In their article 'Homebirth and the future child', Dr De Crespigny
and Professor Savulescu acknowledge that they "lack sufficient evidence"
to establish definitively that homebirth is less safe, yet they conclude
that "couples should be clearly informed of the excess risks of future
child disability" associated with home birth.[1]
We believe that women should be given information about the potential
risks and be...
In their article 'Homebirth and the future child', Dr De Crespigny
and Professor Savulescu acknowledge that they "lack sufficient evidence"
to establish definitively that homebirth is less safe, yet they conclude
that "couples should be clearly informed of the excess risks of future
child disability" associated with home birth.[1]
We believe that women should be given information about the potential
risks and benefits of different birth settings. We are therefore dismayed
at the errors of fact and interpretation and the selective reporting of
the evidence in their 'review of the literature', which many readers may
assume is a summary of the best available evidence. As authors of one of
the cited studies[2] we are writing to correct factual inaccuracies in
their commentary on the Birthplace study and to highlight some highly
relevant published findings from this study that the authors have chosen
to omit.
Birthplace is the largest prospective cohort study of the safety of
planned place of birth and included high quality data on perinatal
outcomes in over 64,500 births to women at 'low risk' of complications,
including nearly 17,000 planned home births. [2 3]
Because individual adverse perinatal outcomes are very uncommon, the
Birthplace study used a composite primary outcome measure that encompassed
a range of adverse perinatal outcomes. This composite measure was designed
to capture adverse outcomes considered likely to be influenced by the
quality of care during labour and delivery. It encompassed intrapartum
stillbirth, early neonatal death, neonatal encephalopathy, meconium
aspiration syndrome, and physical injuries to the bones or nerves in the
baby's shoulder (which may in some instances lead to long-term
disability). It did not include 'delayed breastfeeding initiation' as
stated by De Crespigny and Savalescu. Notably, the composite measure
included neonatal encephalopathy - the condition most likely to be
associated with severe longer-term intellectual disability in the child -
and this was the most commonly occurring component of the composite
outcome (46% of adverse perinatal events). The second most frequently
occurring component of the composite primary outcome was meconium
aspiration syndrome, which may also indicate asphyxia during birth.
Together, these two components thought to be associated with long-term
morbidity accounted for 76% of the Birthplace composite primary outcome,
and 87% of the non-fatal events. The Birthplace study was not powered to
assess differences in individual outcomes such as encephalopathy but,
although confidence intervals are wide (99% confidence intervals were used
because these were secondary outcomes), the findings do not suggest an
excess of these two adverse outcomes in multiparous women planning home
birth. The rates for 'low risk' multiparous women are: neonatal
encephalopathy 1.2 events per 1000 planned home births (99% CI 0.6 to 2.2)
vs. 1.8 per 1000 planned obstetric unit births (99% CI 0.8 to 3.7);
meconium aspiration syndrome: 0.6 events per 1000 births(99% CI 0.2 to
1.4) for planned home births vs. 1.4 per 1000 planned obstetric unit
births (99% CI 0.6 to 3.2) (appendix 8, online supplement to BMJ report
[2]). 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.
The Birthplace findings do indicate that there is an increased risk
of an adverse perinatal outcome for low risk women having a first baby: we
observed 9.3 adverse outcomes per 1000 planned home births compared with
5.3 adverse outcomes per 1000 planned obstetric unit births, and this
difference was statistically significant (adjusted odds ratio 1.75, 95% CI
1.07 - 2.86). However, relatively few women having a first baby opt for a
home birth. In low risk women, the majority of planned home births (73%)
occur in women having a second or subsequent baby and in this group the
Birthplace study found that home birth was not associated with an
increased risk to the baby: there were 2.3 adverse events per 1000 births
in planned home births compared with 3.3 adverse events per 1000 births
planned in an obstetric unit.[2]
Planned home births are also associated with fewer maternal
interventions. While this aspect of home birth is often presented as
making home births 'safer for the mother', lower intervention rates,
particularly caesarean section, are also important for the outcome of
subsequent pregnancies with documented increases in the risk of uterine
rupture,[4] morbidly adherent placenta[5] and peripartum hysterectomy[6]
in subsequent pregnancies, all of which have high perinatal mortality and
morbidity rates. When considering the impact of planned place of birth on
outcomes it is important to consider the impact on both the current and
subsequent pregnancies otherwise we risk missing the whole picture.
