his affiliation with the
CFA; he also outright denies it, violating conflict of interest disclosure
rules. For example, in an article discussing the CFA on a popular
Australian news site, Morris explicitly states: "The authors do not work
for, consult to, own shares in or receive funding from any company or
organisation that would benefit from this article. They also have no
relevant affiliations " (emphasis added). See:
http://theconversation.com/male-circumcision-policy-ignores-research-showing-benefits-8395
vi. Some of whose members, such as C. Terry Russell and Anthony Dilley,
have incomes that come primarily or substantially from performing
circumcisions: see http://www.russellmedical.com.au/;
http://dranthonydilley.ypsitesmart.com.au/.
vii. The RACP statement reads: "After reviewing the currently available
evidence, the RACP believes that the frequency of diseases modifiable by
circumcision, the level of protection offered by circumcision and the
complication rates of circumcision do not warrant routine infant
circumcision in Australia and New Zealand."[13]
viii. Citing an opinion piece in the AAP newsletter [Morris REF: 4] (which
itself includes no references for its assertions) Morris et al. suggest
that circumcision is "riskier" if left to adulthood. Complications may
certainly be better documented for adults, who have the knowledge and
wherewithal to complain if something goes wrong[19]; but there is no
consistent evidence that properly-performed adult circumcision is actually
riskier. It is true that it can be more costly, but only if proper pain
control is used: general anaesthesia is contra-indicated in infants,
meaning that the surgery is performed either with no pain control or with
sub-optimal pain control, driving down costs at the expense of humane
treatment. Only three studies have directly compared the complication
rates of infant and later circumcision. One found no difference;[20]
another found a significantly greater rate following infant
circumcision;[21] and a third found the opposite when using a Plastibell
device.[22] See also Ungar-Sargon[23] for further discussion.
References
1 Donovan B. Book reviews: In favour of circumcision. Venereology
1999;12(2):68-9.
2 Lehman BA. The age-old question of circumcision. Boston Globe, 22 June
1987; 43.
3 Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP
policy report on neonatal circumcision. J Med Ethics 2013;39:434-41.
4 Frisch M, Aigrain Y, Barauskas Y, et al. Cultural bias in the AAP's
technical report and policy statement on male circumcision. Pediatrics
2013;131:796-800.
5 The AAP Task Force on Circumcision 2012. The AAP Task Force on Neonatal
Circumcision: a call for respectful dialogue. J Med Ethics 2013;39:442-3.
6 Task Force on Circumcision. Cultural bias and circumcision: the AAP Task
Force on Circumcision responds. Pediatrics 2013; 131: 801-4.
7 Morris BJ, Tobian AAR, Hankins CA, et al. Veracity and rhetoric in
paediatric medicine: a critique of Svoboda and Van Howe's response to the
AAP policy on infant male circumcision. J Med Ethics 2013; epub ahead of
print.
8 Morris B. Why circumcision is a biomedical imperative for the 21(st)
century. Bioessays 2007;29:1147-58.
10 Frisch M. Author's Response to: Does sexual function survey in Denmark
offer any support for male circumcision having an adverse effect? Int J
Epidemiol 2011;41:312-4.
12 Yasseri T, Spoerri A, Graham M, Kert?sz J. The most controversial
topics in Wikipedia: A multilingual and geographical analysis. In: Fichman
P, Hara N, editors, Global Wikipedia: International and cross-cultural
issues in online collaboration. Scarecrow Press, 2014. Available at:
http://arxiv.org/vc/arxiv/papers/1305/1305.5566v1.pdf.
13 Royal Australasian College of Physicians, Paediatrics & Child
Health Division. Circumcision of infant males. [cited 2010 Sep 29].
Available from URL: http://www.racp.edu.au/page/policy-and-
advocacy/paediatrics-andchild-health
14 Circumcision Foundation of Australia website:
http://www.circumcisionaustralia.org/
15 Hall L. Doctors circumspect on circumcision. Brisbane Times, September
11, 2009. Available at: http://www.brisbanetimes.com.au/national/doctors-
circumspect-on-circumcision-20090910-fjep.html [Accessed September 4,
2013].
