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Displaying 1-10 letters out of 474 published

  1. Response to Holland

    Dear Sir, I thank Dr Holland for his commentary [1] on my article [2]. I am replying to correct a possible misunderstanding he may have about the brain in people with prolonged disorders of consciousness.

    He argues that there are people who are definitely permanently unaware without fluctuation because they have no brain, citing "Tony Bland, whose higher brain had effectively liquefied'". I assume that he bases this statement on two sentences in the original legal judgement in the Bland case. [3] They say "It is sufficient to say that it arises from the destruction, through prolonged deprivation of oxygen, of the cerebral cortex, which has resolved into a watery mass." and "There are techniques available which make it possible to ascertain the state of the cerebral cortex, and in Anthony Bland's case these indicate that, as mentioned above, it has degenerated into a mass of watery fluid."

    Dr Holland has, naturally, interpret these legal statements to mean that there is no residual brain. He therefore argues both that there can be no awareness and that there can be no expectation of any recovery. If his understanding were correct, then his argument would be valid.

    In reality people in a prolonged state of unconsciousness including people in the vegetative state still have some structurally intact brain albeit with considerable atrophy, [4] and this brain still shows electrophysiological activity [5] and changes in blood flow associated with stimuli. [6]

    I suspect that in 1994 the experts made statements such as "the damaged brain has been replaced by cerebro-spinal fluid, which is mostly water". This simply explains that, within the fixed volume of skull, the space once occupied by the brain that has now atrophied is occupied by water; the statement does not say that there is complete absence of brain. However it has been interpreted to mean that all brain has been replaced by or transformed into 'a watery fluid'. In other words it was not made clear that there was still some structurally intact (albeit abnormally structured) brain present. This would have been known at the time. [7]

    This may explain why some people believe it should be easy to determine consciousness. The difficulties in establishing consciousness on the basis of single signs has been shown in another recent publication. [8]

    References. 1. Holland S. Commentary on Derick Wade's 'Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness' and Zoe Fritz' 'Can best interests' derail the trolley?' Examining withdrawal of clinically assisted nutrition and hydration in patients in the permanent vegetative state.Journal of Medical Ethics. 2016;0:1-2 doi:10.1136/medethics-2016-103739

    2. Wade DT. Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness. Journal of Medical Ethics. 2016;0:1-7 doi:10.1136/ medethics-2015-103140

    3. Airedale NHS Trust v Bland (1993) http://www.bailii.org/uk/cases/UKHL/1993/17.html

    4. Guldenmund P, Soddu A, Baquero K, Vanhaudenhuyse A, Bruno MA, Gosseries O, Laureys S, Gomez F. Structural brain injury in patients with disorders of consciousness: A voxel-based morphometry study. Brain Injury 2016;30:343-352

    5. Sitt JD, King JR, El Karoui I, Rohaut B, Faugeras F, Gramfort A, Cohen L, Sigman M, Dehaene S, Naccache L Large scale screening of neural signatures of consciousness in patients in a vegetative or minimally conscious state. Brain 2014;137:2258-2270

    6. Vanhaudenhuyse A, Noirhomme Q, Tshibanda LJF, Bruno MA, Boveroux P, Schnakers C, Soddu A, Perlbarg V, Ledoux D, Brichant JF, Moonen G, Manquet P, Greicius MD, Laureys S, Boly M. Default network connectivity reflects the level of consciousness in non-communicative brain- damaged patients.Brain 2010;133:161-171

    7. McLellan DR, Adams JH, Graham DI, et al. In: Papo I, Cohadon F, Massaroti M, eds. Le coma traumatique. Padova: Liviana Editrice, 1986:165-85.

