We do good not eliminating coercive measures in psychiatry.
The priority of the good on the just one
Prinsen and van Delden ask if we can justify eliminating coercive
measures in psychiatry, because the practice of coercive measures in
psychiatry is controversial. They say also that because there are conflict
between autonomy and beneficence/non-maleficence, human dignity, the
experiences of patients and the eff...
We do good not eliminating coercive measures in psychiatry.
The priority of the good on the just one
Prinsen and van Delden ask if we can justify eliminating coercive
measures in psychiatry, because the practice of coercive measures in
psychiatry is controversial. They say also that because there are conflict
between autonomy and beneficence/non-maleficence, human dignity, the
experiences of patients and the effects of coercive measures, an appeal to
respect autonomy and/or human dignity cannot be a sufficient reason to
reject coercive measures. All together, these ethical
aspects can be used both to support and to reject a non-seclusion
approach. And so the authors argue that reasons such
as respect for autonomy and the violation of human dignity are not
sufficient reasons to eliminate seclusion. Altogether, at least in some
interpretation, these norms can be used both to support and to reject a
non-seclusion approach.
The precaution principle of "primum non nocere" should guide our
actions. The authors choose a perspective of beneficence. This perspective
is a
good choice if beneficence is inserted not in the context of a pragmatic
point of view that belongs to the theory of the principialism but in
the context of the ethics of practical virtues.
I agree with Prinsen and van Delden that reasons such as respect for
autonomy and the violation of human dignity are not sufficient reasons to
eliminate seclusion. The mental illness is either a myth or scientific
object
or something else; but mental illness is real. And the patient above all
is
real and psychiatrists move in the effective and real practice with
difficulties of personal, social and ethical character.
Asking "Can we justify eliminating coercive measures
in psychiatry?" is a badly phrased question, since this is not a justice
issue but an issue of being well and good, and is not an issue that we
can justify.
I support the priority of being good and well on being just . I
support with force the priority of practical reasoning. Also in
medicine and in particular in psychiatry.
1. E J D Prinsen and J J M van Delden, Can we justify eliminating
coercive measures in psychiatry? J Med Ethics 2009; 35: 69-73
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
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.
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.
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.
"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 .
"Through most of human history, around 1% of mothers have died while
giving birth" concludes Homebirth and the Future Child. The citation for
this statement makes no reference to maternal mortality through most of
human history. Still the statement itself raises the interesting
question: How many women died while giving birth through most of human
history? The Talmudic scholars state less than 1 per 1000. They may...
"Through most of human history, around 1% of mothers have died while
giving birth" concludes Homebirth and the Future Child. The citation for
this statement makes no reference to maternal mortality through most of
human history. Still the statement itself raises the interesting
question: How many women died while giving birth through most of human
history? The Talmudic scholars state less than 1 per 1000. They may be
rounding up or down, but there is no better documentation from their time
period (500 AD) to argue that they are off by a power of 10. Evolution
strongly selects for successful childbirth. There is no reason to
believe that the gene for dying in childbirth was a gene that was
reproduced more frequently than 1/1000. Another thing the Talmud
teaches us is that although one-sixth of the Talmud concerns uterine
bleeding, there is no mention of a mother with excessive postpartum
bleeding or hemorrhaging after birth. Not until 1400 is excessive
postpartum bleeding, but not yet hemorrhage, documented.(1) The Talmud
discusses women with no bleeding whatsoever at birth, such as seen in the
animal kingdom. A protocol which completely eliminates PPH > 1000 cc-
calls for squatting out the placenta between 4-5 minutes.(2)
The case of maternal mortality which opens the paper raises a second
question. The article is supposedly about childbirth morbidity of 'the
Future Child' yet opens with a case of maternal death. Judging by the
conclusions of the paper, it is unlikely that the authors are raising the
issue of maternal mortality to emphasize the fact that homebirth is the
best way to prevent an unnecessary cesarean.(3) Whatever the authors
reason for retelling this case of maternal death, a single data point
neither validates or invalidates any theory. Even so, the attentive reader
is alerted to the fact that not even a single data point of perinatal long
term morbidity associated with homebirth is provided by the authors of
this paper. One single data point, at least one baby who suffered long
term morbidity from a homebirth, in the absence of gross malpractice would
be a nice beginning to support a premise that homebirth causes long term
morbidity that is preventable with hospital birth, the supposed topic of
the paper. The entire paper includes only one example of a baby suffering
morbidity at a homebirth, of questionable substance since the authors are
quoting a blog 'essentialbaby.com'. Is the case of maternal mortality
brought in the hope that it would distract the reader from the fact that
the authors found not a single example of perinatal morbidity at
homebirth?