16 Forbes D. No evidence to support routine circumcision. Sydney Morning
Herald, 12 September 2009; http://www.smh.com.au/news/opinion/letters/no-
evidence-to-support-routine-
circumcision/2009/09/11/1252519635874.html?page=fullpage
17 The kindest cut? Sunday Night program. Seven Television Network. May
24, 2009. YouTube. http://www.youtube.com/v/7yDvL4hNny4 (8 August 2011,
date last accessed).
18 Morris B. In favour of circumcision. Sydney: University of New South
Wales Press; 1999.
19 Geisheker JV. The completely unregulated practice of male circumcision:
human rights' abuse enshrined in law? New Male Studies 2013;2(1):18-45.
20 Yegane R-A, Kheirollahi A-R, Salehi N-A, Bashashati M, Khoshdel J-A,
Ahmadi M. Late complications of circumcision in Iran. Pediatr Surg Int
2006;22:442-5.
21 Machmouchi M, Alkhotani A. Is neonatal circumcision judicious? Eur J
Pediatr Surg 2007;17:266-9.
22 Moosa FA, Khan FW, Rao MH. Comparison of complications of circumcision
by 'Plastibell device technique' in male neonates and infants. J Pak Med
Assoc 2010;60:664-7.
23 Ungar-Sargon, E. On the impermissibility of infant male circumcision: a
response to Mazor (2013). Journal of Medical Ethics 2013; epub ahead of
print.
24 Lyons B. Male infant circumcision as a 'HIV vaccine'. Publ Health
Ethics 2013;6(1):90-103.
25 O'Neill O. Autonomy and trust in bioethics. Cambridge: Cambridge
University Press; 2002.
26 Erichsen JE. The science and art of surgery. 7th edition, London:
Longmans; 1877;2:932 .
Beauchamp recently argues that Persson and Savulescu's project of
moral enhancement will exacerbate existing distributive unfairness. That
is, the programme aiming to increase persons' sympathy and other relevant
emotional components of moral sense that are believed to help create a
better future will actually lead to a worse situation. Beauchamp
admonishes that the moral enhancement programme may like other
enhancemen...
Beauchamp recently argues that Persson and Savulescu's project of
moral enhancement will exacerbate existing distributive unfairness. That
is, the programme aiming to increase persons' sympathy and other relevant
emotional components of moral sense that are believed to help create a
better future will actually lead to a worse situation. Beauchamp
admonishes that the moral enhancement programme may like other
enhancements which are so limited that only the affluent can enjoy the
benefits of being enhanced, hence increasing inequalities.
This worry seems to completely miss the point. Even if the moral
enhancement programme cannot equally apply to every individual, in a world
prevailed by capitalism, it still seems utterly great if some of the
affluent would like to join the programme. Since the moral enhancement
will enhance their sympathy towards other individuals in the society,
including the poor and the need, those who can afford and are willing to
participate in the enhancement will probably try harder to ameliorating
the unjust distribution of resources.
It is true that physical or cognitive enhancement, if only available
to the rich, may increase the existing unfairness. Yet, due to the nature
of the moral enhancement, it's difficult to take seriously Beauchamp's
worry that moral enhancement may aggravate existing social prejudices and
distributive unfairness.
I would agree with many of the points that Moen raises in his
intersting journal especially that many of the problems prostitutes face
are secondary to external factors.
Despite this I feel that the analogies he uses almost ridicule many
of the sensitive points he argues. I do not feel you can compare
hairdressing to prostitution because of the act involved. Our morals
around sex form such an integral part of...
I would agree with many of the points that Moen raises in his
intersting journal especially that many of the problems prostitutes face
are secondary to external factors.
Despite this I feel that the analogies he uses almost ridicule many
of the sensitive points he argues. I do not feel you can compare
hairdressing to prostitution because of the act involved. Our morals
around sex form such an integral part of who we are and the act of having
intercourse is far more personal and intrusive than having a haircut.
