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  1. More on Moore and moral status

    I look to clarify and reinforce my criticisms of the Moorean defence by Curtis and Vehmas of their proposition that all humans have an equal moral status that is higher than that of all non-human animals. In particular, I point to the relative scope for inventive new arguments against that proposition, and suggest that what misgivings we have about rejecting it are inadequate to make that type of strategy appropriate.

    Introduction

    In 'Having hands and moral status', I made two principal claims about Curtis and Vehmas' Moorean defence of the following proposition:1

    H>A: Humans have an equal moral status that is higher than the moral status of non-human animals.

    The "basic idea" of their Moorean strategy "is that our confidence in the truth of this proposition is greater than our confidence in the propositions that make up those philosophical views that entail that it is false, and that this is sufficient to justify rejecting those views and to continue to believe H>A."3 In other words, any deductive argument for a contrary proposition is really "no more than an invitation to compare plausibility:"4 if it is more plausible that a premise of that argument is false than that its conclusion is true, then "we should not be moved by the argument".1

    My first claim was that although their strategy is logically valid, "it is not powerful." My second, which I labelled "[m]y own view", was that "resort to the argument the authors make reflects too great a pessimism about the class of accounts which are unresponsive to PIDs", or profound intellectual disabilities. In a short rejoinder, Curtis and Vehmas explain why they believe I fail to establish those two claims. Since the authors misunderstand the points of both of them -- and given the significance of the issues our papers cover -- I look to clarify and reinforce those criticisms here.

    Valid, but not powerful

    Arguments 'for' propositions

    The first sense in which the Moorean strategy is "weak"3-- a word I never use -- is general to any issue to which it is applied. This is that "it does not give one any stronger reason than one had" to believe in the proposition defended: "all it does is point out that one's confidence in that position is a reason not to believe in others."1 In that particular sense, it is not an argument for H>A or for an external world: what disagreement we have about that label is in principle purely semantic.

    Curtis and Vehmas also note -- and read a great deal into -- my aside about ghosts: that a conviction in their reality is a reason to doubt attempts to explain them away, but not a reflexive reason to believe in them more. The comment was not a reductio of their argument, not least because I disagree with their assumption that using the Moorean strategy to defend one's ghostly beliefs against empirical attacks "is obviously not something that one would be justified in doing".3 Rather, my point was precisely that a Moorean argument which plays on how strongly you disbelieve a conclusion does not, as I use the label, count as an argument for your disbelief: "[h]aving confidence in the existence of ghosts is a pro tanto reason not to put stock by attempts to explain away ghostly appearances with optics or psychology, but it is not a reflexive reason to be confident in the existence of ghosts."1

    Out of the sceptical context

    The more important sense in which the Moorean strategy is "weak" is specific to its application to the issue of moral status. In my reply to Curtis and Vehmas' paper, I wrote that:

    Moore's original argument from his confidence he has hands to the existence of external things is unusually powerful because the sceptical arguments he opposes tend not to offer reasons to be confident about any alternatives: rather than suggesting just that we do not have hands, scepticism challenges our reasons to be confident about any of the possibilities; there need not be a change to the order of the options we have confidence about.
    The case of moral status is fundamentally different. Each plausible argument for an account which conflicts with all and only humans having full moral status is potentially capable of tipping the balance against that proposition. Such arguments are not sceptical reasons to doubt our confidence in everything: they advance opposition to the defended account relative to it.1

    The authors assert that I misconstrue Moore's argument, which, on the "common interpretation" which they ascribe to Lycan, "is not from [Moore's] confidence that he has hands to the existence of external things, but from his confidence that he knows he has hands to that he knows that external things exist".3 Lycan actually attributes both versions to Moore, with Curtis and Vehmas' reading being a development of what Moore first intended which makes "a rubber arrow" of an objection to any role played by common sense.4 Moreover, my claim that "[t]he case of moral status is fundamentally different"1 remains importantly true regardless of to which level the shared schema is applied.

    A typical sceptical argument asks us to imagine that we are, for example, brains in vats, fed artificial neural signals which generate a convincing illusion of reality. It then invites us to note that we cannot rule this possibility out, since all of our perceptual experiences would be as they are in actuality; deduces that we cannot know that this possibility is not actual; and concludes that, since we would not have hands were we brains in vats, we do not meet the standard for knowledge of whether we do have hands.

    The Moorean insight is that if it is more plausible that we know that we have hands than that it is possible that we are brains in vats, then the sceptical argument need not be threatening: rather than accepting its conclusion, we ought to -- or at least are free to -- deny that it is possible that we are brains in vats. What makes Moore's anti-sceptical position exceptionally secure, or his defensive strategy "unusually powerful",1 is how difficult it is to make it more credible that a sceptical possibility could be real: that we could be brains in vats or be plugged into the Matrix, or be duped by Cartesian demons or locked in vivid dreams.

