This represents a thoughtful analysis of costly drugs. Recently, the potential overpricing of a device that allows safe bystander delivery of the established staple narcotic antagonist naloxone bears closer examination. As an emergency physician, I am cautious to avoid needle stick injuries when reversing overdoses in patients who are at high risk of HIV or hepatitis B/C. No matter how careful one is, the clinician still incurs significant occupational exposure. I once accidentally stabbed myself in the hand with a central line finder needle used to treat a shocked woman with hepatitis C who became acutely agitated after naloxone. Months of distress and serological testing followed. Economic analyses of medical care should include safety concerns of frontline paramedics, police and hospital staff. Expensive non intravenous and non intramuscular devices that allow the opiate dependent patient to breath effectively reduces bystander and occupational exposures to life changing infections and could avert the need to transport to hospital emergency rooms.

There is no doubt that cost effectiveness assessment of medical and surgical treatment improves the distribution of limited health care spending more equitably across a range of competing demands for funding. As adjudicated by patient focused outcomes (and now clinician safety), these analyses maximize overall health maintenance and gain in society by ensuring that scarce resources are deployed to patient cohorts that will attain the most benefit from a moderate to expensive intervention. The focus goes beyond living longer to living better with enhanced quality of life, social engagement, symptom and pain control and sustaining emotional wellbeing, factors important in cancer care.

Further steps are required to exert material influence on how health dollars could be better spent. Publicly funded clinical trials could be obliged to examine and report cost implications of health gains when a treatment proves to be effective. Medical school curricula and residency programs should emphasize cost effectiveness assessment as much as the magnitude of therapeutic benefit. Clinical practice guidelines promulgated by specialist groups need to be rid of industry sponsors that bias recommendations towards favoring new expensive treatments that are no better than established options. It is also high time that we also critically appraise the health impact and cost-overruns from excessive and inappropriate medical and screening tests ordered by doctors with a vested interest in using them as much as possible.

Conflict of Interest:

None declared

[This is an elaborated version of a blog on May 13, 2014: http://blog.practicalethics.ox.ac.uk/2014/05/is-home-birth-really-as-safe- as-hospital-birth-woman-centred-care-vs-baby-centred-care/#more-8493] Imagine that you and your partner are having a baby in hospital. Tragically something goes wrong unexpectedly during birth and the baby is born blue. He urgently needs resuscitation if there is to be a chance of preventing permanent severe brain damage. How long would it be reasonable for doctors to wait before starting resuscitation? 15 minutes? 5 minutes? 1 minute? What would be a reasonable excuse for delaying the commencement of resuscitation? They wanted to get a cup of coffee? The mother wanted to hold the baby first? The mother had catastrophic bleeding and this needed urgent attention? If it were my baby, I would not want any delay in starting resuscitation. And the only justification for delaying resuscitation would be some more serious, more urgent problem for another patient, such as the mother. Obstetrics is renowned for the sudden catastrophic events that can occur in a previously low risk healthy pregnancy. These may result in serious morbidity or mortality. Yet when people choose homebirth, delay is precisely what they choose. It is simply not possible to start advanced resuscitation in the home within minutes. And their reason is not typically some relevant competing health concern that necessitates delivery at home. Choosing home birth is choosing delay if some serious problem arises which requires immediate resuscitation. If you could know for certain which babies were going to be born needing resuscitation, and which weren't, you could deliver safely at home. But you can't know for certain. Birth can be a dangerous, unpredictable time. About 0.3% of babies are born with serious medical problems. So someone might argue that the chances of something going wrong at home or in hospital is sufficiently low for it not be necessary to further reduce an already small risk. However, given that around 700 000 women give birth in England and Wales every year, this translates to a large number with serious medical problems. Surely we should try to minimise avoidable severe life long disability? If the numbers were very small, there may be reasons of cost-effectiveness not to try to reduce these to the very minimum. But even if the risk were 1/100,000, when it is your baby that is affected, it is a personal tragedy. In a recent paper, we argued that a neglected outcome of choice of birth place was long term, significant avoidable disability. [1] We argued that there are reasons to believe that the risk of this outcome is higher at home than in hospital, though accurate figures are not available. We called for more research to be done on what we call "future disability." The National Institute for Clinical Excellence has issued a draft guideline for consultation entitled "Intrapartum care: care of healthy women and their babies during childbirth" , [2] Two key recommendations are: * Advise low-risk multiparous women to plan to give birth at home or in a midwifery-led unit (freestanding or alongside). Explain that this is because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit. * Advise low-risk nulliparous women to plan to give birth in a midwifery- led unit (freestanding or alongside). Explain that this is because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit, but if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby. The BBC reported, "Home births were just as safe as other settings for low -risk pregnant women who already had at least one child." [3] This guidance is based on the largest prospective cohort study of the outcome of place of birth, The Birthplace Study. This followed nearly 65000 women. It found, "There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth." [4] This study found that home birth was riskier for first time mothers, but not for low risk women who had had at least one child already. But does that make home birth as safe as hospital birth for multiparous women? This study did not examine the rates of severe long term disability arising from choice of birth place, which we argued is ethically the most relevant outcome. It tells us nothing about the outcome that matters most. What did this study measure as primary outcomes? It adopted a composite measure (that is it pooled a bunch of different outcomes): "stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle."[4] Why did it do that? Although they studied nearly 65 000 women these adverse events are relatively rare - only 250 occurred in the study. To get statistical significance, they needed to combine these. But these outcomes are very different ethically. Two outcomes included were a fractured clavicle or humerus, but these are fully correctable. They are completely different to permanent severe brain damage. Moreover, the authors don't even grade the severity of these primary outcomes. Encephalopathy can be mild to severe. Some forms will not be associated with any long term severe disability. Taking these factors into account, this study is just underpowered to detect the outcome that matters most ethically - long term avoidable severe disability. The authors state that neonatal encephalopathy and meconium aspiration syndrome are thought to be associated with long-term morbidity and they accounted for 87% of the non-fatal events of the birthplace composite primary outcome . [5] Yet both of these can have variable long term outcomes. Moreover, the composite outcome employed by the Birthplace Study do not include all causes of long term disability. What is needed are long term follow up studies so we know the risks for serious permanent damage of different places of birth. The authors admit as much: "The weaknesses of the study include the use of a composite primary outcome measure, because of the low event rates for individual perinatal outcomes. We cannot rule out the possibility that the use of a composite may have concealed important differences in outcomes between planned places of birth, such as less severe outcomes in a particular setting. However, examination of the distribution of outcomes by planned place of birth did not suggest that this was the case. In addition, although many of the outcomes included in the composite are likely to reflect problems which occur during labour and birth, their long term implications for the baby are uncertain. For example, although moderate and severe neonatal encephalopathy are associated with development of cerebral palsy and long term morbidity, mild encephalopathy has not been associated with detectable longer term impacts." [6] These outcome measures are reasonable surrogates of future disability. But even if there is no difference in these surrogates, this does not tell us of the rates of future child disability. Such studies would have to be very large and conducted over a long period of time at great cost. There are other reasons to believe that this study does not sufficiently inform us of risks of future child disability. They took a random sample of hospitals providing obstetric care. But there are reasons to believe that hospitals will differ in their capacity to offer rapid resuscitation, just as delivery at home cannot offer this to the highest standard possible. A hospital with a neonatal intensive care facility, and highly trained staff readily available, will be able to offer more effective resuscitation than smaller regional centres. (It is for this reason that our friends who are doctors have their babies in hospitals with access to neonatal intensive care). Even if there were no difference between home and hospital with respect to future disability, this would tell us little about the comparison between best obstetric/paediatric care and best home birth care. Two of the authors of the Birthplace Study in response to our article make the point (which is echoed by the BBC and NICE) that hospital based care can be associated with higher rates of intervention, such as Caesarean, which exposes the mother and future pregnancies to risk. [5] For example, the BBC reports: "The guidelines from NICE - the National Institute for Health and Care Excellence - say a home birth may be just as safe for low-risk pregnancies. Hospital labour wards with doctors should be for difficult cases, it says. Otherwise there is a danger of over-intervention, according to NICE." [3] This is a valid concern. However, if true, it would hardly be a good a reason to have home birth. It would be a reason not to over-intervene in hospital! To be sure, getting hospitals to change their practices (some shaped more by concerns about efficiency, or simply bad institutional habits, than optimal health) may not be easy and does indeed need sustained attention to correct. But our focus should be best obstetric care, not second best care. In addition, the harms experienced by women in hospital are of a different kind to those experienced by a baby from hypoxia. For example, treatable infection is very different to life long severe disability. The NICE guideline talks proudly throughout of "Woman-centred care." At very least, this should be "Woman and Baby-centred care". The authors of The Birthplace Study responded to us by saying that although a composite outcome measure could potentially have disguised important differences in outcomes between birth settings, it is pure speculation to suggest that the effect on longer-term disability would be likely to favour hospital birth. [5] But we did not conclude this. We stated that other evidence suggests that long-term disability may be lower with hospital birth. We further suggested that research is required to document the prevalence of long term disability associated with different birth place choices.