Mr Koch is mistaken about the question of whether the Report by the
Royal Society of Canada expert panel that I chaired was peer reviewed.
It was extensively externally peer reviewed.
As to the journal's purported refusal to publish criticisms of the
Report. We received only one request to publish an article critical of the
Report. The author of said paper requested not only that we accept his
manuscript without...
Mr Koch is mistaken about the question of whether the Report by the
Royal Society of Canada expert panel that I chaired was peer reviewed.
It was extensively externally peer reviewed.
As to the journal's purported refusal to publish criticisms of the
Report. We received only one request to publish an article critical of the
Report. The author of said paper requested not only that we accept his
manuscript without peer review but also that we display it prominently
alongside the Report. The former violates basic publishing standards of
peer reviewed international journals. We declined.
in his recent article Bioethics Journal editor Udo Sch?klenk speaks
grandly about academic freedom and bioethical journals "under seige". And
yet, academic freedom and honesty must go together.
His journal's website carries under a "new" banner a link to the 2012
Royal Society Expert Panel report on End of Life Decision Making. Mr.
Sch?klenk was a principal author of this report.
The report was not peer reviewed. Request...
in his recent article Bioethics Journal editor Udo Sch?klenk speaks
grandly about academic freedom and bioethical journals "under seige". And
yet, academic freedom and honesty must go together.
His journal's website carries under a "new" banner a link to the 2012
Royal Society Expert Panel report on End of Life Decision Making. Mr.
Sch?klenk was a principal author of this report.
The report was not peer reviewed. Requests to Mr. Sch?klenk that balanced
critical reviews be included have been politely declined.
So his journal advances as new an old report he helped author as if it
were the last and only word on a complexlly contentious subject
This seems to make some hash of his calls for vigilance, balance, and
forthrightness in journals.
A recent Commentary piece by Lang1 contains a substantial historical error. He writes "Milah is
merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of
the organ system (including all its essential functions) intact." No reference is cited, but the source appears to
be Wallerstein2. Medical considerations make this unlikely,...
A recent Commentary piece by Lang1 contains a substantial historical error. He writes "Milah is
merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of
the organ system (including all its essential functions) intact." No reference is cited, but the source appears to
be Wallerstein2. Medical considerations make this unlikely, and the available historical evidence
contradicts it. From the medical perspective, if the circumcision scar can migrate in front of the corona
glandis it tends to shrink and create a secondary phimosis or a trapped penis. If treated early this can be
remedied without further operation3 but re-circumcision may be necessary4. Leaving it
untreated can have serious consequences5. Successful outcomes, with or without further surgery, result
in a fully exposed glans. Deliberate removal of only the excess foreskin, without subsequent retraction and
exposure of the glans, therefore poses a serious risk of creating an intractable secondary phimosis.
All available evidence suggests that Jewish circumcision did expose the glans. There is no pre-Hellenic
representation of Jewish circumcision - there is almost no surviving early Jewish iconography, and the Jewish
prohibition of exposing the genitals6 means that in any case penises would not be depicted. However,
Egyptian circumcision long predates Jewish circumcision, and there is good reason to believe that the Jewish
practice was derived from the Egyptian7. Iconography of circumcised Egyptians is abundant, and
detailed7. One can see from these that the glans was completely exposed, though there could be a 'cuff'
of residual inner foreskin behind the glans. This is exactly what would be expected from descriptions of the
chituch operation (described by Lang1 as milah). The foreskin is forcefully stretched
forward and severed in front of the glans. The outer layer springs back behind the glans and the residual inner
foreskin is pushed back to meet it7. There is a 5,000 year old Egyptian illustration of the
technique7, and the same technique is still used today in both medical and ritual circumcisions. There
is also much textual evidence that Jewish circumcision exposed the glans. It is recorded that Jewish athletes
competing in Graeco-Roman games wore a cap to cover the glans8.