    That security is not transferrable to questions of moral status. As a project, sophisticated opposition to H>A is still relatively immature. There is plausibly plenty of scope for inventive new arguments for positions with which H>A conflicts, whether drawing on unconsidered intuitions, metaethical innovations, zoological discoveries, or studies of psychological biases. Curtis and Vehmas note in their original paper how the best-known objections to H>A are "based upon a set of theoretical claims, such as the claim that moral status can depend only upon the possession of intrinsic properties," and that new arguments which drew on empirical facts would be "of an entirely different sort than those usually offered".2 The point is that there is ample latitude for such arguments to be developed or publicised, whereas the same is not nearly so plainly true of sceptical opposition to Moorean dogmatism. In this sense, the authors' deployment of the strategy is importantly different and significantly less enduringly effective.

    Reflecting too great a pessimism

    Denying H>A

    Recall that my original second claim was that "resort to the argument the authors make reflects too great a pessimism about the class of accounts which are unresponsive to PIDs."1 The Moorean strategy is one to adopt when none of the positions we can positively defend are anything but barely appealing: when the arguments for them are so uncompelling that we feel free to assume their conclusions are false. With this in mind, I used the final paragraph of my discussion to outline an account on which a being's moral status is proportionate to the "magnitude" of their interests, or more roughly to their capacity for satisfactions and dissatisfactions. Non-human animals -- or at least those of which we know, and then as far as we know them -- plausibly do have a smaller scope of interests than we as humans do.

    That account is "unresponsive to PIDs" in the sense that it does not make any person's moral status directly dependent on their cognitive capacities: that is, to borrow from Curtis and Vehmas, "those capacities to do with conceptual abilities, understanding, problem solving and rational decision-making."2 Instead, the entitlements, rights, or distributive heft of a person depend entirely and exclusively on their capacities for joys, disappointments, excitements and distresses: if PIDs are relevant to moral status, it is via those amplitudes only.

    In their restatement of my claim, Curtis and Vehmas replace "the class of accounts which are unresponsive to PIDs" with "the accounts available that purport to justify H>A", then finding my comments "puzzling" because on my proposal H>A is false.3 The conclusion they should instead have drawn is that I do not think an account needs to vindicate H>A to be compelling enough to make a struthious Moorean strategy inappropriate; it is in that sense that falling back on the strategy "reflects too great a pessimism".1 In particular, I do not think that accounts which satisfy H>A are unique in respecting what we find most troubling about the traditional criteria for moral status, nor that H>A is robust and self-evident enough to be aptly labelled "common sense".2

    What is troubling about those accounts of moral status which follow the liberal Lockean tradition -- making one's status contingent on autonomy, agency, or cognitive capacities -- is not in itself that they are sensitive to real differences within and across species, but rather that they fixate on distinctions which ought not at all to matter. Lacking cognitive capacities does not make a person any less inherently and importantly valuable and dignified: it does not justify inequalities of moral consideration. As Alastair Norcross put it, the fact that beings "can't be moral agents doesn't seem to be relevant to their status as moral patients: moral status "is not some kind of reward for moral agency."5 We agree, I think, in opposing "the view that such intrinsic psychological capacities as rationality and autonomy are requisites for claims of justice, a good quality of life, and the moral consideration of personhood",6 but we part soon after there.

    If one human is ever entitled to less than another, it ought to be because they have less use or need for what is at stake: that they lack some latitude to be satisfied or dissatisfied. That latitude, or that magnitude of interests, plausibly does matter to our dues or to our heft in distributive algorithms, and it plausibly is what creates moral gradations amongst known sentient beings.7, 8 It is not that we are innately unequal as beings or as humans, but rather that our interests are:9 that "a mayfly imago which needs not even feed will also not be fearing homophobia or pondering the frustration of its childhood dreams."1 Provided we keep this distinction in mind, H>A might if anything seem implausible in principle; short of that, it does not just seem "common sense".

    Non-human animals

    Curtis and Vehmas draw attention, however, to the account's implications for those humans and non-humans who share their sentient capacities for joys and disappointments.2, 3 Suppose, to take their example, that equality is true of humans with PIDs and dogs, and that we begin with the credible assumption that the moral status of a humans with PIDs exceeds -- perhaps significantly -- that of a dog. The standard argument is that we then face a trilemma: either acknowledge that dogs have greater moral status than we thought, being equal to that of humans with PIDs; accept instead that the status of humans with PIDs is lesser than assumed, being equal to that of dogs; or endorse, after all, something similar to H>A, and here defend it with a Moorean shift. I have, like many, no attraction to the second option. I will close this paper by both suggesting that the first is favourable to third and attempting to undermine any concerns.