1. de Crespigny L, Savulescu J. Homebirth and the Future Child.
Journal of Medical Ethics 2014.
2. 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.
3. Hollowell J, Puddicombe D, Rowe R, Linsell L, Hardy P, Stewart M,
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. London: NIHR Service Delivery and
Organisation programme, 2011.
4. Fitzpatrick KE, Kurinczuk JJ, Alfirevic Z, Spark P, Brocklehurst
P, Knight M. Uterine rupture by intended mode of delivery in the UK: a
national case-control study. PLoS medicine 2012;9(3):e1001184.
5. Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P,
Knight M. Incidence and risk factors for placenta accreta/increta/percreta
in the UK: a national case-control study. PloS one 2012;7(12):e52893.
6. Knight M, Kurinczuk JJ, Spark P, Brocklehurst P, on behalf of the
UKOSS Steering Committee. Cesarean Delivery and Peripartum Hysterectomy.
Obstetrics & Gynecology 2008;111(1):97-105
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...
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.
In J Med Ethics 2009 (35) Walter Glannon [i] claims that deep brain
stimulation (DBS) improves symptoms of some conditions, but could also
have impact on thought, personality, and behaviour. His argument –
although rich and in detail – misses three important points:
(1) Why should the disruption of thematic unity of one`s life story
always be a harm? Glannon appeals to our intuitions when he claims that
cohere...
In J Med Ethics 2009 (35) Walter Glannon [i] claims that deep brain
stimulation (DBS) improves symptoms of some conditions, but could also
have impact on thought, personality, and behaviour. His argument –
although rich and in detail – misses three important points:
(1) Why should the disruption of thematic unity of one`s life story
always be a harm? Glannon appeals to our intuitions when he claims that
coherence is one of our aims. But intuitions must not be true. A life can
be worth living and happy, though not being coherent throughout lifetime.
Thus, a more detailed examination of the phenomenon of coherence as an
universal aim would be helpful.
(2) Glannon examines the question of “how much alteration of one`s
thought and personality in treating a neurological or psychiatric disorder
with DBS would be consistent with a patient`s rational choice to undergo
the procedure”[ii]. The answer should include two aspects: first, one
needs to compare personality alterations induced through DBS with
alterations caused by other influences (education, pharmaceuticals, etc.).
Second, one needs to give criteria in order to define the point when an
alteration is no longer a change in degree but in quality, e.g., a total
change of personality. While doing this, one must be aware of not entering
the well-known “sorites-problem” (“heap-paradox”).
(3) DBS can be switched on and off immediately. But it is not, as
Glannon claims, just a kind of “trade-off […] between acceptable quality
of life regarding motor control and alteration of the mind.” (Glannon, p.
289) It might be much more: both states are connected with a specific self
-awareness and self-description as well as with a subjective experience of
one`s own. We therefore need to understand how it feels [iii] for the
patient to be under DBS treatment. Additional research approaches, e.g.
biographical patient stories as well as feedback from the patient`s social
environment (e.g. spouse) may help to explain the Janus-faced character of
DBS.[iv]
REFERENCES:
[i] Glannon, W Stimulating brains, altering minds, J Med Ethics 2009: 35;
289-292.
[ii] Glannon, p. 289
[iii] For the subjective character of experience see Nagel T. (1974) What
Is It Like to Be a Bat? Philos Rev, 83 (4):435-450.
[iv] Following Glannon`s model case, being free to move but manic may be
considered a comfortable state for the patient but a problem for his
spouse, who postoperatively does not find the person restored he has loved
previously.
