Recent eLetters

We would like to thank Professor Stewart Justman for his thoughtful paper "Placebo: the lie that comes true", in which he highlights the often neglected deception in research on placebos and points out the potential harms related to half-truths or exaggerated claims about the "power of the placebo" (1). We agree strongly with his conclusion that "it is necessary to root the placebo effect in the attentive practice of medicine itself". We also agree with his other conclusion that the "appropriate response to this dilemma is first of all to consider the placebo effect as a therapeutic benefit arising from the conscientious performance of the rituals of good medicine, and not as a resource to be tapped by the use of trickery (with equivocations counting as trickery) or dispensed in the form of pills."

As Justman also remarks, much of the confusion related to placebos and placebo effects is related to the ambiguous nature and many understandings of these concepts. We'd like to develop this point further and repeat our earlier suggestion to replace the ambiguous "placebo effect" with a new term "care effect" in the clinical context (2). In the research context, the term "placebo effect" could be replaced by the expression "the effect in the control group" when the outcome of the research is discussed. The equivocal concept "impure placebo" confuses more than it clarifies and should be abandoned totally. If a method of treatment is ineffective in its own right, it should be called an ineffective treatment for a particular patient or problem.

References: 1. Justman S. Placebo: the lie that comes true. J Med Ethics 2013;39:243- 248. 2. Louhiala P, Puustinen R. Rethinking the placebo effect. J Med Ethics; Medical Humanities 2008;34:107-109.

Authors: Pekka Louhiala, Hjelt Institute, University of Helsinki, Finland, pekka.louhiala@helsinki.fi Raimo Puustinen, Medical School, University of Tampere, Finland, raimo.puustinen@uta.fi

Conflict of Interest:

None declared

I am grateful for the response to my paper.

For clarity's sake, however, I would like to point out in reply that I do not cite Ahsan to 'legitimize' any claim. Rather I present it as legal authority for a claim about legal principle. The principle is clear, though the respondents to my paper seem not to understand it quite.

I would therefore emphasise that the idea of best interests applies to patients individually, and thus necessarily varies from patient to patient. I do not for a moment consider that best interests supports the measures discussed in the paper for all patients; rather I suggest that it does so in some cases.

The respondents to my paper seem to suggest that a preponderance of relgious opinion renders my interpretation of the law impossible.

Their argument rests on a fundamental failure to appreciate that the law respects a plurality of distinct values. Many systems of beliefs are respected.

It would not be true that it would be in everyone's best interests, as that idea is understood in English law, to become organ donors. But it is wrong to suggest that this means that it can be in no-one's best interests.

Conflict of Interest:

None declared

In a recent article by Walter Sinnott-Armstrong and Franklin G. Miller, the argument is made that ability should be the metric of value among human life and thus the determining factor on what constitutes moral harm when killing. Someone who has permanently lost all abilities no longer has value and killing them would not only fail to add more harm and it would also fail to take away any more value.

In the authors' case, to say that "Betty is not worse of dead" is to presume knowledge about death. It's taken for granted what the authors believe about death is true: a descent into non-existence and nothingness. However, we cannot say whether it is better to become nothing than to be conscious and totally and irreversibly disabled mainly because we have experienced neither, and we have no ability to comprehend what it would be like to "be nothing" (a contradictory phrase, but one that captures the farce in making the claim that someone is "not worse off dead" if one presupposes nothing after death). I certainly don't believe that we descend into nothingness when we die, and indeed the things that happen after we die could be much worse than our present life, but I'm only using the authors' own views to determine that they aren't justified to say that Betty is not worse off dead; even if she were, it would be a matter of personal preference toward either nothingness or total and irreversible disability.

Furthermore, the authors divorce morality from truth when they say "one advantage of this position is that it simplifies the structure of morality." Either that which is most simple is always true, or else morality and truth have no relationship and we pursue that which is most useful to us, regardless of its veracity. Why should simplicity win on the merit of simplicity alone? The authors identify the simplification of morality as an advantage of this perspective, regardless of whether that simplification is born out of truth: is it actually true that it is wrong to kill a universally and irreversibly disabled person? The truth, it seems, doesn't matter as much as the simplicity of the moral system.

The authors also assume that it is worse to cause a person to be deaf and blind rather than only blind. However, this begs the question, for this is only worse in their system of morality in which abilities are the metric of value. In that system, it makes sense that it is worse to deprive a person of two abilities rather than one. However, in other systems, depriving a person of any abilities ("without adequate reason") reaches maximum heinousness and to add increasing quantities of ability deprivation to that doesn't make it any more wrong, but only more tragic. The authors' example here, then, isn't helpful to them because it assumes the system of value they're trying to establish.