    Many of our thoughts about the moral status of animals relative to humans with PIDs may, firstly, stem simply from a lack of knowledge of what most humans with PIDs are like. Eva Kittay, for example, describes her own daughter -- "diagnosed as having severe to profound retardation" -- as "enormously responsive, forming deep personal relationships with her family ... and friendly relations with her therapists and teachers," and with a discerning taste for "especially but not exclusively classical symphonic music".10 Kittay's daughter is not comparable to any non-human animal as most of us understand them: if there is a dog which matches her for sentience, then that dog is truly exceptional. Our misgivings may not be about genuinely equal cases.

    Secondly, we need to be clear that moral status need not even closely align with how a person should be treated: it is not a guide to whether we can "farm and eat the flesh" of people,2 or an indication of how much we value them. We stand in relations to humans with PIDs which we rarely if ever do with any non-human animals: we care deeply about them and about our relationships with them, and the facts that they matter so much to us, that we identify with them, and that they may depend on us give us perfectly permissible reasons to treat them exceptionally well. It is a fallacy that two beings with equal moral status need to be treated the same, and we should consider how much this accounts for the extent to which we find the first option challenging.

    Thirdly -- and finally -- recall the reasons I gave for thinking the Moorean strategy which Curtis and Vehmas proposed to be, albeit "valid", far from "powerful."1 We must be incredibly careful not to see that strategy as permitting us to be more confident about the truth of H>A: despite the titles of both their papers, it is not an argument for that proposition in the most conventional evidential sense. If H>A was ungrounded before, it remains as ungrounded now: it is a dialectical last resort. I suggest that we have greater reason to adopt an alternative view than we do to maintain H>A in the face of foundational difficulties "that we do not know how to overcome";2 H>A is, at least, nothing like our convictions that we really know that we have hands.

    References

    1. Roberts AJ. Having hands and moral status: a reply to Curtis and Vehmas. J Med Ethics 2016;42:265 doi:10.1136/medethics-2015-103355.

    2. Curtis B, Vehmas S. A Moorean argument for the full moral status of those with profound intellectual disability. J Med Ethics 2016;42:41--5 doi:10.1136/medethics-2015-102938.

    3. Curtis B, Vehmas S. The Moorean argument for the full moral status of those with profound intellectual disability: a rejoinder to Roberts. J Med Ethics 2016;42:266--7 doi:10.1136/medethics-2016-103437.

    4. Lycan WG. Moore against the new skeptics. Philos Stud 2001;103:39+42 doi:10.1023/A:1010328721653.

    5. Norcross A. Puppies, pigs, and people: eating meat and marginal cases. Philosophical Perspectives 2004;18:243 doi:10.1111/j.1520-8583.2004.00027.x.

    6. Kittay EF. At the margins of moral personhood. Ethics 2005;116:100 doi:10.1086/454366.

    7. Singer P. Speciesism and moral status. Metaphilosophy 2009;40:567-81 doi:10.1111/j.1467-9973.2009.01608.x.

    8. DeGrazia D. Moral status as a matter of degree? South J Philos 2008;46:181-98 doi:10.1111/j.2041-6962.2008.tb00075.x.

    9. DeGrazia D. Equal consideration and unequal moral status. South J Philos 1993;31:17-31 doi:10.1111/j.2041-6962.1993.tb00667.x.

    10. Kittay EF. The personal is philosophical is political: a philosopher and mother of a cognitively disabled person sends notes from the battlefield. Metaphilosophy 2009;40:616 doi:10.1111/j.1467-9973.2009.01600.x.


    orcid.org/0000-0002-7080-478X

    Conflict of Interest:

    None declared

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  2. Classification of Hyper-parenting

    Although genetic selection has a slew of issues involved with the process, what dictates hyper-parenting? If being a hyper-parent is the same for genetic selection as it is for having an organized schedule for one's child, at what point do you tier different levels of hyper- parenting? If everyone seems to be a hyper-parent in their own right, wouldn't the argument of "gene selector hyper-parents" become moot?

    Conflict of Interest:

    None declared

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  3. Defining Consent

    It seemed as if the paper never defined consent. Consent defined, giving permission for an action that affects the self under full disclosure of the action.

    Conflict of Interest:

    Taking a biomedical ethics course at the College of Charleston.