In what scenario, does homebirth result in increased perinatal
morbidity? The authors suggest that "infection, intrapartum hemorrhage,
cord accidents , prolonged labor and shoulder dystocia" as the causes of
increased morbidity of homebirth. Infection, bleeding in labor, and
prolonged labor are very amenable to timely intrapartum hospital transfer,
so they are irrelevant to the premise of the paper. Cord prolapse has
been demonstrated to benefit from emergency cesarean although some cases
are managed successfully vaginally.(4) A recent study showed that cord
prolapse has never been documented in the absence of vaginal exams and
amniotomy(5) making cord prolapse completely preventable at low risk
vertex term labor, in any location. Therefore the only unpreventable cause
of morbidity at low risk birth that might have different outcomes by birth
place is shoulder dystocia. But morbidity is not prevented by hospital
birth. On the contrary, it is too late for a cesarean and the outcomes
depend on the talents and motivations of the practitioner and ability of
the woman to push hard. It can be argued that shoulder dystocia outcomes
are better at home where the woman can easily be turned over to all 4s and
is not anesthetized with an epidural. (http://www.youtube.com/watch?v=O-
OqnqfHQ2Q) If the practitioner is experienced, the baby will be
delivered within 5 minutes without a problem. If the practitioner is new,
tired, unmotivated, etc. the baby has a 10% risk of anoxia. At home
anoxia is more likely to result in death, whereas in hospital, it is more
likely to suffer morbidity. Morbidity from a case of homebirth shoulder
dystocia has yet to be documented. If one were to assume it has occurred
at some point, does it happen often enough to justify all low risk women
being assigned to planned hospital births, as suggested in Homebirth and
the Future Child? Furthermore, would it even be relevant to the 50% of
term pregnancies where the estimated weight of the fetus is under 3100?
The paper brings no studies about homebirth or hospital long term
morbidity, only short term outcomes such as seizures and apgars <7
which appear not to have long term implications in the absence of
underlying problems.(6)
The authors state: "These data confirm what might be expected
intuitively- the inability to achieve timely access to emergency obstetric
care to expedite delivery in the setting of fetal compromise and
paediatric care to optimize neonatal resuscitation and implement
neuroprotection, will impact on the rate of HIE and subsequent
disability." The data to support this is Cheng et al which is a one
paragraph oral presentation based on unreliable birth certificate data, in
which homebirth short term morbidity may be due to hospital interventions
after transfer; and Wax metaanalysis which the authors use to suggest
that neonatal mortality implies "future child morbidity", which
contradicts the obvious fact that when the baby is dead, there is no
future morbidity.
Morbidity is a familiar occurrence in hospitals where almost all
newborns are heroically kept 'alive' at least for a few days, even those
born without a pulse.(7)
The authors display ignorance of the homebirth setting by stating
that ventilation cannot be optimally provided in the homebirth environment
and uncited statements such as, "At home deliveries, there are few
resources to detect and manage complications." ....."Vital delays can
lead to disability, which was avoidable if the delivery had occurred in
hospital, especially in a large country or when support services are
suboptimal." These statements contradict research findings to the
contrary.(8) At planned attended homebirth of straightforward
pregnancies in the presence of a trained midwife the only risk that has
better outcomes in hospital is cord prolapse which can be eliminated by
not performing amniotomy or vaginal exams. In the recent case study of a
bad outcome from a cord prolapse at home, it did not lead to disability
but rather to death.(9)
The scientific method demands that research be built on a cohesive
theory. In this case homebirth is not a rare exotic cancer but something
millions have experienced. The absence of a single case a low risk full
term vertex pregnancy delivered at a homebirth attended by a trained
practitioner in the absence of rank malpractice that resulted in long term
morbidity that would have been prevented at planned hospital birth
negates the credibility of the paper's claims. The current evidence
supports the only correct statement in the paper: 'It is theoretically
possible that high tech hospital care might have higher morbidity than
homebirth.'
Funding statement - no funding
Competing interests- no competing interest
1. Medieval Woman's Guide to Health: The First English Gynecological
Handbook.1981. Croom Helm, London.
2. Cohain JS. A Proposed Protocol for Third Stage Management- Judy's
3,4,5,10 minute method. Birth 2010:37(1)84-5.
3. Cohain JS. Is Action Bias one of the numerous causes of
UnneCesareans MIDIRS MIdwifery Digest 2009:19(4)495-499.
5. Cohain JS. The Less Studied Effects of Amniotomy. J Matern Fetal
Neonatal Med. 2013:26(17):1687-90.
6. Hafstr?m M, Ehnberg S, Blad S, Nor?n H, Renman C, Ros?n KG, et
al.Developmental outcome at 6.5 years after acidosis in term newborns: a
population-based study. Pediatrics. 2012:129(6):e1501-7.
8. Menticoglou SM. How often do perinatal events at full term cause
cerebral palsy? J Obstet Gynaecol Can. 2008:30(5):396-403.
9. Richardson J. Supervisory issues: lessons to learn from a home birth.
BJM. 2009;17(11):710-12.
I would argue that a totally and irreversibly disabled person HAS
ceased to exist. Personhood, medically, exists in the brain. If the brain
has been made permanently incapable of sustaining coherent thought or
experience, it no longer belongs to a person. This view seems to be widely
held by relatives of those with Alzheimer's disease, who speak very
vividly of the gradual loss the person they once knew and loved. Many
p...