The chituch type of circumcision does leave sufficient loose skin for foreskin reconstruction by
stretching to be possible, and there is Biblical evidence that this did occur9. Roman surgeons wrote
about techniques for foreskin restoration to re-cover the glans after circumcision8. Many Jews became
Hellenised and wished to compete in athletic events9, for which a reconstructed foreskin was a more
seemly solution than a cap (especially since the cap could be lost in the heat of competition8). It has
long been accepted that periah - ablation of the inner foreskin - was a later introduction into Jewish ritual
circumcision10. This technique is also still currently used in both ritual and medical
circumcision7. Foreskin restoration would have been virtually impossible after the introduction of
periah so periah could not have been part of the operation before the Hellenistic period, and it was a
prescribed part of the rite in the Talmudic period three of four centuries later. It is therefore hard to escape
the idea that periah was introduced to hinder circumcision reversal1,2,7. Following the
destruction of Palestinian Jewish culture in AD 70 Jewish populations were dispersed. Since new ideas would not be
adopted everywhere at the same time, it would be unlikely that periah was adopted by all Jewish communities
at the same time. Circumcision reversal was still a topic of discussion late in the first century AD11.
The important point is that periah did not affect the exposure of the glans penis, it just made circumcision
reversal more difficult.
We would also add, as a postscript, that Lang's use of the sale of Viagra as a metric of erectile dysfuntion1
seems curious when many studies in the developed and developing countries have actually investigated the topic
directly. Large-scale studies in the US12, Australia13 and Africa14 have shown
that circumcised men are significantly less likely to suffer from erectile dysfunction. Sales of Viagra in the
richest country of the world reflect nothing more than the ability to pay for it.
REFERENCES
1. Lang DP. Circumcision, sexual dysfunction and the child's best interests: why the anatomical details matter.
J Med Ethics 2013. (Epub ahead of print May 28. doi 10.1136/medethics-2013-101520).
2. Wallerstein E. Circumcision - An American Health Fallacy. New York: Springer, 1980:281pp.
3. Blalock HJ, Vemulakonda V, Ritchey ML et al. Outpatient management of phimosis following newborn
circumcision. J Urol 2003;169:2332-4.
4. Patel H. The problem of routine infant circumcision. CAMJ 1966;95:576-581.
5. Sancaktutar AA, Kilincaslan H, Atar M et al. Severe phimosis leading to obstructive uropathy in a boy with
lichen sclerosus. Scand J Urol Nephrol 2012;46:371-4.
6. Genesis 9, verses 20-24
7. Cox G, Morris BJ. Why circumcision, from prehistory to the 21st century. In: Bolnick DA, Koyle M, Yosha A
(eds), Surgical Guide to Circumcision London: Springer. 2012:243-59.
8. Rogers BO. History of external genital surgery. In: Horton CE (ed). Plastic and Reconstructive Surgery of
the Genital Area. Boston: Little Brown & Co. 1993:3-15.
9. 1 Maccabees 1, verses 15-16
10. Bryk F. Circumcision in Man and Woman. (tr. Felix Berger). New York: American Ethnological Press,
1934:342 pp. (Facsimile reprint New York: AMS Press, 1974)
11. 1 Corinthians 7, verse 18
12. Laumann EO, Maal CM, Zuckerman EW. 1997. Circumcision in the United States. Prevalence, prophylactic effects,
and sexual practice. JAMA 1997; 277:1052-7.
13. Richters J, Smith AMA, de Visser RO, Grulich AE, Rissel CE. Circumcision in Australia: prevalence and
effects on sexual health. Int J STD AIDS 2006;17:547-554
14. Krieger, JN. Circumcision, sexual function and sexual satisfaction. In: Bolnick DA, Koyle M, Yosha A (eds),
Surgical Guide to Circumcision London: Springer 2012:233-239
Sir,
Waleed Al-Herz and colleagues have posed a common yet not so easy-to
answer situation. No doubt, honourary authorship is to be discouraged in
medical reporting, yet it's easier said than done.The authors have tried
to delve in deep into the problem, however, the overbearing impact of the
"publish or perish" conundrum has to be taken at the face of it. We have
to evolve methods of evaluating the scientific contribut...