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  4. Opting in or Out

    Wales, (one of the nations of UK), has its' own devolved Health service. It has been decided to use an Opt out as well as Opt In policy during an introductory stage.. It is not perfect but there has been an attempt to introduce the policy ethically by posting a booklet to every household in Wales. There are links whereby people can obtain further information both via the internet or over the phone. Inevitably some will fall through the net, especially as a failure to declare an Opt Out decision will eventually lead to an assumption of Opt In and recorded on the organ/blood donation register.. A safeguard is included in that it has been made easy to also register a Change of Mind -for those who are aware of it. There have also been publicity campaigns via the media especially local TV and these need to be repeated.. One criticism is that although it is promoted as absolutely the individual's choice, the information is openly biased towards Opting In. for example the letter of acknowledgement of an Opt Out reminds people that they are more likely to need a donor than to donate their organs. That part is highlighted. Followed by what to do if the person changes their mind. The letter also instructs people to let their friends and relatives know of their decision. This part highlighted. Many will have nobody or not wish to tell anybody. It rather undermines trust that the individual's decision will definitely be honoured regardless of others' opinions.

    Conflict of Interest:

    No competing interests but choose to opt out.

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  5. Dr. Miller disagrees but does not overcome the facts and logic

    Dr. Miller cites the "professional integrity of physicians" and the uncertainty of whether additional interventions will restore a patient's desire to live.

    Does Dr. Miller's professional integrity include honesty, truthfulness, and sincerity when speaking to severely treatment-resistant patients? Particularly with respect to the efficacy of treatments that will provide rapid response and prolonged remission? Does that integrity extend to honestly communicating with these patients regarding scientific data on the likelihood, severity, and duration of relapse or recurrence?

    Or is Dr. Miller referring to the integrity that embodies a physician's personal ethics, morality and righteousness? Given Dr. Miller's emphasis of the uncertainty about whether additional interventions with the patient can improve quality of life, it appears the physician's beliefs should trump the ability of informed patients to decide.

    As Drs. Schuklenk and van de Vathorst stated, "if the pace of developments leading to therapeutic success in major depressive disorder is anything to go by, many people suffering from TRD would have reason to be sceptical about the odds of such a treatment regimen coming about within a timeframe that they would consider acceptable."

    Patients suffering from treatment-resistant major depression have likely undergone extensive long-term professional psychiatric care. "Typically they would have tried a fairly significant number of antidepressants, psychotherapy, probably electroconvulsive therapy, and they would have experienced the failure of these varied therapeutic approaches."

    Dr. Miller places considerable weight on the "uncertainty of whether additional interventions will restore a patient's desire to live." As Dr. Schuklenk points out, this argument unjustly ignores "the high burden that is paid by patients who happen to wait unsuccessfully for a successful treatment that may not come about at all or that may come about too late."

    Drs. Schuklenk and van de Vathorst provided sound recommendations in their article. Dr. Miller appears to personally disagree.

    Conflict of Interest:

    None declared

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  6. A calculus vs a developing guideline

    Bentham's hedonic, or felicific, calculus doesn't work, in practice, either, so the criticism of a calculus being difficult or not absolute applies equally to utilitarianism.

    The hedonic calculus allows conclusions with no benefit, or negative benefit, or positive pain for some. If the net calculation is positive for all, then the negative consequences for one or more individuals is subsumed by the greater good and, essentially, ignored. Worse, you can, in theory, have a negative consequence for one individual, such as torture, that seems acceptable because of the overall positive result.

    With transactional audit, every individual has an absolute requirement for some quantum of dignity.

    If the dignity of any one person is to be compromised, to maximise dignity, that is explicit in the calculation.

    A decision to act against the dignity of one or more, is then the least bad option - rather than, with utilitarianism, an the optimal decision.

    I think this is an important step forwards, ethically. As the article puts it: 'The starting point is that everyone's dignity counts. Everyone is a stakeholder in every transaction.'. Even after the decision, the importance of individual dignity remains.

    Wouldn't next step be, similar to law, to try to establish precedents? To invite the registration of specific decisions that used transactional analysis, so that they can be referred to, eventually, as a body of knowledge, a guide for future decisions?

    Abstract worked examples, or even concrete examples worked by one person, are less likely to be complete, satisfactory, and widely considerate of all stakeholders, and their dignity, than a recorded history of decisions made in similar circumstances, and building on precedent.

    Having a collection of such decisions as a benchmark would also make matters much easier, and, one hopes, fairer, when the time available decide is too short to carry out a full audit.

    The only specific problem I see, with the maximisation of dignity as an objective, is much the same as for utilitarianism. If 100 stakeholders are distant enough for their dignity to be impacted by 1/100th, then they have the equivalent stake in dignity as the patient. Fair enough, but, if you consider 20 million people, they only need a very tiny stake indeed to counter the interests of the patient.

    This seems wrong. Some cut-off distance, for stakeholders not in close proximity to the patient, seems necessary to mitigate the potential tyranny of the majority.

    Conflict of Interest:

    None declared

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  7. Montgomery: A clinician's view

    In their recent article Farrell and Brazier [1] assert that the recent decision in Montgomery v Lanarkshire Health Board [2] should not cause doctors any anxiety or concern. However the legal perspective on the case is perhaps not the same as the clinician's perspective. From the clinician's perspective there are reasonable concerns.