    8. Fischer DB, Truog RD. What is a reflex? A guide for understanding disorders of consciousness. Neurology 2015;85:543-548

    Conflict of Interest:

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  2. Proposed FGM 'compromise' illuminates medical complicity with non-therapeutic fee-paying surgery on infants

    The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation, and the UK Royal Colleges of Obstetricians and Gynaecologists and Paediatrics and Child Health, amongst others.(5)

    Many mistakes slipped through: (i) the authors say the prevalence of FGM is stable, but provide figures showing it falling; (ii) they claim to medically recategorise all procedures (amateur, accidental or surgical) - matters beyond the scope of ethicists to judge; (iii) they state the impacts of surgery on male and female genitals can be assumed to be similar - they cannot; (iv) likewise, comparisons with adult surgery (including cosmetic female genital surgery) are not relevant to children; (v) there is no such thing as a "nick that heals completely" without leaving scar tissue; (vi) indeed, they later admit that "de minimus" procedures will involve "tissue being removed", the amount being difficult to regulate; (vii) controversially, they describe asymptomatic healthy children as "patients" thus generating an overweaning sense that doctors owe a duty of care regarding social matters; (viii) despite arguing for autonomy they did not suggest leaving parents with responsibility for performing the 'nick'; (ix) far from seriously considering the utilitarian calculus, they have no insight into the damage their proposal has on trust in the medical profession; (x) the concept of 'harm limitation' need not be applied(6) to justify changing the present global consensus, especially without evidence of rising harm in countries where FGM is illegal; (xi) they neglect entirely physicians' conflicted pecuniary interest when surgically altering healthy children's genitals, even if by request of loving parents for socio-cultural benefits; (xii) revealingly, they use a self-referential test for acceptability based on one gynaecologist's previous defence of male circumcision(7).

    Surgeons should respect the basic ethical principles of 'first of all, do no harm' and informed consent to irreversible surgery on the basis of medical necessity, particularly when performed on children. In the USA (but less so in Europe), there may presently remain a 'liberal' tolerance of male circumcision whose protection appears to be the article's real purpose. The weak arguments presented might lead to the opposite conclusion: far from condoning renamed non-therapeutic procedures (no doubt performed for a fee on defenceless girls), why not turn the spotlight onto medically sanctioned traditional 'ritual' practices on male infants?

    References (1) Arora KS, Jacobs AJ. J Med Ethics Published Online First: 22nd February 2016 doi:10.1136/ medethics-2014-102375 (2) American Academy of Pediatrics. Ritual genital cutting of female minors. Pediatrics 2010; 125: 1088-93. (3) American Academy of Pediatrics. Policy statement: ritual genital cutting of female minors. Pediatrics 2010; 126: 191. (4) MacReady N. AAP retracts statement on controversial practice. Lancet 2010; 376: 15. (5) Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 12 May 2010

    https://www.rcog.org.uk/en/news/joint-rcogrcpch-statement-on-the-aap- policy-statement-on-fgm/ (6) Pearce AJ, Bewley S. Medicalization of female genital mutilation. Harm reduction or unethical? Obstet Gynaecol Reprod Med 2014;24(1):29-30 (7) Jacobs AJ. The ethics of circumcision of male infants. Isr Med Assoc J. 2013;15:60-5.

    Conflict of Interest:

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  3. Ethical Discrimination?

    A properly worded consent form must make risks transparent but if the person has not even been asked to participate, discrimination is too easily slipping in. Even giving the reason as duty of care can be mis/used to eliminate some people - but their participation may be valuable as well as ethical. There can be an unconscious bias to avoid difficulties for researchers but discrimination will miss opportunities for the unexpected to be revealed by the exclusion of risk. Intolerance of risk means whole groups may not benefit from research carried out and they subsequently may be treated incorrectly, that is in the same way as the findings conclude for others with low risk. Exeter University has carried out much ground breaking work to enable wider participation in research by the public including via self referral and genuine rather than tokenistic efforts to involve the wider community. It has been promoted in other parts of the country by now but how much the public is aware of it is questionable. (Patient and Public Involvement Exeter web site) Open selection does not always happen though as some projects still select participants via GPs acting as gatekeepers. For example COBRA. (On Exeter web site) Researchers will not always get it right and results can be skewed. It would be interesting to see a comparison of the same or other studies conducted both by self referral and via gatekeepers. One area which could do more to become transparent to the public is, although more loosely described as research , the issue of conferences and events which are held by researchers/practitioners/professionals to debate and share information with each other exclusively , any resulting write ups are also exclusive. Many are not open to the public either because admission is only for stated specialist groups or because the cost of admission is entirely prohibitive for those who are not funded. These events are using information given directly or indirectly by the public and paid for by citizens. On these grounds as well as it being ethically right to make debate inclusive to all citizens - events and conferences which have an impact on or interest to the public should be made open access.