Authors of the eLetter are:
Uta Bittner & Henriette Krug
[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...
[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.
Dignity need not be coupled with theology. The South African offence
of 'crimen injuria' is the offence defined as the act of "unlawfully,
intentionally and seriously impairing the dignity of another."
It is based on the 'Latin phrase crimen iniuriae, which should mean
'accusation of abusive behaviour' (
https://en.wikipedia.org/wiki/Crimen_injuria ).
The search for an understanding of a secular basis...
Dignity need not be coupled with theology. The South African offence
of 'crimen injuria' is the offence defined as the act of "unlawfully,
intentionally and seriously impairing the dignity of another."
It is based on the 'Latin phrase crimen iniuriae, which should mean
'accusation of abusive behaviour' (
https://en.wikipedia.org/wiki/Crimen_injuria ).
The search for an understanding of a secular basis for the notion of
'dignity' could benefit from an examination of Roman and South African
case law.
The word itself goes back to the Roman 'dignitas', a strongly related
notion, that also may be worth examining to gain a secular picture
(https://en.wikipedia.org/wiki/Dignitas_(Roman_concept) ).
This article ( http://athensdialogues.chs.harvard.edu/cgi-
bin/WebObjects/athensdialogues.woa/wa/dist?dis=22 ) on three types of
dignity considers, inter alia, the Ancient Greek model, which would have
informed the Roman.
In support of the universality of the notion if dignity, it is wirth
noting that it also appears in the Chinese and Japanese constitutions:
http://www.chinahumanrights.org/cshrs/Developments/t20130206_1037860.htm
The specific question of how dignity relates to the treatment of the
dead is, I think, related, but separate. A corpse, in Roman law, is a res
nullius, a thing that belongs to nobody, which attracts only duties, not
rights. Organ transplant from corpses, of course, complicates this because
a human organ can be possessed, and has value, possibly even monetary
value, but this does not relate to dignity.
The inarticulate, or instinctive, belief, or feeling, that corpses
are special, and must be treated with respect, relates more to the notion
of the 'sacred', which also exists in a secular sense. This sense relates
to aesthesics and sentimental preciousness, rather than to dedication to
the gods, but is a real and important human universal.
The question of the treatment of the deceased might be considered as
part of the wider question of what, in a secular world, is sacred - a
question that most certainly does not have the answer 'nothing'.
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 persiste...
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.
I am wholeheartedly in agreement with Dr. Stricker's and Ms.
Johnson's response to Dr. Gershon's letter. Lyme Disease and its
associated conditions are extremely complex illnesses, and patients who
are suffering from them have their suffering exacerbated by misguided
attempts to "treat ideologically".
Just last week, a new patient gave me the history that her clotted
'pic' line was ignored for hours by an ER p...
I am wholeheartedly in agreement with Dr. Stricker's and Ms.
Johnson's response to Dr. Gershon's letter. Lyme Disease and its
associated conditions are extremely complex illnesses, and patients who
are suffering from them have their suffering exacerbated by misguided
attempts to "treat ideologically".
Just last week, a new patient gave me the history that her clotted
'pic' line was ignored for hours by an ER physician who said he didn't
"believe" in treating Lyme Disease IV, and who had his working diagnosis
as psychiatric, until the infection became fulminant in the ER!
Such needless risk and suffering would be best avoided if we can at
least "agree to diagree" and carry on with supporting the treatment plan
of the specialist who began the treatment. I find the collaboration of my
local colleagues invaluable, as we cope with the increase in severity and
number of cases of tick-borne illnesses of all types in this area.
Many thanks to Dr. Stricker and his colleagues from around the world
for sharing their experiences in treating these conditions, which appear
to have some regional variations in the types of illnesses presenting, as
well as their frequency and severity. I would encourage all who are
interested in these conditions to attend the excellent LDA/IDSA
conferences which will be held in Bethesda, MD in October this year.
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 s...
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.