    Firstly, we should note that the damages in Montgomery amounted to approximately 5.25 million pounds [3] and were recovered in negligence as a result of the breach of the duty to adequately inform. An action for a breach of the GMC rules of conduct would not have resulted in an award of this size. Montgomery may not have changed the expected rules of conduct for clinicians, but in terms of enlarging the extent of liability for breach, the case has taken the velvet glove off the mailed fist.

    Secondly, the model underlying medical decision-making is now to firmly place the liability for ordinary consequences flowing from medical decision-making in the hands of the patient:

    "treats [patients], so far as possible, as adults who are capable of understanding that medical treatment is uncertain of success and may involve risks, accepting responsibility for the taking of risks affecting their own lives, and living with the consequences of their choices."[4]

    The obligation on the doctor is, through the provision of information, to place the patient in the position to make the necessary choices. In order to achieve this outcome it is asserted that the Court has made a combination move in Montgomery:

    (a) there is a shift in the yardstick used to judge the standard of disclosure from the Bolam standard towards a modified objective patient standard; and

    (b) there a shift of view point from the perspective of the clinician towards the perspective of the patient.

    The first point has been well telegraphed by the Courts as Farrell and Brazier point out. However, the second point is not so clearly already embedded in clinical practice. Briefly, let us put aside the reasonable patient disclosure limb of the standard and focus only upon the particular patient disclosure limb of the test.[5] The particular patient disclosure limb disclosure requires disclosure where:

    (i) the doctor is aware that the particular patient would be likely to attach significance to the risk; or

    (ii) the doctor should reasonably be aware that the particular patient would be likely to attach significance to the risk.

    The question has changed from, what can and should the clinician deliver to what does this patient need to know? [6]

    "The assessment is therefore fact-sensitive, and sensitive also to the characteristics of the patient."[7]

    Conforming to such a particularist legal rule is hard in practice because it requires the clinician to have some insight into the thoughts of each patient. Thoughts that the patient need not express until the court hearing for breach of the duty of care, as the facts of Montgomery demonstrate.

    Given that the mind of the patient is not necessarily in full purview to the clinician the question is what does the clinician have to do in practice in the particular case in order to prove valid consent? Simply answering the patient's questions is no longer enough. A signed consent form is no longer enough. What would be enough?

    Developing and then embedding a process approach to consent with adequate documentation to avoid liability is a new demand on already overstretched resources. The Court recognized that more clinical time will be needed in order to secure adequate consent.[8] But this will have to be costed and delivered.

    The decision in Montgomery leaves process failures to be challenged in public law rather than in tort.[9] Given the differences between judicial review actions and negligence actions, the effect is likely to be to push liability for process failures downstream onto clinicians.

    Thirdly, there is the question of whether a patient can be told too much? After the fact, the patient can complain that there was something could have been known and that were not told that adversely affected their judgement sufficiently to justify an action in negligence. But, by analogy, can the patient also complain about facts that they were told but should not have been told? Would such a positive affront to the autonomy of the patient be actionable?

    In conclusion, there are things in the judgement that reasonably give clinicians pause for thought.



    [1] Farrell AM, Brazier M. Not so new directions in the law of consent? Examining Montgomery v Lanarkshire Health Board. J Med Ethics 2015 (online first) doi:10.1136/medethics-2015-102861

    [2]Montgomery v Lanarkshire Health Board[2015] UKSC 11

    [3] BBC News. Nadine Montgomery wins ?5 m from NHS Lanarkshire over brain damage to her son. 11 Mar 2015. http://www.bbc.co.uk/news/uk-scotland-glasgow-west-31831591(accessed 03/01/2016)

    [4]Montgomery v Lanarkshire Health Board[2015] UKSC 11 at para 81.

    [5]Montgomery v Lanarkshire Health Board[2015] UKSC 11 at para 87.

    [6] Heywood R. R.I.P. Sidaway: patient-oriented disclosure-a standard worth waiting for? Montgomery v Lanarkshire Health Board[2015] UKSC 11. Med Law Rev 2015;23(3):455-66.

    [7]Montgomery v Lanarkshire Health Board[2015] UKSC 11 at para 89.

    [8]Montgomery v Lanarkshire Health Board[2015] UKSC 11 at para 93.

    [9]Montgomery v Lanarkshire Health Board[2015] UKSC 11 at para 75.