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  4. Re:Moral value of newborn infants

    Dear Editor,

    Giubilini and Minerva's paper, 'After-birth abortion: why should the baby live?' [1] is a 'thought experiment' expressing old ideas supported by old arguments, [2] with the only innovation being to extend killing of newborns to those who are normal, apart from being unwanted. It is redolent of the almost mathematical approach to human life much favoured by some philosophers, and Giubilini and Minerva have every right to discuss the idea.

    We believe publication in a high-profile medical journal is another matter. It was brought to public notice as headline news, expressed with characteristic journalistic hyperbole in some Australian and British newspapers and was bound, therefore, to elicit maximum repugnance from most readers, yet also to give ammunition to extremists in both directions. We question both the motivation and the act of publishing the paper, which does not add to useful discussion and which exposes bioethicists to ridicule.

    While Giubilini and Minerva correctly identify the infant and the mother as central in the argument, they seem na?ve in regard to the subsequent effects of killing the baby, let alone the fact that such events take place in a society which collectively sets general ethical and legal standards. Their use of the disingenuous euphemism 'after-birth abortion' for infanticide is in the same league as 'collateral damage' for non-combatants killed in warfare. Lacking a clear indication of when it would no longer be OK to kill a newborn baby and how anyone would be able to decide when the baby becomes a person, this paper is mere moral posturing.

    We find the argument that neonates are morally equivalent to fetuses and the whole concept of retrospective abortion morally unacceptable. Neonates who die are dead babies, not products of abortion. We no longer leave newborns with Down syndrome to die of dehydration. We oppose throwing newborn girls in the trash because they are the wrong gender. Additionally, the authors argue that adoption is not in the best interest of people without explaining or justifying this extraordinary statement.

    As paediatricians, we have spent a lot of our lives acting as child advocates and arguing that newborns are morally under-valued. [3] Over a million newborns died last year in the world and newborns are responsible for 40% of all childhood deaths under 5 years, almost all in developing countries. [4] Neonatal intensive care is highly cost-effective and compares favourably with adult intensive care. [5] The Nuffield Council report on bioethics argues convincingly that neonates are morally equivalent to older children and adults. [6]

    If the paper has any value, it should be to stimulate efforts to re- define the true moral value of newborn infants. [3]

    References

    1. Giubilini A, Minerva F. After-birth abortion: why should the baby live? J Med Ethics published online February 23, 2012: doi:10.1136/medethics-2011-100411.

    2. Singer P. Rethinking life and death. New York, St Martin's Press 1994:180-3.

    3. Janvier A, Bauer KL, Lantos JD. Are newborns morally different from older children? Theor Med Bioeth 2007;28:413-25.

    4. Oestergaard MZ, Inoue M, Yoshida S, et al. Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Med 2011;8:e1001080.

    5. Doyle LW; Victorian Infant Collaborative Study Group. Evaluation of neonatal intensive care for extremely low birth weight infants in Victoria over two decades: II. Efficiency. Pediatrics 2004;113:510-4.

    6. Nuffield Council on Bioethics. Critical decisions in fetal and neonatal medicine: ethical issues. Oxford, Nuffield Council, 2006. Available on http://www.nuffieldbioethics.org/neonatal-medicine (accessed 29 March 2012).

    Conflict of Interest:

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  5. A devil's advocate outflanked by demons: Is it really time to stop talking to anti-vaxxers?

    Brennan offers an interesting strategy in "A libertarian case for mandatory vaccination," though in form it is the common "devil's advocate." The apparently least charitable bases for one's own position (in this case libertarian premises) are granted for the sake of argument; one's position is nevertheless found defensible (mandatory vaccination); and thus the harshest critics are answered without having to pay out a full rebuttal. One need not endorse or condone the "devil" for this to work; it is not sophistry to pick your battles - if libertarianism is right, mandate vaccines; if it is wrong, mandate vaccines by a probably more obvious argument than if it is right. No commitment necessary.