This is an excellent paper and Dr. Lizza very cogently demonstrates
that the presence of intracranial neurological function, however it is
going to be defined, is the only criterion for life. The practical
application of any other definition produces results that are incoherent
with respect to universally accepted concepts of human life and death.
It is therefore puzzling that Dr. Lizza has elsewhere defended u...
This is an excellent paper and Dr. Lizza very cogently demonstrates
that the presence of intracranial neurological function, however it is
going to be defined, is the only criterion for life. The practical
application of any other definition produces results that are incoherent
with respect to universally accepted concepts of human life and death.
It is therefore puzzling that Dr. Lizza has elsewhere defended using
the cessation of circulation as a criterion for death in the case of non-
heart beating organ donation(1). The Waldo thought experiment reveals
the problems not only with the use of this criterion, but also with his
use of potential in determining death.
Assume that Waldo's head was attached to a machine that provided
circulation (oxygenated blood). One could turn the machine off, leave it
off for a period of time (thus depriving Waldo of circulation), and then
turn it on again. The time period could be a few seconds or an hour. If
it was only a few seconds, Waldo would not lose any neurological function.
If it was an hour and no steps were taken to protect Waldo's brain, he
would irreversibly lose all neurological function. If it was an hour, and
steps were taken to preserve Waldo's brain (medications, hypothermia), he
would again not lose any function(2). Regardless of the time period,
circulation could be restored. Assuming that we agree that a
neurologically intact Waldo is alive, and if Waldo has irreversibly lost
neurological function he is dead, the circulatory status is entirely
incapable of determining Waldo's life and death status. Lack of
circulation is useful only if it successfully predicts a concomitant loss
of neurological function. In the modern era of medicine, circulation
status is no longer an independent predictor of life and death. It is a
vestige of a model of body interdependence which is no longer accurate.
In situations where the neurological and circulatory determinations
differ, the neurological findings are controlling. Therefore, organs can
be harvested from a non-heartbeating patient only when the lack of
circulation has resulted in irreversible cessation of neurological
function.
Use of circulation as a criterion for death also leads to discussions
of potential versus irreversibility(or, permanent versus irreversible to
use Bernat's formulation). Until there is necrosis of the blood vessels,
circulation can always be provided by machines, even in a body that all
agree is dead. To avoid this problem, Dr. Lizza allows that
circumstances, including a patient's wishes, can limit the potential for
irreversibility. There a number of problems with this approach.
Assume that Waldo is a conscious thinking head attached to a pump
supplying oxygenated blood. We have already agreed that a conscious Waldo
is alive. He has specifically stated that if the pump stops, he does not
want it to be turned on again. If the pump is turned off, he will still be
conscious for at least 10 seconds or more. However, according to Dr.
Bernat(3), Waldo is dead the moment the pump stops . According to Dr.
Lizza, Waldo is dead because, having stated his wishes which must legally
be obeyed, he has lost the potential for circulation. The position
therefore lacks coherence since it provides a circumstance where a
conscious person is labeled as dead.
The life or death status of a human being is an intrinsic quality of
that human being's body. The label of life or death that we apply to that
body should reflect as best as possible, that intrinsic characteristic of
the body. Therefore that label should not be affected by conditions
extrinsic to the body. Perhaps aside from liver function, neurological
function is the only function of the body that cannot be approximated with
machines to some extent. Irreversible cessation of neurological function
is something that can be determined. It is only the usage of the
circulatory criterion that requires employing
potential/permanent/irreversible gymnastics.
Death should be irreversible, and 'recovery' from death should be a
rare occurrence due only to mistakes in the determination of facts. Under
Dr. Lizza's construct, 'recovery' from death could occur by disobeying the
law and/or violating the patient's wishes. In fact resuscitation has been
done on patient's who have been declared dead and some have regained some
neurological function(4). While this is obviously quite the exception, it
is reasonable to expect that criteria to determine death would eliminate
this possibility as much as possible.