Sir,
Waleed Al-Herz and colleagues have posed a common yet not so easy-to
answer situation. No doubt, honourary authorship is to be discouraged in
medical reporting, yet it's easier said than done.The authors have tried
to delve in deep into the problem, however, the overbearing impact of the
"publish or perish" conundrum has to be taken at the face of it. We have
to evolve methods of evaluating the scientific contribution to biomedical
research including an "Integrity Index". Now what all would be included in
this index would require like-minded ethicists to put their heads together
and evolve.
Conflict of Interest:
Member of Institutional research & Ethics Committeee
I believe that the practical framework produced by Sofaer, Lewis and
Davies, is the best document available for research ethics committees on
post- trial obligations and responsible transition of research
participants from the last visit of a study to the appropriate healthcare.
This document should be taken into account for future discussion of the
Declaration of Helsinki 2013 draft paragraph on post-trial obligations
(...
I believe that the practical framework produced by Sofaer, Lewis and
Davies, is the best document available for research ethics committees on
post- trial obligations and responsible transition of research
participants from the last visit of a study to the appropriate healthcare.
This document should be taken into account for future discussion of the
Declaration of Helsinki 2013 draft paragraph on post-trial obligations
(see DoH, paragraph 34).
I've written my PhD dissertation on the topic of these guidelines. And
I've attended the seventh consultation at the Brocher Foundation in Geneva
and translated into Spanish an advanced draft of "Care After Research"
Guidelines, that it's available open access to download here:
http://philpapers.org/rec/SOFADD
I hope these materials reach the suitable audience in time.
Javier Hidalgo's response[1] to my commentary[2] was unsatisfactory and
is likely to mislead the readership of JME. First, biomedical journals often discourage authors from citing unpublished studies. After reading
Hidalgo's response, one can see the wisdom of that rule. He quotes several
incorrect assertions made by Michael Clemens in 2007 in an unpublished
paper[3] about my article with Frederic Docquier.[4]
Javier Hidalgo's response[1] to my commentary[2] was unsatisfactory and
is likely to mislead the readership of JME. First, biomedical journals often discourage authors from citing unpublished studies. After reading
Hidalgo's response, one can see the wisdom of that rule. He quotes several
incorrect assertions made by Michael Clemens in 2007 in an unpublished
paper[3] about my article with Frederic Docquier.[4]
Second, Hidalgo repeats the misleading quote from page 6 of Clemens[3]
in his response:
"Bhargava and Docquier note that the fraction of physicians abroad has a
positive and significant effect on the number of adult deaths due to AIDS
in general, while - interestingly--- it has a negative and significant
effect on AIDS deaths in countries where HIV prevalence is low."
In fact, I had spelled out how the net effect of physician emigration rate
on adult deaths due to AIDS is computed in non-linear models[2] and stated
that:
"Thus, the net effect at the sample midpoint was positive; net effect was
very close to 0 (-0.005) when computed at the start of the sample in
1991."
Thus, Clemens is wrong about the negative effect being significant-- it is
not statistically different from zero at the start of the sample. In fact,
to show that the negative net effect is statistically significant for
countries with low HIV prevalence rates, one would have to evaluate its
standard error that in turn depends on standard errors of two other
estimated coefficients and their sample covariance.[2] Such computations
could not have been performed by Clemens since the covariance between the
estimated coefficients was not reported by Bhargava and Docquier.[4]
Further, the net effect was positive at the sample midpoint where the
expectation should be evaluated in such models. This is because the net
effect is a function of the random variable HIV prevalence rates that
varies across countries and over time. Thus, evaluating the net effect at
the sample midpoint is a reasonable approximation for its mathematical
expectation.