Other issues that may impact on whether the primary outcome provides a measure of long term disability include questions about why in this low -risk population of women were 20 of the 32 deaths in the home or Freestanding Midwifery Unit groups? And why did 1 in 5 of the women in the obstetric units group have complications at the onset of birth compared to the 5-7% of the other low-risk women? [7] In addition, what were the number & proportion transported in labour? What was the average, minimum and maximum time interval from the decision to transport the maternal and fetal patient to in-hospital intervention? [8]

Other criticisms of this influential study include that there was a failure to include the lifetime costs for support of severely disabled children, estimated to be ?5 million per child. [9]

In Dahlys' analysis of the published research paper (or supplementary data) he notes that the paper doesn't provide outcome information specifically for women planning a homebirth who wound up transferring to hospital, which is unfortunate. [10]

Tuteur reports that the list of study exclusion criteria employed in this study was far more restrictive than the actual exclusion criteria for homebirth in the UK. Therefore, a substantial proportion of the women who actually had a homebirth were excluded from the study even before it began. Of the 18,269 low risk women planning homebirth at the start of the study, 1346 (7.4%) were excluded from the study despite the fact that they went on to have a homebirth under the auspices of the National Health Service. [11] She notes that the supplemental material includes the outcomes for those women who had homebirths but did not meet the very restrictive criteria of the study. [12] She compares them with the low risk women electing hospital birth who also failed to meet the more restrictive criteria for inclusion in the study. Homebirth doubled the risk of an adverse outcome for both nulliparous women and multiparous women in the "higher risk" group. [11]

She states that this is further confirmation of the central finding of the study. Homebirth doubles the risk of adverse perinatal outcomes. Therefore, the claim of the Royal College of Midwives and other homebirth advocates that ".., [f]or women having a second or subsequent baby ... homebirths appear to be safe for the baby" is not true. [11]

Homebirth is safe only when nothing goes wrong. Since there is no way to predict with complete accuracy whether something is going to go wrong, and facilities, equipment and expertise for complete management of mother and baby are compromised or lacking in the home, homebirth is riskier than hospital birth. [11] The fact is, we just don't know if best practice home birth is as safe with respect to future disability as best practice hospital birth. There is not enough research. There is evidence it is more dangerous for first time mothers (though again this is not in relation to the outcome of future disability) and there are good reasons based on understanding of the risks of child birth and the interventions available to concerned whether there will be some elevated risk at least related to delay in resuscitation associated with transfer. In our article, we reviewed a variety of arguments and existing evidence that suggest risk associated with home birth of future disability will be higher. For example, a meta- analysis which included 12 studies and 500,000 planned homebirths in healthy low risk women showed neonatal mortality tripled. [13] But good direct research has not been done and it would require extremely large studies over many years. The elevation of future child risk associated with home birth, if it exists, is likely to be small. But small risks of tragic outcomes ought to be minimised. For this reason, the Royal College of Obstetricians recommends that home birth only be considered "provided transport arrangements are in place for hospital transfer in the event of an emergency ". [3] But what kind of "transport arrangement" would minimise risk? An ambulance on stand-by? Whatever transport is arranged, it will involve an inevitable delay compared with delivery in a tertiary centre. And minutes can matter for the baby. Some might argue this is excessively risk averse. But the risk of injury to the child from not wearing a seat belt on any single trip, or even over a year is extremely small. Nonetheless, we believe that it is right to minimise this risk by putting on a seat belt. Women should have choice over their place of delivery. But they should make that choice in full knowledge of the facts, arguments and gaps in evidence. There may be reasons to do with cost and distributive justice that preclude every woman and child being offered the best care possible. But where there is a choice, people should at very least know what is known, and what is not known, about the risks and benefits of each option. References: 1 de Crespigny L, Savulescu J. Homebirth and the Future Child. Journal of Medical Ethics Published online first: 22 January 2014. Doi: 10.1136/medethics-2012-101258.

2 NICE guideline. Intrapartum care: care of healthy women and their babies during childbirth. Draft for consultation, May 2014. P10. http://www.nice.org.uk/nicemedia/live/13511/67644/67644.pdf

3 Roberts M. Labour wards not for straightforward births' says NICE. BBC News, Health. 13 May 2014. http://www.bbc.co.uk/news/health-27373543 (accessed 24 June 2014)

4 Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011; 343: d7400: 1.

5 Hollowell J, Brocklehurst P. Homebirth and the future child: factual inaccuracies in commentary on the Birthplace study. JME [e- letter] 28 April. http://jme.bmj.com/content/early/2013/10/08/medethics- 2012-101258/reply

6 Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400: 4.