    It should be noted, though, that Brennan's intended "devil" is clearly a pro-vaccine libertarian. The anti-vaxxer audience is lost by assumptions (A)-(D) that take for granted the efficacy, safety, and obviousness of vaccines, plus a quip about Jenny McCarthy.

    The damage here is not in directly insulting a particular reader (I would be suprised if many anti-vaxxers read the JME), but in what such disregard entails. For instance, the author briefly mentions that libertarians can tolerate government advertisement campaigns, but he does not feature this as a serious criticism, presumably because the anti- vaxxer is not only irrational, but unreachable. While it is true that any attempt to persuade a dogmatic believer can backfire and cause further polarization instead, this danger applies also when outreach is forsaken in favor of compulsion. It could be replied that, in the time it takes for outreach to work, we will fail to stop harm to others, but in the time it takes to debate each other about a mandate (and eventually to pass it), there will also be infected. Force is seen as efficacious only after diplomacy has been discarded.

    By disregarding the anti-vaxxer as an agent with potentially revisable beliefs, this article becomes about what "we" are to do about "them." "We" are very diverse (so some devil's advocacy is required), but "they" are demonized with words like "irrational," "stupid," and "self- destructive." "They" aren't invited to this article, where the "them- problem" is discussed and resolved (by government policy, no less). Liberals and libertarians should be the first to get chills, at which point Brennan also loses the very audience he attempts to court, who are particularly wary of government-enforced marginalization.

    So here is a "demon's advocate" portrait of an anti-vaxxer, based on close friends of mine who have not vaccinated their children (though I do not claim how far the portrait can be generalized): They are people. They are firm in belief, and when I finish talking to them, I do have feelings of frustration that one might express through name-calling (I have done so privately). However, they are not those names; they are concerned mothers and fathers who share many premises in common with me and probably with you - for instance, a high regard for the welfare of their children. Their premises diverge from mine on which sources of health information are most trustworthy, as we have both a different religious and educational upbringing, and they have felt (not unjustifiably) estranged from the mixture of impersonal, corporate, and politicized healthcare that differs strikingly from their intuitions on what "health" or "care" mean. They prefer personal relationships with small-town doctors who spend time taking their histories, and who typically engage in preventive, holistic, minimally pharmaceutical, and minimally invasive forms of care (primum nocere). Adverse events and side-effects are judged more heavily than potential gains in health or improvements in one's natural history, so most drug labels are off-putting and some minor maladies shrugged at; preferences sometimes align with what evidence-based medicine would prescribe and sometimes not. Drug and supplement companies who advertise as being all-natural, small-scale (non-PHARMA) businesses have taken the time to understand, magnify, and exploit some of these preferences to share information "that the FDA doesn't want you to know," along with conspiracy theories about FDA, Pharma, and government agendas (only marginally more far-fetched when compared to confirmed events like the Tuskegee or US Radiation studies, which, to use Brennan's phrase, "a minimal amount of research" can easily uncover for any American worried enough to look for it).

    If we are both clever and patient enough to derive government mandates from libertarianism, is our rhetorical distance from this portrait so much greater? Couldn't some of their own premises favoring preventive care and corporate transparency be used to expose the misinformation?

    *The opinions expressed in this letter are personal and do not necessarily represent the views of my institution

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  6. A hierachy of access to information/ knowledge is unethical

    There is a hierarchy of means to access opinions and information published in journals. This is unethical in a democracy which uses citizens' information to contribute to debates- from which they are then excluded. This to some extent mirrors my position that it is unethical to with hold information from clients in therapy. It is taking advantage of vulnerability however it is dressed up but also creates a hierarchy of the informed. There are some prospective clients who will be more informed by reading up on the practice and many others who will rely mainly or only on what is disclosed by the therapist. There is also the problem of the therapist him/herself deciding who will be given how much information. Which can be discriminatory. Withholding information can also be used defensively by therapists to hide their own insecurities.