    Conflict of Interest:

    None declared

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  8. Children in Australian immigration detention - justice demands action

    Abstract

    Despite a damning 2014 Australian Human Rights Commission report into the plight of children in immigration detention, the disturbing findings of reported in the 2015 Moss Inquiry into allegations relating to conditions and circumstances at the Australian regional migrant processing centre in Nauru, and compelling evidence of the harm suffered by these children, Australia continues to hold children in immigrant detention. Procedural justice has been retarded or withheld, and for a country rich in resources and previously generous in providing opportunities for migrants, distributive justice has been tragically lacking. Recently enacted border protection legislation constrains government contracted staff from disclosing the circumstances in immigration detention centres. The Australian Federal Government has repeatedly, and arrogantly, flouted its obligations under International Human Rights Legislation and Conventions with bipartisan political support. International action is warranted with Australia's bid for a seat on the United Nations Human Rights Council providing a potential lever for catalysing change. It would be unconscionable for Australia to take a seat on the Council while refugee children remain in detention.

    In 2014 the Australian Human Rights Commission published a damning report, "The forgotten children: national inquiry into children in immigration detention", which found that mandatory immigration detention was harmful to children and violated the Convention on the Rights of the Child.1 Despite this unequivocal moral and legal condemnation, 174 children remain in immigration detention facilities as of 30 November 2014.2

    David Isaacs' eloquent discussion of the conundrum facing health care professionals working in Australia's immigration detention centres focuses on the competing moral duties to provide care, thus effectively condoning torture, and/or to speak out, with likely legal reprisal.3 However, holding children, often for extended periods, in detention presents an untenable ethical situation. Perpetuating this practice, despite confirmation of abuse, and expert evidence of long term - avoidable - medical and psychology harm, provides incontrovertible evidence that the Australian government has been derelict in balancing the principles of beneficence (doing good) and non-maleficence (avoiding or minimizing harm) when dealing with these children.4-8

    Procedural justice has been retarded or withheld, with inordinately long periods of detention and no indication of the period of confinement. Australia, a country that is rich in resources and previously demonstrated laudable generosity in providing opportunities for migrants, could rightly be accused of withholding distributive justice from these children.

    Human rights legislation can be a useful foil against political expediency. It can buffer prejudicial actions against minorities where these measures are popular with the powerful majority.9 Tragically, as demonstrated by the arrogant response of Australia's former prime minister, quoted by Isaacs, compliance by a country's government with its humanitarian obligations requires a willingness to acknowledge fault where this exists and to take decisive corrective action.

    The freedom of those Australians most acutely confronted with the realities of life in detention facilities to voice their concern without fear of retribution may have been legally muzzled in Australia. Bipartisan flouting of international legal obligations has not provoked the ire of the broader populace beyond some enlightened non-governmental organisations and professional medical and ethics bodies. Thus, international action is warranted. Australia's bid for one of the two seats on the United Nations Human Rights Council that will become vacant for the period 2018 to 2020 should be used as a catalyst to accelerate reforms to Australia's offshore processing arrangements, particular those relating to imprisoning children. It would be unconscionable for Australia to take a seat on the UN Human Rights Council while refugee children remain in detention. International pressure appears morally justified in the cause of justice.

    References

    1. The Forgotten Children: National Inquiry into Children in Immigration Detention. Australian Human Rights Commission, 2014. https://www.humanrights.gov.au/sites/default/files/document/publication/forgotten_children_2014.pdf (accessed 29 Dec 2015).

    2. Australian Government Department of Immigration and Border Protection. Immigration detention community statistics summary. 30 November 2015. https://www.border.gov.au/about/reports- publications/research-statistics/statistics/live-in-australia/immigration- detention (accessed 29 Dec 2015).

    3. Isaacs D. Are healthcare professionals working in Australia's immigration detention centres condoning torture? J Med Ethics Published Online First: 23 December 2015.

    4. Murphy L. Beneficence, law and liberty; the case of required rescue. Georgetown Law J 2001; 3: 605-65.

    5. Dudley M, Steel Z, Mares S, et al. Children and young people in immigration detention. Curr Opin Psychiatry 2012; 25: 285-92.

    6. Green JP, Eagar K. The health of people in Australian immigration detention centres. Med J Aust 2010; 192: 65-70

    7. Moss P. Review into recent allegations relating to conditions and circumstances at the Regional Processing Centre in Nauru, 6 February 2015. https://www.border.gov.au/ReportsandPublications/Documents/reviews-and- inquiries/review-conditions-circumstances-nauru.pdf (accessed 29 Dec 2015).

    8. Paxton G, Tosif S, Graham H, et al. Perspective: The forgotten children: National inquiry into children in immigration detention. J Paediatr Child Hlth 2015; 51: 365-8.

    9. McNeill PM. Public health ethics: asylum seekers and the case for political action. Bioethics 2003: 17: 487-502.

    Conflict of Interest:

    None declared

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  9. Prostitution, harm, and disability: Should only people with disabilities be allowed to pay for sex?