7 Falconer T. Re: Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. JME [e-letter] 1 December 2011. http://www.bmj.com/content/343/bmj.d7400?tab=responses

8 Arabin B. Re: Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. JME [e-letter] 18 January 2012. http://www.bmj.com/content/343/bmj.d7400?tab=responses

9 Svensson G. Re: Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. JME [e-letter] 28 November 2011. http://www.bmj.com/content/343/bmj.d7400?tab=responses

10 Dahly. Are homebirths really risky? Statistical Epicimiology. Published 4 December 2011. http://statisticalepidemiology.org/are- homebirths-really-more-risky/ (accessed 24 June 2014)

11 Tuteur A. Birthplace study yields additional disturbing information. The Skeptical OB. Published 19 December 2011. http://www.skepticalob.com/2011/12/birthplace-study-yields-additional.html (accessed 24 June 2014)

12 Hollowell J, Puddicombe D, Rowe R, et al. The birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth. Birthplace in England research programme. Final report part 4. Published November 2011. http://www.netscc.ac.uk/hsdr/files/project/SDO_FR4_08-1604-140_V03.pdf (accessed 24 June 2014)

13 Wax JR, Lee Lucas F, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Americal Journal of Obstetrics and Gynecology, Volume 203, Issue 3, 243.e1 -243.e8; September 2010.

Conflict of Interest:

None declared

It is ironic that Dr. Gershon, president of the IDSA, would decree the article by Johnson and Stricker to be full of “inaccuracies and misleading information” only to mislead readers using inaccurate information. A look at the science may be enlightening.

The IDSA holds that Lyme disease is easily cured, yet data from treatment trials cited in the 2006 IDSA guidelines suggests otherwise. The issue of persistent symptoms following treatment for Lyme disease is a particularly vexing one, and the etiology of these symptoms remains unproven. Animal studies and human case reports suggest that persistent infection with the Lyme spirochete does occur. To investigate this further, four separate trials studied the use of additional antibiotics in patients with persistent symptoms following standard IDSA-sanctioned therapy for Lyme disease. The patients in the retreatment trials had been ill for extended periods of time. For example, in one study, patients, on average, had been symptomatic for roughly 4.5 years despite previous antibiotic therapy. The response to treatment in these trials was mixed. While one investigator found no improvement with treatment, two others found a significant and sustained treatment-related reduction in fatigue. Debilitating fatigue is a prominent complaint in patients with persistent symptoms following standard antibiotic therapy for Lyme disease. Thus the statement by Dr. Gershon, “(b)linded, randomized controlled trials show that long-term antibiotic treatment is not effective for any condition described as ‘chronic Lyme’ ” is inaccurate and misleading.

The semantics involved in identifying patients who remain symptomatic after treatment is important. Dr. Gershon notes that there are no consistent markers for chronic Lyme disease, implying that there is no evidence for its existence. Yet the IDSA guidelines create a new diagnostic category, “post-Lyme syndrome”, with a similar problem: “Post- Lyme syndrome” implies the existence of definitive evidence that the initial bacterial infection has been cleared. However, available testing modalities cannot provide such evidence, nor is there a specific biologic marker for “post-Lyme syndrome”. Rather, the syndrome seems to be defined by failure of a restricted course of antibiotics to eliminate Lyme disease -related symptoms in a given individual. It is more likely that “post-Lyme syndrome” represents a failure of restricted antibiotic therapy to clear the infection, as outlined in the animal and human studies mentioned above, rather than a nebulous entity with no clear definition and no available treatment.

Dr. Gershon contends that Lyme disease is not a fatal illness. This statement is incorrect. Lyme disease has been associated with fatal myocarditis and encephalomyelitis (1,2), as well as intrauterine fetal death (3). Furthermore, tick-borne coinfections with the agents of Babesiosis, Anaplasmosis, Ehrlichiosis, Rickettsiosis and Tularemia are well-known direct causes of mortality, and these coinfections can be transmitted together with the Lyme spirochete (4-7). Because of clinical ignorance about these diseases and poor laboratory test sensitivity, it is likely that fatal cases of tick-borne diseases may go unrecognized and consequently are under-reported (7,8).

Politicians, including the Attorney General of Connecticut, are drawn into the Lyme disease arena because IDSA has allowed politics to enter into the discussion of this illness through its restrictive guidelines process. Generalizable studies that address the many variables affecting patients with Lyme disease are desperately needed to improve our understanding of the illness in order to better guide treatment. Until that work is completed, minds and options need to remain open. The 2006 IDSA guidelines take the opposite approach, which is why they need to be substantially revised.