By making the concept of irreversibility dependent on a patient's
wishes, the patient, under certain circumstances, is deciding if he is
dead or not. Admittedly Dr. Lizza has restricted the patient input to
defining potential of reversal. But it is still very much different than
deciding if resuscitation should be done or not. While I admire his
struggle with how to deal with issues of potential, in the case of
determining death it results in incoherence. Waldo has shown that.
1.Lizza, JP. Potentiality and Persons at the Margins of Life.
Diametros nr 26 (grudzie? 2010): 44-57
2. Hypothermic cardiac arrest has been successfully used in surgery
for up to 72 minutes.
3. Bernat's concept is that permanent cessation of circulation is
death. Permanent is defined as a situation where the circulation will not
spontaneously restart, and a decision has been made that outside power
will not be used to restart it. Obviously the pump is off and will stay
off unless an outside power turns it on.
4. See case histories here: http://www.alcor.org/ a patient was
declared dead based on cessation of circulation. The cryopreservation
protocol called for chest compression and ventilation to preserve the
brain until the preservatives could be injected and cooling begun. Not
surprisingly, at least one patient was noted to resume 'agonal
respirations'.
On Marquis's future of value account, "what makes it wrong to kill
those individuals we all believe it is wrong to kill, is that killing them
deprives them of their future of value" (1,2). Recently Carson Strong
(3,4), Don Marquis (1), and I (5,6) have been arguing about a set of
supposed counterexamples to the future of value account proposed by
Strong, involving either a terminally ill patient or an individual
severely...
On Marquis's future of value account, "what makes it wrong to kill
those individuals we all believe it is wrong to kill, is that killing them
deprives them of their future of value" (1,2). Recently Carson Strong
(3,4), Don Marquis (1), and I (5,6) have been arguing about a set of
supposed counterexamples to the future of value account proposed by
Strong, involving either a terminally ill patient or an individual
severely and permanently cognitively impaired. Strong argues that it would
be wrong to kill those individuals despite their not having a future of
value like ours. I have argued that there are some serious interpretative
problems with both Marquis's concepts of "future like ours" and "future of
value" and with Strong's counterexample (5); and that, on a charitable
interpretation that sets aside those problems, Strong's counterexamples
fail because they involve burdening and ultimately unacceptable moral
claims in violation of basic principles of equality: they involve, to put
it simply, the claim that the individuals in the counterexamples do not
have a valuable future.
I have distinguished (6) between a narrow interpretation of "future
of value", according to which those individuals do not have a future of
value; and a liberal interpretation of "future of value", which allows us
to regard the future of terminally ill patients and severely cognitively
impaired individuals as valuable. And I have argued that we must not
interpret "future of value" as narrowly as Strong proposes - so that we
can avoid his violation of basic principles of equality; and that a more
liberal interpretation has the consequence that it will enlarge the domain
of wrongful killing: we should welcome this outcome.
Marquis has responded by also distinguishing between a narrow and
broad interpretation of his future of value account; arguing that, on the
narrow view, Strong's terminally ill counterexample does not work -
because the terminally ill patient does have a future of value
qualitatively like ours, just shorter. But Marquis concedes that Strong's
second counterexample, involving a severely and permanently cognitively
impaired individual, does succeed - because on the narrow view the
cognitively impaired individual does not have a future of value like ours.
This counterexample would not work against a broader view of future of
value, concludes Marquis. "According to the broad view, one has a future
of value just in case, if not killed, one's future will consist, on
balance, of experiences one will value" (1).
While I argue (6) we should adopt the more liberal interpretation of
"future of value", Marquis opts for the narrow view, because "the narrow
version does not even suggest that killing rabbits or mosquitoes may be
wrong" (1). Here I argue, contra Marquis, that we should instead pursue
the broader more liberal interpretation of "future of value". There are
overwhelming reasons for it: first, the broad view does not violate basic
principles of equality; second, the broad view is not subject to Strong's
severely and permanently cognitively impaired counterexample; third, the
broad view, in widening the domain of wrongful killing, is ethically
preferable.