    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

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  10. After Birth Abortion: Three Years On

    To the editor.

    Three years ago, on February 23rd, 2012, the Journal of Medical Ethics pre-published electronically the paper by Alberto Giubilini and Francesca Minerva, which proposed the new term "after-birth abortion" as a key concept for re-interpreting an old debated issue, i.e. the moral relevance of birth for the right to life of fetuses/newborns. As is well- known to the readers of this Journal, a few days afterwards media and web- sites around the world raised a storm on such paper, deploying such titles as: "Slaughter newborn kids, say academics. Fury at call to legalize 'after-birth abortions'", "Academics - Who Else? - Call for the Killing of Babies", "Infanticide as a Right: Killing Babies No Different From Abortion, "Experts" Say". The editor of the JME promptly rebutted the attacks, highlighting the cultural and liberal line of the journal and of academic discussion in general. This, however, was not enough to stop the wave of offences and insulting criticisms to the authors, editors and anyone showing interest in the issue. In particular, Giubilini and Minerva received death-threats and were exposed to other forms of ostracism, such as being classified as "insane" and needing psychiatric support or being intellectually dumb and philosophically immature, along with serious consequences for their professional life.[1]

    One of the aims of this strong reaction was to make clear that the new term as well as the corresponding idea was so outrageous that it shouldn't have deserved any discussion at all, and that the whole issue had to return to a complete oblivion. It was courageous and wise of the Journal of Medical Ethics to publish in 2013 a double issue discussing the various aspects of the story. But with the exception of a few other important academic journals (such as The Hastings Center Report, Bioethics, and Monash Bioethics Review), the problem appeared to be carefully avoided and set aside in public discussion, since stupid ideas are to be forgotten and leave space to more interesting ones. In this general scenario it may be interesting to notice that this trend was recently reversed by cardinal Angelo Bagnasco, one of the most authoritative figures in the Catholic Church, president of the Conference of the Italian Catholic Bishops since 2007 and vice-president of the Conference of European Catholic Bishops since 2011. Already in 2012 Bagnasco showed interest in the issue, and in his official Address for the opening of the Permanent Committee of the Italian Bishops (March 26, 2012), he remarked that "another thesis has emerged in the last few weeks concerning the legitimization of infanticide absurdly presented in an international scientific journal: something that is aberrant in itself, if not also monstrous. For these scholars, of Italian origin, what is permissible to do to the foetus - that is abortion - is also permissible to do to the newborn child. And why not also even later?"[2]. After this outcry of disgust for the thesis, a thick veil of silence was hanged down the issue, even with some forms of boycott (for example some invitations to conferences were withdrawn or withheld, as were some job offers).

    Recently, at the end of January and early February 2015, Bagnasco came back again with three official speeches on the issue, using the term "post-partum abortion" [aborto post-partum] to refer to what Giubilini and Minerva had called "after-birth abortion". Of course, Bagnasco mentioned the issue in order to denounce it as a terribly immoral idea, but by insisting on it he seems to think that it is a lively and timely issue to be discussed. While three years ago it was simply to be discarded and immediately rejected, now he thinks that it has to be seriously considered and examined, not least because, according to him, it appears to be supported "at the European level" (whatever this means). This step is crucial and shows how relevant academic freedom of discussion is, as defended by the Journal of Medical Ethics and other journals: reflection and discussion at the academic level has the potential to shape public debates and to prompt people to reflect on important, neglected issues. Bagnasco spoke for the first time on the issue during the opening Address of the Permanent Committee on January 26, 2015: in presenting the next conference of the Italian Church, titled "In Jesus Christ the new humanism", which will be held in Florence the next November, Bagnasco said that it is important to think over again on the issue because nowadays there is an "anthropological challenge", whereby some want to "overturn the alphabet of the human and redefine the bases of the person and of society". In this context he explicitly said that "in Europe some want abortion declared as a basic right so to bar any "conscientious objection", and urge that so-called post-partum abortion be recognized" [3].

    A few days later, Saturday 31st of January 2015, Bagnasco was the keynote speaker in Brescia at a conference on the Encyclical Humanae Vitae organized by the local bishop in honour of pope Paul VI, who was born in Brescia. In the middle of his speech, Bagnasco said that "we do not know if Paul VI had imagined to what extent the principles that he had stated would have become so relevant for the new challenges that we have to face today. We do not know this. We can only hint to genetic manipulation, to the possibility of patenting human embryos as well as of freezing and destroying them, up to the so-called post-partum abortion that some want to be legalized at European level" [4].

    Again, on February 6, 2015 at a Conference organized in Montesilvano by the bishops of two Italian Regions, before over 500 delegates cardinal Bagnasco was criticizing the moral "desert" created by secular ideologies, repeating the same words pronounced at the Address to the bishops: "in Europe some want abortion declared as a basic right so to bar any "conscientious objection", and urge that so-called post-partum abortion be recognized" [5].