1: Tavora F, Burke A, Li L, Franks TJ, Virmani R. Postmortem confirmation of Lyme carditis with polymerase chain reaction. Cardiovasc Pathol. 2008; Mar-Apr;17(2):103-7. 2: van Assen S, Bosma F, Staals LM, Kullberg BJ, Melchers WJ, Lammens M, Kornips FH, Vos PE, Fikkers BG. Acute disseminated encephalomyelitis associated with Borrelia burgdorferi. J Neurol. 2004 May;251(5):626-9. 3: Markowitz LE, Steere AC, Benach JL, Slade JD, Broome CV. Lyme disease during pregnancy. JAMA. 1986 Jun 27;255(24):3394-6. 4: Javed MZ, Srivastava M, Zhang S, Kandathil M. Concurrent babesiosis and ehrlichiosis in an elderly host. Mayo Clin Proc. 2001 May;76(5):563-5. 5: Bakken JS, Dumler JS. Clinical diagnosis and treatment of human granulocytotropic anaplasmosis. Ann N Y Acad Sci. 2006 Oct;1078:236-47. 6: Penn RL, Kinasewitz GT. Factors associated with a poor outcome in tularemia. Arch Intern Med. 1987 Feb;147(2):265-8. 7: Paddock CD, Holman RC, Krebs JW, Childs JE. Assessing the magnitude of fatal Rocky Mountain spotted fever in the United States: comparison of two national data sources. Am J Trop Med Hyg. 2002 Oct;67(4):349-54. 8: Millar BC, Xu J, Moore JE. Molecular diagnostics of medically important bacterial infections. Curr Issues Mol Biol. 2007 Jan;9(1):21-39.

Brian D. Earp University of Oxford

Introduction

Is prostitution harmful? And if it is harmful, should it be illegal to buy (or sell) sexual services? And if so, should there ever be any exceptions? What about for people with certain disabilities--say--who might find it difficult or even impossible to find a sexual partner if they weren't allowed to exchange money for sex? Do people have a "right" to sexual fulfillment?

In a recent issue of the Journal of Medical Ethics, Frej Klem Thomsen[1] explores these and other controversial questions. His focus is on the issue of exceptions--specifically for those with certain disabilities. According to Thomsen, a person is "relevantly disabled" (for the sake of this discussion) if and only if:

(1) she has sexual needs, and desires to exercise her sexuality, and

(2) she has an anomalous physical or mental condition that, given her social circumstances, sufficiently limits her possibilities of exercising her sexuality, including fulfilling her sexual needs. (p. 455)

There is a lot to say here. First, in order to figure out the merits of making an exception to a general ban on prostitution (for people with disabilities or for anyone else), we have to start by deciding what to think about the advisability of such a ban in the first place. For, if we don't think that it's a good idea to begin with, then we can skip all the talk about making exemptions, and just argue against the overall ban. But Thomsen doesn't pursue that route. Instead, he wants to make a case for an exception. So, he has to try to convince his reader that a general prohibition makes at least some kind of moral and/or practical sense. How does he go about making this argument?

A case for prohibition?

Thomsen spells it out like this:

(1) Prostitution is bad because it causes harm to prostitutes.

(2) We have reason to avoid harm to persons.

(3) Prohibiting prostitution will reduce harm to prostitutes.

(4) Therefore, we have reason to prohibit prostitution. (p. 453)

Is this a good argument in favor of prohibition?

The harm of prostitution

We can start with the first claim: that prostitution is bad because it causes harm to prostitutes. Is that a convincing claim?

It does have a certain intuitive appeal, and most people would probably say "yes." But in another recent essay (also published in the JME), the philosopher Ole Martin Moen has put forward a powerful set of arguments that call into question conventional wisdom.[2]

According to Moen, while it is true that prostitution is not a harmless line of work:

(1) it is no more inherently harmful (on balance) than a long list of other occupations which we do not see fit to ban, but instead choose to regulate; and

(2) most of the harm that does go along with prostitution is actually a consequence of its being illegal (and otherwise socially stigmatized)-- i.e., contingent, external factors that have little to do with prostitution per se.

Let us take a closer look at Moen's argument. To do this, we can start by considering one specific type of harm as an example: the apparently higher rates of physical and mental health problems among sex workers compared to members of the general population. As Moen argues, this purported harm of prostitution might be due--at least in part--to the legal prohibition against the activity, which prevents sex workers from taking certain actions that would predictably improve their lot. For example: "joining labour unions, organizing their work in brothels, renting a place where they can work, hiring security agencies, advertising and forming work contracts (regarding salary, working hours, working conditions, health insurance, retirement savings, and so on)" ([2], p. 3).

In fact, Moen does a good job of addressing most of the arguments that claim to show that prostitution is inherently harmful (including in ways that are not just physical, but also more abstract, symbolic, or moral), by performing a similar analysis for each one. Readers who are skeptical, of course, can read Moen's paper themselves, and reach their own conclusions.

Thomsen's critique

Thomsen actually considers Moen's argument. Only he doesn't find it entirely convincing. Among other issues, his main objection that even if "extrinsic" factors like social stigma and legal prohibition were responsible for some of the harms associated with prostitution, they wouldn't necessarily account for all of the harms associated with prostitution. (As far as I can tell, Moen doesn't dispute this claim, but let us set that aside for now.)