Third, I had made several points about the importance of micro data
that are essential for "integrating the epidemiological evidence from
developing countries with the results from analyses of country-level
data". One of the problems in policy oriented research is that some
authors may not be familiar with quantitative analyses necessary for
extracting information from longitudinal data sets covering heterogeneous
individuals over time. While it is easy to base one's claims on analyses
of country-level data, the ethical quandary is whether to incorporate the
findings from elaborate micro studies that may support or contradict the
assertions. For example, I had cited our study in South Africa[5] showing
the benefits of uptake of healthcare services for AIDS patients' CD4 cell
counts and quality of life indicators. There are numerous vacancies for
nurses and physicians in South African clinics because many staff members
have left for more lucrative venues in OECD countries. For a policy debate
to be constructive, it is essential that the available evidence be
examined. It would have been helpful if the micro evidence especially from
sub-Saharan African countries received greater prominence in this
discussion.
Finally, Clemens has claimed that our definition of emigrating
physicians is "problematic"- a claim that Hidalgo repeats. Because the
data agencies in OECD countries use three definitions, we compared the
alternative definitions of emigrating physicians in a subsequent paper[6]
and found this issue to be unimportant. In fact, correlations between
bilateral stocks of emigrating physicians on the basis of countries of
birth and countries of training were very high for countries such as the
U.S. (0.98), France (0.97), and Canada (0.94). Moreover, developing
countries are justified in recovering the investments made in educating
the emigrating physicians.
In summary, policy debates surrounding the emigration of physicians
need to be conducted in a scholarly manner. This can be achieved to some
degree by conducting several empirical or analytical studies and
summarizing the findings for a policy readership. As I had noted
previously, "the policy of regularly recruiting physicians from developing
countries runs contrary to the ethos of technology transfer". Hidalgo's
response avoids addressing many issues that are important from a policy
viewpoint.
REFERENCES
1. Hidalgo, J. Defending the active recruitment of health workers: a
response to commentators. J. Med Ethics. Published online first: 31 may 2013. doi: 10.1136/medethics-2013-101325
2. Bhargava, A. Physician emigration, population health and public
policies. J Med Ethics. Published online first: 26 January 2013.
doi:10.1136/medethics-2012-101235.
3. Clemens, M. Do visas kill? Health effects of African health
professional emigration. Center for Global Development Working Paper
Number 114 2007:1-47.
4. Bhargava, A., Docquier, F. HIV pandemic, medical brain drain and
economic development. World Bank Econ Rev 2008: 22:345-66.
5. Bhargava, A., Booysen, F. Healthcare infrastructure and emotional
support are predictors of CD4 cell counts and quality of life indices of
patients on anti-retroviral treatment in Free State Province, South
Africa. AIDS Care 2010:22: 1-9.
6. Bhargava, A., Docquier, F., Moullan, Y. Modeling the effects of
physician emigration on human development. Econ Human Biol 2011:9: 172-83.
The Health Research Authority (HRA) is fully supportive of, and
strongly encourages, the involvement of patients and the public as active
partners in all aspects of the research process. Such involvement produces
high quality ethical research consistent with the HRA's mission to
'protect and promote the interests of patients and the public in health
research'. The HRA will shortly launch a three-month consultation on its...
The Health Research Authority (HRA) is fully supportive of, and
strongly encourages, the involvement of patients and the public as active
partners in all aspects of the research process. Such involvement produces
high quality ethical research consistent with the HRA's mission to
'protect and promote the interests of patients and the public in health
research'. The HRA will shortly launch a three-month consultation on its
public involvement strategy which sets out our proposed approach for
involving patients and the public in our work, and how we can support and
enable the research community to involve patients and the public more in
their work.
The HRA agrees that patient involvement (PI) offers real benefits as
described in this article. However, it does take issue with the author's
central thesis that the role of lay members on research ethics committees
(RECs) is to be understood as primarily providing a "patient perspective"
involving "checking the accessibility of written materials" and ensuring
that researchers produce "a summary for a lay audience". The HRA is proud
of, and is grateful to all its volunteer REC members who give up their
valuable time to review health research in the NHS in order to ensure that
the rights, safety, dignity and well-being of research participants are
protected. Whilst checking written materials and lay summaries are
important aspects of that review we do not recognise this somewhat narrow
conception of the lay member's contribution put forward in this article.