    The claim that it is acceptable to 'benignly' deceive clients undermines what is the more important component - trust .To deceive as a means to an end is unethical and more likely to be a component which adds to dissatisfaction if the therapy is unsuccessful.

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  7. Response to Roberts

    Dear Editors, I read with interest the recent article on the ethics of doctor's strikes.1 I accept most of the arguments expressed in the article, however, there is one shortcoming to the framework: its under-analysis of the role that the social context can have when evaluating the ethics of doctors strikes.2 I contend that there is a need to contextualise industrial disputes of this nature, namely, reflecting on and evaluating the nature of the healthcare system, its values and vision, and its relationship to the prevailing socio-political landscape. Such an approach would offer a more integrated ethical understanding of doctors decision to strike and extend the value of the ethical framework being proposed. Roberts does attempt to contextualise the strike, by referring to the 'party line' adopted by various government officials and departments that the junior doctor strike exposes patients to serious harm 1(p.3), and how the media can be used to promote the government position. However, the link between the doctors' actions and the social context is not properly formulated. Healthcare systems can be categorised into four basic models- Beveridge model (UK), the social insurance model (e.g. Germany), the national insurance model (e.g. Canada) and a market driven model (e.g. India).3 Each of these systems employ different principles of healthcare. It would be worth incorporating this dimension of health care to an ethical framework for evaluating doctors' strikes. In this article the NHS and the Department of Health are framed as the doctors 'employers'. While this is factually correct, it is worth remembering that the Department of Health and the NHS are also significant social institutions, key apparatuses of the UK welfare state and custodians of its principles of universality, equality and justice.4 In this particular case, it would be appropriate to check the actions of the government and that of the doctors decision to strike against these principles.5 The NHS has undergone a period of profound restructuring and reorganisation under the austerity driven focus of a conservative coalition government (2011-2016) and more recently a majority conservative government (2016-present).6 The 'better outputs with fewer resources'8 logic of austerity calls into question whether equality, access and quality of health services can be achieved when fiscal rectitude rather than universality is the operational mode.7 9 In the UK the annual health spend per capita in real terms is slowly recovering from -1.3% in 2010(compared with 0.1% for the OECD average for the same year). In 2013 the figure was 0.6 %, however, this was still behind the 1.0% average for the OECD. 6 This concerted strategy to underspend in the area of healthcare also included a two year policy of pay freezes and staff redundancies.6 It is clear that these political decisions have had an impact on the delivery of healthcare, impacting of the range of services provided and the working conditions for staff. Austerity then not only amplifies health inequalities of society and but also erodes at the 'the very principle of relatedness and mutuality'10 that defines these public health services and initiatives. Incidentally, this belief in state responsibility for the health of UK citizens has proved a rallying call for some of the striking doctors. During the escalation of the industrial strikes in April 2016, a make- shift banner was posted on the wall of a NHS hospital near my place of work. It read: 'The NHS will last as long as there are folk left with faith to fight for it- Aneurin Bevan'. This poster betrays the striking doctors' sympathy with the ethical vision of the founding father of the NHS and adds further legitimacy to their actions. It would appear that the values of the healthcare system and the type of priority it is given or not by a government are also important factors to consider when evaluating the reasons why doctors strike. I think that this amendment is worth making and highlighting for consideration.