To support his position, Thomsen cites an empirical study by a researcher named Vanwesenbeeck.[3] According to Thomsen, this study showed that "roughly half--but no more than half--[of] the variance in [certain negative emotional outcomes] experienced by indoor prostitutes in the Netherlands was explained by external factors including stigma, lack of control and poor working conditions" ([1], p. 453, emphasis added).

The implication, then, is that the other half of these negative outcomes (for example, emotional exhaustion) must be due to something intrinsic to prostitution.

Intrinsic vs. extrinsic

There are a few ways to respond to this line of thought. First, there is the problem of non-random sampling: some people turn to prostitution because of pre-existing issues with addiction or mental health, and so the arrow of causation is not entirely clear. Second, it seems unlikely that the study by Vanwesenbeeck measured every possible "external factor" that could be responsible for the various harms of prostitution, which introduces a further limitation to what we can infer from these results. But even if it did--so, even if we were justified in saying that "roughly half" of the variance in (say) emotional exhaustion experienced by this particular sample of Dutch prostitutes was due to something intrinsic about their selling sex--we would still have to put this information in context.

What sort of context do I mean? Well, consider the fact that many careers contribute to, e.g., emotional exhaustion (and other negative emotional outcomes): just think of the burn-out that grief and trauma counselors experience, for example, which is probably due to factors that are (at least in large part) intrinsic to that particular line of work. Or think of the various harms that are "built in" to any number of jobs, like the dangers of construction work, or professional boxing; or the job- insecurity of being an actor (unemployed after every show); or the "degrading" nature of, say, collecting people's garbage or cleaning out their toilets.

When it comes to these careers, however, no one thinks we should prohibit people from choosing to pursue them, just on account of the fact that they carry some degree of risk, or are stigmatized, or are otherwise less than ideal. Instead, we try to think of ways of reducing the various risks that are involved, and/or we compensate people--usually monetarily-- for the harms and difficulties that do in fact come along with their choice of employment.

None of this is to suggest that the intrinsic harms of prostitution are identical to those in the other lines of work just mentioned. They may very well be much more problematic. The point is only that the mere fact that some occupation has intrinsic harms, whatever those turn out to be, is not sufficient to show (without further argument) that it should therefore be prohibited.

The importance of choice

Note the importance of choice here. My position has to do with people --men, women, intersex, and transgender people--who freely choose to sell sexual services in exchange for money. If someone is forced to sell sexual services, that is sexual slavery, not prostitution, and that is a different matter entirely.[4]

Now, someone might argue that prostitution is so inherently harmful or degrading, that someone would only "choose" to exchange sex for money if in reality they were forced by their circumstances (i.e., extreme poverty).[4] A similar argument has been made about the prospect of establishing a market for selling kidneys: only people who are pressured (by their circumstances) to sell their kidneys would end up doing so--the argument runs--so this kind of vending is not really a free "choice."

This takes us to yet another recent JME article, by Luke Semrau, entitled, "The Best Argument Against Kidney Sales Fails."[5] Semrau points out that there are two types of pressure to tease apart here: a specific pressure to sell one's kidney (or to engage in prostitution), which would in fact be directly coercive--and which could conceivably be relieved by prohibiting the activity in question--and a more general kind of pressure (i.e., economic insecurity), which, by contrast, could actually be relieved by any number of activities, including not only selling one's kidney or engaging in prostitution, but also other types of employment.

In this latter case, however, prohibiting the activities in question does not actually relieve the more general pressure. Instead, it may actually compound it--because it would take away otherwise viable employment options. So, if someone has another way of relieving their poverty apart from kidney-vending or prostitution (or collecting garbage, or cleaning toilets, or filling out spreadsheets, or flipping burgers)-- but regards one of those options as being preferable to the alternatives-- then it's hard to see how we could say that they had been specifically pressured into choosing that career.

Harm and prohibition

All of which is to say the following. Even we if were to grant the first point from Thomsen's argument--the one that says that prostitution causes at least some intrinsic harm to prostitutes--this wouldn't necessarily mean that we should favor a ban on prostitution. For one thing, if Moen is right, a ban might actually increase the level of harm to prostitutes, compared against the alternative policy of not having a ban, and setting up reasonable health and safety regulations, encouraging de-stigmatization, etc. And for another thing, as Thomsen himself points out, even if a ban did not have this harmful effect, we might still have other reasons to argue against it.

For example, we might endorse what Thomsen calls the "antipaternalist challenge." This view holds that "prohibition constitutes an unjustifiable interference in the freedom of consenting adults" ([1], p. 454). Peter de Marneffe[6] puts the view like this:

"Discretionary control over one's own sexual activity [is] central to sexual autonomy, [to] control over one's body, and so to personal autonomy. ... It is important that adults have the discretion to make personal choices about the kind of sex they engage in with other adults, even if these choices are unwise. So it is objectionable for the government to prohibit a person for using her own body and sexuality for prostitution." (quoted in [1], p. 454).