Let me emphasize the sorts of problems involved in endorsing the
narrow view: the narrow view cannot account - by Marquis's own admission -
for the wrongness of killing severely and permanently cognitively impaired
individuals; and it therefore cannot account for the wrongness of killing
foetuses that will develop into severely and permanently cognitively
impaired individuals. Those foetuses, according to the narrow view, do not
have a future of value. So they might be killed - or, at least, their
killing is not wrongful. That is going to represent a substantial
exception to the general rejection of abortion that Marquis (2) put
forward with his "future of value" account. It is wrong to kill some
foetuses and it is not wrong to kill other foetuses. What's the
difference? It is wrong to kill foetuses that have a "future of value";
while it is not wrong to kill foetuses that do not have a "future of
value". This emphasizes in what sort of intractable moral territory the
narrow view forces us: as I have argued before (6), we are forced into the
nasty business of evaluating futures.
Now, it might be objected that this dirty work needs to be done.
After all, recognising the differences between severely cognitively
impaired individuals and healthy ones acknowledges the tragedy for those
born with such impairments and their families. Those differences, the
objection goes, must be emphasized. And that is painfully true. But the
question is whether this difference should be emphasized in terms of moral
value. That's where I think that the narrow view of "future of value" is
in violation of basic principles of equality. We may be as brutal as to
say that the lives of severely cognitively impaired individuals are
qualitatively inferior to ours. And I agree that such brutality is
necessary, as a form of respect towards the lives of the severely
cognitively impaired. But that is still not the same as saying that those
lives are morally less valuable than our lives. It is not the same as
saying that it is wrong to kill some foetuses and not wrong to kill
others. And it is in this respect that I think the broad view should be
preferred to the narrow view.
A note of clarification: it might be thought that I have overstated
my argument by emphasizing that the narrow view would imply that it is
wrong to kill some foetuses and not wrong to kill other foetuses. It might
be proposed that, rather, all that the narrow view implies is that killing
some foetuses is morally worse than killing other foetuses; that there are
differences in the various moral evaluations of the different killings is
not the same as saying that some killings are permissible while others
not. Those who might find it an unacceptable consequence of the narrow
view that some foetuses may be killed while others may not, could on the
other hand live with the weaker claim that the narrow view implies
different moral evaluations for different killings. I agree that this
latter proposal is importantly different and in this respect not as
problematic, but I think that the narrow view implies the former claim,
namely that killing some foetuses is wrong while killing others is not
wrong. To see this, take Marquis's statement of the narrow view:
"Let us call our (ie, yours and mine, readers) futures of value `p-
futures of value`. P-futures are the kind of future lives that can be
characterised as the lives of persons. I have a p-future. The fetus I once
was had a p-future. (Note that this claim is a simple consequence of the
way 'future of value' was defined and well-known facts.) According to what
I shall call `the narrow view` valuable futures are futures like ours as
long as they are p-futures of value... The severely retarded human beings
to which Strong refers do not have p-futures of value" (1)
Don has a p-future and it is therefore wrong to kill Don. The foetus
that Don once was had a p-future and it was therefore wrong to kill that
foetus. On the other hand John, a severely and permanently cognitively
impaired 40-year-old, does not have a p-future. The foetus that John once
was did not have a p-future either. Therefore it is not wrong to kill John
now, and forty years ago it would not have been wrong to kill the foetus
that John then was. So the narrow view does imply that it is wrong to kill
some individuals while it is not wrong to kill others. And it does imply
that it is wrong to kill some foetuses while it is not wrong to kill
others.
So the narrow view allows for too much killing, I have argued. But
Marquis is rather worried that the broad view does not allow for enough
killing - that's his reason for sticking to the narrow view. I think,
contra Marquis, that we should welcome the restrictions of the broad view.
Here I should first of all caution about the difficulty in evaluating the
future of value account against the worry that it does not allow for
enough killing. Recall the statement of the future of value account with
which we started: "what makes it wrong to kill those individuals we all
believe it is wrong to kill, is that killing them deprives them of their
future of value" (1). The account is a bit more specific than just the
wrongness of any killing. The future of value account is, specifically,
about the wrongness of killing a certain class of individuals: those
individuals we all believe it is wrong to kill.