Staley correctly states that NRES (a Directorate of the HRA)
identifies one aspect of the lay contribution as "taking a balanced view
of the likely harms and benefits of a research project by bringing a lay
perspective..." but neglects to point out that the Department of Health's
'Governance arrangements for research ethics committees - A harmonised
edition' (updated April 2012), states that:
"4.2.2 RECs are expected to reflect current ethical norms in society
as well as their own ethical judgement. REC members may come from groups
associated with particular interests but they are not representatives of
those groups. REC members are appointed in their own right to participate
in the work of a REC as equal individuals of sound judgement, relevant
experience and adequate training in research ethics and REC review.
4.2.3 A REC should contain a mixture of people who reflect the currency of
public opinion ('lay' members), as well as people who have relevant formal
qualifications or professional experience that can help the REC understand
particular aspects of research proposals ('expert' members)."
The important role of lay members as "equal individuals of sound
judgement" reflecting "the currency of public opinion" is thus an integral
part of an ethics committee's function. Lay members are already charged
with taking the very perspective that Staley argues will be necessary as a
result of increasing levels of patient involvement, namely the
contribution of "their views as a 'member of the public'" as a "general
citizen - or reasonable person".
Staley suggests that "If the patient perspective is incorporated into
research projects through early PI, then the quality of these PI processes
will need to be assessed as part of the REC review". In fact RECs already
assess the level of patient involvement through consideration of the
answer given to question (A14-1) of the current Integrated Research
Application System (IRAS) application form: "In which aspects of the
research process have you actively involved, or will you involve,
patients, service users, or members of the public?". This question draws
the attention of both researchers and RECs to the importance of patient
involvement with researchers being challenged to justify any absence of
patient and/or public involvement to the committee.
The HRA welcomes and actively promotes the involvement of patients
and public in the design of health research but this is, unfortunately, a
long way from becoming standard practice, with some researchers still
taking patient involvement to mean that patients are sufficiently
'involved' by virtue of their simply being research participants. So,
whilst REC members do already assess and promote patient involvement in
health research, reflect public opinion and ensure transparency and public
accountability, the "patient perspective", brought not just by lay members
but expert members too (who we should not forget are also patients and
members of the public), will continue to play an important part in the
ethical review of health research in the UK.
Joan Kirkbride (Director of Operations, Health Research Authority)
& Prof. Andrew George (NREAP Chair)
Conflict of Interest:
Joan Kirkbride is the Health Research Authority's Director of Operations with responsibility for the operation of research ethics committees within the National Research Ethics Service. Prof. Andrew George is the Chair of the Health Research Authority's National Research Ethics Advisors' Panel (NREAP) and an expert member of the West London & GTAC REC
"Professor Morris is a man on a mission to rid the world of the male foreskin."
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in his recent article Bioethics Journal editor Udo Sch?klenk speaks grandly about academic freedom and bioethical journals "under seige". And yet, academic freedom and honesty must go together. His journal's website carries under a "new" banner a link to the 2012 Royal Society Expert Panel report on End of Life Decision Making. Mr. Sch?klenk was a principal author of this report. The report was not peer reviewed. Request...
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Javier Hidalgo's response[1] to my commentary[2] was unsatisfactory and is likely to mislead the readership of JME. First, biomedical journals often discourage authors from citing unpublished studies. After reading Hidalgo's response, one can see the wisdom of that rule. He quotes several incorrect assertions made by Michael Clemens in 2007 in an unpublished paper[3] about my article with Frederic Docquier.[4]
Se...
The Health Research Authority (HRA) is fully supportive of, and strongly encourages, the involvement of patients and the public as active partners in all aspects of the research process. Such involvement produces high quality ethical research consistent with the HRA's mission to 'protect and promote the interests of patients and the public in health research'. The HRA will shortly launch a three-month consultation on its...
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