    REFERENCES 1 Roberts AJ. A framework for assessing the ethics of doctors' strikes, J Med Ethics Published Online First: 20 May 2016 doi:10.1136/medethics-2016- 103395. 2 Weinstein BD. Dental ethics. Philadelphia: Lea and Febiger 1993. 3 Physicians for a National Health Program. Healthcare systems-Four Basic Models, http://pnhp.org/single-player- resources/health_care_systems_four_basic_models.php (accessed 8 Jun 2016). 4 Weir S. 2015. The welfare state is dead - what is rising from the grave?. http://opendemocracy.net/ourkingdom/stuart-weir/welfare-state-is- dead-%E2%80%93-what-is-rising-from-grave (accessed 7 Jun 2016). 5 Pearse N. 2015. Welfare debate marks opportunity to renew Beveridge's legacy. http://opendemocracy.net/ourkingdom/nick-pearse/welfare-debate- marks-opportunity-to-renew-beveridge%E2%80%99s-legacy (accessed 7 Jun 2016). 6. OECD. Country Note: How does health spending in the United Kingdom compare? 7 July 2015. OECD Heath Statistics http://www.oecd.org/health (accessed 7 Jun 2016). 7 Quaglio GL, Karapiperis T, Van Woensel L, et al. 2013. Austerity and Health in Europe. Health Policy 2013; 113: 13-19. 8 Thomas S, Burke S, Barry S. 2014. The Irish health-care system and austerity: sharing the pain, Lancet, May 3, 2014; 383: 1545-1546. 9 Suhrcke M, Stuckler D. 2012. Will the recession be bad for our health?: it depends. Soc Sci Med 2012; 74: 647-653. 10 Lynch, K. 'New managerialism' in education: the organisational form of neoliberalism, Open Democracy, 16 Sept 2014. https://opendemocracy.net/kathleen-lynch/'new-managerialism'-in-education- organisational-form-of-neoliberalism (accessed 7 Jun 2016).

    Conflict of Interest:

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  8. Contempt for Conscience, Contempt for the Profession

    A major conceptual problem this paper suffers from is the suggestion that those whose views do not accord with the majority are, by default, not tolerable.

    Such people, whom the authors assume are exclusively religious, are twice said to possess an idiosyncratic view of the universe. These remarks exclude the possibility that there might be good, even non-religious, reasons for conscientious objections. Moreover, they betray a contempt for religious views.

    These people are also said to have "ultimately arbitrary" views, and that because it is "ultimately up to society to determine the scope of professional practice", those who wish to conscientiously object should leave the profession. Two things here are cause for alarm. The first, relating to the previous point, is: the authors suggest that off-beat views are nonsensical. This is a disrespectful posture which colours the entire argument.

    The second is the largely undefended assumption that society defines the scope of the medical profession. This is intellectually untenable. Professions have always enjoyed a degree of independence from the State. This degree of autonomy prevents certain conflicts of interest, and allows a profession to develop its own aims and standards. Professional standards are not determined by plebiscite, but by rational reflection.

    Of course, the professions are accountable to the State and the nation, but not dictated by them. Only tyranny contradicts this. Simply, it is not in the general interest for the professions to be merely a tool of the government. Since the authors appear to suggest the opposite, that the professions should acquiesce entirely to others' demands, their attempted ethical argument is built upon political presuppositions. If their argument is to stand, so must these political assumptions be defended.

    In conclusion, doctors of all stripes and beliefs should be most distressed by the proposals laid out in this paper. Morality and medicine are not issues to be settled, in the final analysis, democratically. The professions should resist unreasonable interference from other bodies. It would be most undesirable for them to bow to the absolutism of public demand or government decree. Though the authors dismiss all analogy with historic totalitarian regimes, they seem to suggest that conscientious objection is never appropriate. And this is manifestly false.

    Conflict of Interest:

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  9. Proposed FGM 'compromise' illuminates medical complicity with non-therapeutic fee-paying surgery on infants.

    The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation, and the UK Royal Colleges of Obstetricians and Gynaecologists and Paediatrics and Child Health, amongst others.(5)