In assessing the worry that the broad view does not allow for enough
killing, we need to know who those individuals we all believe it is wrong
to kill are. I guess Don Marquis is one of them. I am probably one too, as
are most if not all the readers that Marquis addresses. Already when we
move to the foetuses that the aforementioned individuals once were, it
becomes trickier. But that's ok, because after all that was exactly the
point of Marquis's original argument (2): not to have to deal directly
with the status of the foetus, but rather with the much less controversial
status of the future individuals in which foetuses normally develop. But
what about John? Do we all believe it is wrong to kill John? Amongst
philosophers it is perhaps unsurprising that we don't all agree. (7,8) But
it seems that in society at large there is also no consensus.
Why is this important? Individuating which individuals the future of
value account of the wrongness of killing refers to is important because
Marquis's reason to choose the narrow view against the broad view is that
"the narrow version does not even suggest that killing rabbits or
mosquitoes may be wrong" (1). If society cannot agree on John, it
certainly cannot agree on the killing of rabbits. Are rabbits individuals
we all believe it is wrong to kill? No, they are not - it's a simple
statistical fact about human opinion that we don't all believe it is wrong
to kill rabbits, nor do we all believe it is not wrong to kill rabbits. In
this respect, there is a simple solution about Marquis's worry with
rabbits, and therefore a simple rebuttal of his argument in favour of the
narrow view: if we should choose the narrow view over the broad view
because the narrow view, as opposed to the broad view, does not suggest
that killing rabbits may be wrong, then that is no reason to choose the
narrow view over the broad view simply because the future of value account
is not about rabbits; and therefore neither the narrow view of the future
of value account nor the broad view of the future of value account suggest
that it may be wrong to kill rabbits simply because the future of value
account does not talk about rabbits.
In one sense, then, we are already finished: we have given
overwhelming reasons against the narrow view; and we have refuted the
stated reason against the broad view. But it might be objected that we
should not be so strict in the application of the future of value account;
after all, the objection might go, the account is only interesting in so
far as it deals with more individuals than just those about whom we all
agree - there might not be many of those around, I am afraid. Therefore we
should be charitable about the future of value account, and at least also
evaluate it as a general account of the wrongness of killing, and not only
as a particular account of the wrongness of killing those individuals that
we all believe it is wrong to kill.
Let us pay our dues to the principle of charity and evaluate the
future of value account also as a general account of the wrongness of
killing. What should we then say about the worry that the broad view of
the future of value account does not allow for enough killing because it
suggests that killing rabbits might be wrong? I think we should just
embrace this worry, and consider this consequence of the future of value
account as a positive upshot. Indeed, progress in animal ethics might
suggest that a general account of the wrongness of killing might have to
say something about non-human animals. A particular account of the
wrongness of killing only those individuals that we all believe it is
wrong to kill does well to avoid the intricate questions of animal ethics
- as we said, it is a statistical fact about human opinion that there is
no agreement on that point in either philosophical circles or society at
large. But a general account of the wrongness of killing has to say
something about non-human animals, especially now that animal ethics has
earned its place within moral philosophy. So it is a further advantage of
the broad view that it accounts for the wrongness of killing animals.
Someone might be worried that we have gone too far: they might accept
that including some non-human animals amongst those to which the account
applies might be a welcome consequence, but object that the problem for
the future of value account arises when it can no longer distinguish
between the wrongness of killing an healthy adult human being and the
wrongness of killing a rabbit. So that the application of the future of
value account to non-human animals might be seen as a reductio of the
original argument. This reductio could take two forms:
1) future of value reasoning shows that it is wrong to kill non-human
animals. But it is absurd to think that it is wrong to kill non-human
animals. So future of value reasoning must be flawed.