As it happens, I tend to agree with this kind of analysis.[7, 8, 9, 10] Just think: adults are allowed to have sex with someone they might find otherwise unappealing in exchange for almost anything they desire except cash: promises of emotional support, the prospect of economic security, or maybe just a few drinks at the bar. This doesn't mean that those are good reasons to engage in sexual intercourse--but it's up to each of us how we negotiate our needs and desires.

More generally, however, when it comes to prohibition, one has to remember that it is no small step from (on the one hand) getting one's ethical analysis in order--in terms of establishing if a given practice is in fact harmful, and in what particular way--to (on the other hand) determining what kinds of social and legal changes would best reduce the harm in question, with the least amount of collateral damage.[11]

To put it simply, prohibition is often a bad idea, even if the targeted activity is harmful.[12]

Back to Thomsen

Thomsen actually appears to agree with this. So, after taking several pages to try to convince us that prostitution can plausibly be regarded as bad (because it is at least somewhat intrinsically harmful), and that the best arguments to the contrary are not as strong as they may seem--he nevertheless concludes that the "case for [actual] prohibition is murkier and weaker than its proponents sometimes suggest" ([1], p. 455). A mere three sentences later, however, Thomsen shifts gears rather awkwardly and asks us to go ahead and just "assume for the sake of argument that the balance of reasons favours a general prohibition of prostitution" (ibid)!

Presumably, this is so that Thomsen can set up his case for the advisability of an exception to an overall ban. He points to two facts that lay the groundwork for his position:

(1) Many or most persons have a sexuality that generates strong needs for sexual relations, and

(2) Some disabled persons are partially or entirely incapable of satisfying this need except through the purchase of sexual services from a prostitute. ([1], p. 455)

Buying sex--for people with disabilities only?

Let me give you an example of what he means. Quoting from another source,[13] he cites the case of a man who "couldn't walk and his carer would bring him. You had to lift him out of the wheelchair and into the Jacuzzi and he was stiff because he didn't move his arms or legs. He couldn't move, could get an erection but that was about it" ([1], p. 455).

Evidently, in exchange for money, someone was willing to have sex with this man under the stated conditions, and this was helpful for resolving his "needs for sexual relations." (Note that Ezio Di Nucci has suggested a very interesting alternative: namely, establishing non-profit charities whose members would voluntarily provide sexual pleasure to the severely disabled.[14] For a related story, see the fascinating autobiographical account, "Head Nurses" by William Peace in Atrium magazine.)[15]

What should we say about a case like this? The first thing to point out is that the man's disability didn't make it so that he physically couldn't have sex (if that were the case, hiring a prostitute would not help his situation); instead, the issue was more that he couldn't find a willing sexual partner ... for whatever reason.

Now, it seems reasonable to conclude that--in this particular instance--the "reason" had something to do with his physical disability. In other words, it seems likely that (all else being equal) relatively few people would desire, as their first choice, to form a sexual relationship with someone who could not "move his arms or legs" (although I imagine that there are many exceptions). This is for the simple reason that some, presumably enjoyable, sexual experiences are only possible if it is the case that one's partner can make use of his external limbs without assistance.

But that is a very specific issue--and it glosses over a more general point. And that is that all sorts of people find it difficult to find a willing sexual partner--or enough willing sexual partners--to "satisfy" their sexual needs, for a whole range of reasons that have nothing to do with physical (or mental) disability of the "obvious" kind exemplified by this man. They may simply be perceived as unattractive. Or they may be shy. Alternatively, they may be very attractive--and not at all shy--and just have an insatiable sexual appetite. Are all of these people "disabled" on Thomsen's account?

Defining disability

It's hard to tell. On the one hand, Thomsen could define "disability" in a very narrow sense that captures only the "obvious" cases that everyone would recognize--perhaps typified by the man in the example. But this would result in an extremely unreliable, and indeed almost absurdly arbitrary proxy for the "real" underlying issue at stake, which is the difficulty that some people have in finding a willing sexual partner(s) sufficient to meet their sexual needs without having recourse to prostitutes.

After all, innumerable people with physical and/or mental disabilities have extremely satisfying sexual relationships, so the connection between "having a disability" (of some kind) and "being perceived as sexually unappealing" is so tangential as to be almost offensive. On the other hand, Thomsen has the option of defining "disability" in a very broad sense--which is what he does in fact choose to do--which carries its own set of problems. For one thing, it refers to an extremely vague and amorphous group of people who (to quote from Thomsen's definition) have "an anomalous physical or mental condition that, given [their] social circumstances, sufficiently limits [their] possibilities of exercising [their] sexuality, including fulfilling [their] sexual needs" ([1], p. 455).