    Many mistakes slipped through: (i) the authors say the prevalence of FGM is stable, but provide figures showing it falling; (ii) they claim to medically recategorise all procedures (amateur, accidental or surgical) - matters beyond the scope of ethicists to judge; (iii) they state the impacts of surgery on male and female genitals can be assumed to be similar - they cannot; (iv) likewise, comparisons with adult surgery (including cosmetic female genital surgery) are not relevant to children; (v) there is no such thing as a "nick that heals completely" without leaving scar tissue; (vi) indeed, they later admit that "de minimus" procedures will involve "tissue being removed", the amount being difficult to regulate; (vii) controversially, they describe asymptomatic healthy children as "patients" thus generating an overweaning sense that doctors owe a duty of care regarding social matters; (viii) despite arguing for autonomy they did not suggest leaving parents with responsibility for performing the 'nick'; (ix) far from seriously considering the utilitarian calculus, they have no insight into the damage their proposal has on trust in the medical profession; (x) the concept of 'harm limitation' need not be applied(6) to justify changing the present global consensus, especially without evidence of rising harm in countries where FGM is illegal; (xi) they neglect entirely physicians' conflicted pecuniary interest when surgically altering healthy children's genitals, even if by request of loving parents for socio-cultural benefits; (xii) revealingly, they use a self-referential test for acceptability based on one gynaecologist's previous defence of male circumcision(7).

    Surgeons should respect the basic ethical principles of 'first of all, do no harm' and informed consent to irreversible surgery on the basis of medical necessity, particularly when performed on children. In the USA (but less so in Europe), there may presently remain a 'liberal' tolerance of male circumcision whose protection appears to be the article's real purpose. The weak arguments presented might lead to the opposite conclusion: far from condoning renamed non-therapeutic procedures (no doubt performed for a fee on defenceless girls), why not turn the spotlight onto medically sanctioned traditional 'ritual' practices on male infants?

    References (1) Arora KS, Jacobs AJ. J Med Ethics Published Online First: 22nd February 2016 doi:10.1136/ medethics-2014-102375 (2) American Academy of Pediatrics. Ritual genital cutting of female minors. Pediatrics 2010; 125: 1088-93. (3) American Academy of Pediatrics. Policy statement: ritual genital cutting of female minors. Pediatrics 2010; 126: 191. (4) MacReady N. AAP retracts statement on controversial practice. Lancet 2010; 376: 15. (5) Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 12 May 2010

    https://www.rcog.org.uk/en/news/joint-rcogrcpch-statement-on-the-aap- policy-statement-on-fgm/

    Conflict of Interest:

    I was involved in setting up an FGM clinic 1996, have publications on FGM, and received a fee for expert advice in the UK's first FGM trial 2014.

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  10. Utilitarianism in disguise will remain unconvincing to many

    The authors submit an ethical theory which rejects categorical conceptions of right and wrong, and adopts a scaled view of rightness, believing that it can depolarise the debate over the use of human embryonic stem cells (hESC) in medical research. I will argue that their proposal is unsuccessful.

    They argue that binary ethics must be forgone in preference of a non- binary understanding of rightness and wrongness: pro and contra reasons cannot be reduced to a binary moral conclusion, and a single pro or contra reason should ever rule out acts which go against it (and vice versa). If it were otherwise, an illegitimate "deontic leap" is made, and a binary conclusion (e.g. action X is right/wrong) is forced. Below I offer one major reason why this theory cannot do what the authors claim it can.

    Crucially, "right" and "wrong" remain (apparently) undefined, though they are essential to the debate. Those who oppose to the use of hESC often assume that embryocide is murder--a belief not easily trumped even by the forceful argument of medical research.1 So, if the means to an end are seen as absolutely wrong, the "non-binary" analysis will mean nothing to those whose ethic includes deontological considerations such as "do not kill".

    The authors do not seem to recognise this. Hence, they imply that "right" and "wrong" are synonyms of "pro" and "con" respectively; they assume a quantitative view of ethics. Thus, they reveal that their ethic is utilitarian. Regardless of whether utilitarianism is valid or not, it is na?ve to think that it could resolve a debate so bound up in religion and politics.2 Simply, it is a different ethical language to that of some of the major voices in the debate.

    Espinoza and Peterson's non-binary ethical theory falls short of its promise to depolarise the ethical debate. Its utilitarian design sidesteps other ethical considerations in order to redefine the terms of the debate, making it unconvincing to many.

    1. Meilaender, G. 2013. Bioethics: A Primer for Christians. Cambridge: Eerdmans 2. Green, R. M. 2008. "Embryo as epiphenomenon: some cultural, social and economic forces driving the stem cell debate". Journal of Medical Ethics, 34, pp 840-844.

    Conflict of Interest:

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