    More recently, on May 30 Bagnasco was invited to open the Conference for the 10th Anniversary of Scienza&Vita, a prominent pro-life Association closely connected to the Italian bishops waiting for directions. The first part of the discourse was devoted to criticize so-called "proportionalism", a moral theory spread in Catholic moral theology. Bagnasco remarked that such a theory has good intentions since it aims at preventing human suffering. But it is wrong, because it justifies many actions against life, like abortion and embryo experimentation, going "up to abortion post-partum, a definition used to sweeten infanticide", he added speaking off the cuff [6].

    Not only is it very interesting that Cardinal Bagnasco in the last months came back on the issue of post-partum abortion several times as something worth discussing, but he even suggested that "in Europe some [...] urge that so-called post-partum abortion be recognized". I had no information about this claim to "recognition" before reading Bagnasco's speeches, but if confirmed, it would be a real revolution. Giubilini and Minerva presented their ideas as a logical hypothesis to be explored, without any practical implication nor any proposal for public policy. Now cardinal Bagnasco informs us that that hypothesis is going to be recognized at some European Union level. This is really surprising. I can only explain it by recalling that sometimes a new word forces us to create a new category, and that, as Hegel said, "all cultural change reduces itself to a difference of categories" [7]. This alone, however, does not account for the rapidity of the cultural change in this case: in only three years a new category - afterbirth abortion- passed from being an academic, logical proposal to being a topic of public discussion In any case, we have to acknowledge that cardinal Bagnasco's statements inform us that the debate has entered now a new phase. It is no longer in the field of the "absurd" that shouldn't even be considered or mentioned, but it is jumped into that of the "debatable" that needs to be taken seriously and analysed. We have to acknowledge as well that it is a merit of the Journal of Medical Ethics to have started this debate and promoted this new discussion, and it would also be desirable that for Giubilini and Minerva the form of ostracism of the last years come to an end.

    Maurizio Mori

    Professor of Bioethics

    Dipartimento di filosofia e scienze dell'educazione

    Universita di Torino, Italia

    References

    1. Minerva F. New Threats to Academic Freedom", Bioethics, (2014): 28(4); 157-162

    2. A. Bagnasco, Prolusione "Un'altra tesi ? emersa nelle ultime settimane, la legittimazione dell'infanticidio, assurdamente presentata in riviste scientifiche internazionali: in s? qualcosa di aberrante, se non addirittura di mostruoso. Per questi studiosi, di origine italiana, quello che secondo loro si pu? fare sul feto, ossia l'aborto, sarebbe possibile anche sul bambino appena nato. E perch? anche non successivamente?"

    3. A. Bagnasco, Prolusione, 26 gennaio 2015: "In Europa si vuole far dichiarare l'aborto come un diritto fondamentale cos? da impedire l'obiezione di coscienza, e si spinge perch? sia riconosciuto il cosiddetto aborto "post partum"!".

    4. A. Bagnasco: words available on the web at: https://www.youtube.com/watch?v=mrPz43xCT40. Last access on February 5, 2015. They are at minute: 48-50. There is no written text available so far. In Italian the words are the following: "Non sappiamo se paolo VI abbia immaginato fino a che punto i principi da lui affermati sarebbero divenuti attuali, nelle nuove sfide che oggi siamo chiamati a fronteggiare. Non sappiamo questo. Possiamo qui solo accennare alla manipolazione genetica, alla possibilit? di brevettare degli embrioni, di crioconservarli e distruggerli, di praticare l'aborto, fino al cosiddetto aborto "post partum" che si vuole legalizzare in sede europea".

    5. The words of Bagnasco are reported in inverted commas in an article of P. Greco, "Si vuole capovolgere l'alfabeto dell'umano", Avvenire, 7 marzo 2015, p. 17.

    6. The full text of Bagnasco's discourse is published in Avvenire, May 30, 2015, pp. 14-15. The sentence I quoted is reported in a complementary paper by L. Liverani, "Bagnasco: difendiamo l'uomo da pretese di interessi e ideologie", Avvenire, May 30, 2015, p. 13: ?Fino all'aborto post-parto - aggiunge a braccio al testo del discorso -, definizione usata per addolcire l'infanticidio?. For an analysis of Bagnasco's views, cfr. M. Mori e D. Neri, "Editoriale", Bioetica. Rivista interdisciplinare, xxiii (2015), no. 1.

    7. "All revolutions, whether in the sciences or world history, occur merely because spirit has changed its categories in order to understand and examine what belongs to it, in order to possess and grasp itself in a truer, deeper, more intimate and unified manner" GWF Hegel.

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    None declared

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