I would argue that a totally and irreversibly disabled person HAS
ceased to exist. Personhood, medically, exists in the brain. If the brain
has been made permanently incapable of sustaining coherent thought or
experience, it no longer belongs to a person. This view seems to be widely
held by relatives of those with Alzheimer's disease, who speak very
vividly of the gradual loss the person they once knew and loved. Many
people in the early stages of Alzheimer's disease would rather die early
than be left completely incoherent. Keeping humans alive at that point
amounts to embalming them, almost like the ancient Egyptians, in order to
attempt to preserve something that is already lost: Personhood.
In the brief report, "Conflict of interest in online point-of-care
clinical support websites" (J Med Ethics doi:10.1136/medethics-2013-
101625), Kyle A. Amber et al. offered their perspectives on the role of
conflicts of interest in clinical decision support resources. It is an
important dialog, one UpToDate, a Wolters Kluwer Health company, supports
and welcomes. Indeed, as an organization we continuously and proactively...
In the brief report, "Conflict of interest in online point-of-care
clinical support websites" (J Med Ethics doi:10.1136/medethics-2013-
101625), Kyle A. Amber et al. offered their perspectives on the role of
conflicts of interest in clinical decision support resources. It is an
important dialog, one UpToDate, a Wolters Kluwer Health company, supports
and welcomes. Indeed, as an organization we continuously and proactively
engage clinicians in meaningful conversations about many of the concerns
Dr. Amber cites, as well as their perceptions, expectations and use of
these tools in daily practice.
UpToDate is authored by more than 5,000 of the world's experts who are
clinically active and publish regularly in the fields in which they write.
As such, some individual conflicts of interest are unavoidable. UpToDate
has addressed this by complete transparency with regard to authorship and
potential conflict, and by employing a rigorous, multi-layered peer review
process that is unparalleled among point-of-care clinical decision support
resources.
While we welcome any opportunity to advance these discussions, it is
important that they be based upon a factual foundation. To that end, there
were several inaccuracies and mischaracterizations in the report that must
be addressed.
* All UpToDate topic reviews are written by the listed authors in
conjunction with an in-house Deputy Editor. Deputy Editors are physicians
who work primarily at UpToDate and are specialists in the topic areas they
edit. UpToDate prohibits Deputy Editors from accepting any funds from the
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place internal policies requiring thorough review of any monies or other
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from or hold grant funds from any pharmaceutical organization.
* UpToDate has accomplished what Amber et al. are looking for in the
study: an editor with no conflicts who ensures the integrity of the
article has not been violated. In point of fact, none of the Deputy
Editors associated with the sample topics used for the report has
conflicts of interest. UpToDate's stringent policies and rigorous
editorial process ensure that our content remains impartial, unbiased and
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is to prevent inappropriate material from being published in UpToDate
topic reviews.
* Any potential conflict of interest that may exist with a
contributor is fully disclosed to our readers and we may elect not to
publish material written by an author with a conflict in a controversial
therapeutic area.
* Given the constraints of the UpToDate/Dynamed comparison, there are
several issues in the report that require addressing:
o With regard to conflicts of interest for Dynamed, the study
concludes that "No authors or editors reported a conflict of interest in
the six review articles..." In truth, no specific authors are attributed
to Dynamed articles. Users are instead directed to a page listing the
Dynamed Editorial Team. The lack of transparency prohibits a user from
determining the specific author of an article. As a consequence, the study
writers were themselves unable to directly check for conflicts of interest
for the authors and editors who contributed to the individual articles.
o The authors assert that an anonymous peer review system like that
of UpToDate is a liability that increases the risk for conflicts of
interest. In addition to anonymous peer reviewers, UpToDate material is
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In closing, we appreciate the opportunity to address issues in the
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UpToDate and other clinical decision support resources play in advancing
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The priority of the good on the just one
Prinsen and van Delden ask if we can justify eliminating coercive measures in psychiatry, because the practice of coercive measures in psychiatry is controversial. They say also that because there are conflict between autonomy and beneficence/non-maleficence, human dignity, the experiences of patients and the eff...
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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.
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"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...
"Through most of human history, around 1% of mothers have died while giving birth" concludes Homebirth and the Future Child. The citation for this statement makes no reference to maternal mortality through most of human history. Still the statement itself raises the interesting question: How many women died while giving birth through most of human history? The Talmudic scholars state less than 1 per 1000. They may...
I would argue that a totally and irreversibly disabled person HAS ceased to exist. Personhood, medically, exists in the brain. If the brain has been made permanently incapable of sustaining coherent thought or experience, it no longer belongs to a person. This view seems to be widely held by relatives of those with Alzheimer's disease, who speak very vividly of the gradual loss the person they once knew and loved. Many p...
In the brief report, "Conflict of interest in online point-of-care clinical support websites" (J Med Ethics doi:10.1136/medethics-2013- 101625), Kyle A. Amber et al. offered their perspectives on the role of conflicts of interest in clinical decision support resources. It is an important dialog, one UpToDate, a Wolters Kluwer Health company, supports and welcomes. Indeed, as an organization we continuously and proactively...
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