But that could include just about anyone! For one thing, there is the nearly boundless room for interpretation surrounding most of the key terms in Thomsen's definition: "anomalous," "physical," "mental," "condition," "sufficiently," and "fulfill." For example, what is "anomalous" - ? Statistically rare? How rare? As measured along what dimension? Also, why should the condition have to be "anomalous" in any event? Isn't it the (lack of) functional outcome that is the morally relevant concern here?

Or think about the word "condition" - meaning what? Is shyness (to repeat that example) a "mental condition" that counts as a disability? And what about "sufficiently"? How shall we determine the cut-off? In other words, just how "hard" does it have to be to find a willing sexual partner before one is allowed to register oneself as "sexually disabled," say, and pick up her "prostitution exemption" card? And finally--"fulfill." Wouldn't, say, most married couples report that their sexual needs were not "fulfilled" in some relevant way? Indeed, one survey puts the figure at 57%.[16]

Conclusion

So this doesn't seem to be the way to go. Either the definition of disability is so narrow as to be unjustifiably arbitrary as a proxy for the real underlying moral issue, or it's so broad as to include almost anyone. Why not--instead--just argue against a general prohibition, and let mature individuals decide for themselves (a) what kind of consensual sex they wish to engage in, and (b) in exchange for what.

Acknowledgments

Thanks to Julian Savulescu, John Danaher, Michael Hauskeller, Daniel Goldberg, and Ole Martin Moen for feedback on these ideas. This paper is adapted from a blog post with the same title originally published at the Journal of Medical Ethics Blog, available here: http://blogs.bmj.com/medical-ethics/2015/06/17/prostitution-harm-and- disability/. Although most of the text is identical to that in the blog post, I have made some minor improvements to the text in terms of both style and content. Please note that Dr. Moen and I are preparing a formal academic paper expanding on the ideas presented in this e-letter, and that some passages are expected to overlap substantially.

References

[1] Thomsen, F. K. (2015). Prostitution, disability and prohibition. Journal of Medical Ethics, 41(6), 451-459.

[2] Moen, O. M. (2014). Is prostitution harmful? Journal of Medical Ethics, 40(2), 73-81.

[3] Vanwesenbeeck, I. (2005). Burnout among female indoor sex workers. Archives of Sexual Behavior, 34(6), 627-639.

[4] Weinberg, J., de Marneffe, P., Demetriou, D., Earp, B. D., Fuller, L., Gauthier, J., Hay, C., Marino, P., Pettit, P., & Whisnant, R. (2015). Philosophers on prostitution's decriminalization. Daily Nous. Available at http://dailynous.com/2015/08/13/philosophers-on-prostitutions -decriminalization/.

[5] Semrau, L. (2015). The best argument against kidney sales fails. Journal of Medical Ethics, 41(6), 443-446.

[6] de Marneffe, P. (2009). Liberalism and prostitution. Oxford University Press.

[7] Vierra, A., & Earp, B. D. (2015). Born this way? How high- tech conversion therapy could undermine gay rights. The Conversation. Available at https://www.academia.edu/12055156/Born_this_way_How_high- tech_conversion_therapy_could_undermine_gay_rights.

[8] Earp, B. D. (in press). Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework. Medicolegal and Bioethics, in press. Available at https://www.academia.edu/10270196/Female_genital_mutilation_and_male_circumcision_Toward_an_autonomy -based_ethical_framework.

[9] Earp, B. D., Sandberg, A., & Savulescu, J. (2014). Brave new love: The threat of high-tech "conversion" therapy and the bio-oppression of sexual minorities. AJOB Neuroscience, 5(1), 4-12.

[10] Maslen, H., Earp, B. D., Cohen Kadosh, R., & Savulescu, J. (2014). Brain stimulation for treatment and enhancement in children: An ethical analysis. Frontiers in Human Neuroscience, 8(953), 1-5.

[11] Earp, B. D. (2014). Things I have learned (so far) about how to do practical ethics. Practical Ethics. University of Oxford. Available at http://blog.practicalethics.ox.ac.uk/2014/03/things-ive-learned-so-far- about-how-to-do-practical-ethics/.

[12] Earp, B. D. (2013). The ethics of infant male circumcision. Journal of Medical Ethics, 39(7), 418-420.

[13] Sanders, T. (2007). The politics of sexual citizenship: commercial sex and disability. Disability & Society, 22(5), 439-455.

[14] Di Nucci, E. (2011). Sexual rights and disability. Journal of Medical Ethics, 37(3), 158-161.

[15] Peace, W. (2014). Head nurses. Atrium, Winter, 12, 20-22.

[16] National Survey of Marital Strengths. Available at https://www.prepare- enrich.com/pe_main_site_content/pdf/research/national_survey.pdf.

Conflict of Interest:

None declared