2) Future of value reasoning shows that it is just as wrong to kill a
non-human animal as it is to kill a human. It is absurd to think that it
is just as wrong to kill a non-human animal as it is to kill a human. So
future of value reasoning must be flawed.
We have already addressed 1. Two points here about 2: first, many
might actually want to go that far and welcome an account that does not
distinguish between the wrongness of killing humans and the wrongness of
killing non-human animals. Looking at the animal ethics literature
suggests that an account such as the one 2 criticises would not be taken
to be going particularly far (7,8,9).
Secondly, I don't think that the broad view of the future of value
account must imply that there is no moral difference between killing
humans and killing animals. Recall the statement of the broad view:
"According to the broad view, one has a future of value just in case, if
not killed, one's future will consist, on balance, of experiences one will
value" (1). That seems to embrace at least some non-human animals (10).
But it does explicitly refer to the subjective evaluation of one's
experience. The point about the broad view is, indeed, that we are no
longer evaluating and comparing futures and experiences across different
individuals; it is enough that the one individual values (or would value)
her future experiences.
This still leaves room for various possibilities, all of them short
of the view that there is no moral difference between killing humans and
killing animals. It may be that the sense in which humans value their
experiences is not available to non-human animals. That is, for example,
where many introduce consciousness: it is not as if non-human animals do
not have phenomenal experiences (think of pain); it is rather that their
experiences are not conscious or self-conscious the way human experience
is11. One might think that this is a relevant moral difference: not enough
to deny that it is wrong to kill some non-human animals (because they have
the experience of pain, for example); but enough to deny that there is no
significant moral difference between killing humans and killing animals.
Alternatively, one classic strategy (from Mill's higher-lower pleasure
distinction (12)) is to distinguish between the quality of human
experience and the quality of animal experience: again, that might suggest
that there is a moral difference between killing humans and killing
animals. Still, killing animals would not be morally irrelevant. So there
is no reason to think that the broad view of the future of value account
will lead to conclusions about killing animals that some might hold to be
implausibly demanding.
Summing up, I have argued against Marquis's argument for the narrow
view over the broad view and for my earlier suggestion6 that we embrace
the more liberal version of the future of value account. This I have
motivated by raising some serious problems with the narrow view and by
arguing that the implications of the broad view, in particular about the
killing of non-human animals, are not problematic and should, rather, be
welcomed.
References
1) Marquis D. Strong's objections to the future of value account. J
Med Ethics (forthcoming).
2) Marquis D. Why abortion is immoral. J Philos 1989;86:183-202.
3) Strong C. A critique of 'The best secular argument against
abortion'. J Med Ethics 2008;34:727-31.
4) Strong C. Reply to Di Nucci: why the counterexamples succeed. J
Med Ethics 2009;35:326-7.
5) Di Nucci E. Abortion: Strong's counterexamples fail. J Med Ethics
2009;35:306-7.
6) Di Nucci E. On how to interpret the role of the future within the
abortion debate. J Med Ethics 2009;35:651-52.
7) Singer P. Practical Ethics. Cambridge: Cambridge University Press,
1979.
8) Singer P. Animal Liberation. New York: New York Review Book, 1975.
9) Regan T. The Case for Animal Rights. Berkeley: University of
California Press, 1984.
10) Allen C. Animal Pain. Nous 2004;38:617-43.
11) Carruthers P. Brute Experience. J Philos 1989;86:258-269.
In their article 'Homebirth and the future child', Dr De Crespigny and Professor Savulescu acknowledge that they "lack sufficient evidence" to establish definitively that homebirth is less safe, yet they conclude that "couples should be clearly informed of the excess risks of future child disability" associated with home birth.[1]
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On Marquis's future of value account, "what makes it wrong to kill those individuals we all believe it is wrong to kill, is that killing them deprives them of their future of value" (1,2). Recently Carson Strong (3,4), Don Marquis (1), and I (5,6) have been arguing about a set of supposed counterexamples to the future of value account proposed by Strong, involving either a terminally ill patient or an individual severely...
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