The rebuttal to the objection regarding God's commandment is superficial. First, it assumes that the strength of God's commandment is in the reason that justifies his commandment and not the command itself. This is not evidenced throughout Judeo-Christian theology, the theology that I would be prepared to assert and defend; instead, God should be obeyed because he is God. This is why Lot's wife was turned into a pillar of salt: because she disobeyed God. It doesn't matter what God's reasons were for commanding her not to look back on the destruction of Sodom and Gomorrah. What matters is that he commanded it at all and his commands are self-justifying because he is God. This leads us into a discussion regarding the sovereignty of God and epistemology, which isn't the main topic at hand, but suffice it to say that the authors dismiss this objection without actually rebutting it.

The authors go on to further establish, in their rebuttal of the anticipated objection by secular theorists, how they are begging the question in their argument. The main question of their paper may be, "Why is life valuable in this extreme case when it includes no ability?" They're trying to show in their argument that killing people in this state is not wrong because lack of ability constitutes total loss of value. To dismiss this objection by assuming that the metric of value is ability is to beg the question in the rebuttal.

They reduce moral theory to a matter of preference when they write, "these arguments will have no force at all for those of us who prefer our moral theories to be independent of religion." Therefore, it doesn't matter what is actually true; what matters is what one prefers. They further support this idea by stating that it is problematic to depend on religious belief in philosophical theory as well as public policy. They imply that what is good is an agreeable solution for all, even if that means that the agreeable solution isn't what's actually true. Is this right or even good? Unfortunately that small question alone is irrelevant to those who do not care about what's right but instead only what serves their preferences! Thus this discussion cannot even begin until we deal with moral relativism, a discussion unto itself.

They go on to nearly refute their entire argument when addressing concerns regarding whether using ability as the metric of value would lead to the assignment of variable values to humans with non-zero quantities of ability.

For their first response regarding possession of abilities greater than plants, why would that be the case? Why plants in particular? If one is going to hold the "minimal ability threshold" stance, does that mean a human with, say, one ability is equivalent to a chimpanzee with one ability? Indeed, under this view, why aren't chimpanzees and humans equivalent, or any non-plant life? The authors fail to flesh out this rebuttal to make it consistent with the rest of their argument. Furthermore, they establish earlier in their argument that if it is wrong to remove one ability, it is more wrong to remove two, and maximally wrong (indeed, equivalent to murder) to totally and irreversibly disable someone. Their argument cannot be paired with this objection because this objection assumes that abilities do not have individual value but only the trait of "ability possession" (in which a person may only possess one ability) is what actually grants value.

Their second response (that it would be morally wrong to treat people differently based on their different abilities) does a good job of overturning the argument for which the paper was written. Are we not treating the totally and irreversibly disabled person differently based on their lack of ability? Yet the authors argue that one could rebut the aforementioned objections by declaring that it's wrong to do just that.

The third response is antiquated: quality- and disability-adjusted life years (QALYs and DALYs) are already used to compare people with different disabilities and sets of abilities. This is not a perfect system, but it's what's being used for any number of purposes now. If one is going to respond in this way, one would have to make the point of doing away with QALYs and DALYs.

The fourth response is essentially what the authors are doing in this paper. They're insisting that ability should be the metric of value, yet they haven't established why that should be the case and they've done a poor job of dealing with the anticipated objections. Indeed, if ability is the metric of value, then a myriad of questions are raised that the authors don't address: for someone who is reversibly disabled, how many abilities must they recover to gain value again and thus pull themselves from the chopping block? What if they can follow simple commands? Write their name? Speak? Maintain urinary and bowel continence? Do abilities differ in value, as this would become a real concern in determining whether to harvest someone's organs? If not, would it be accurate to say all who are disabled at all are equally disabled?

The fifth and final response is essentially selling the agenda; somehow get people to believe that what is wrong isn't that wrong, or what is wrong is actually good. When variable value is assigned to humans, such that some are worth less than others, that is the stuff out of which tyrannies, discrimination, eugenics and persecution are made. It is not hyperbole to indicate this because that is precisely the philosophy of historical figures like Adolf Hitler: some people were worth more than others during the Third Reich and some people were worth so little and so detrimental to society that they were better off exterminated. This, of course, is the extreme conclusion of the authors' argument, but the authors' argument sets the precedent for it; it paves the way for other arguments to march, one step at a time, toward that conclusion.

In stating that it is bad to shorten life and thus worse to shorten it more in killing younger or healthier individuals, the authors assume that quantity is what gives life value; in this particular point, not just quantity of abilities, but quantity of years left to live. They neglect the possibility that life, regardless of the quantity remaining, maintains maximum value until death. An analogy would be currency: whether you have $1000 or $1, a dollar is still worth a dollar (putting aside inflation and other economic confounders). Thus, as you spend your money, your money doesn't lose value. By the time you're down to your last dollar, it's not worth $0.10 or some other amount; it's still worth a dollar. The subjective value of that dollar to its owner may be greater (it becomes more precious to its owner because the owner does not have the other $999), but the objective worth of it is still one. If anything, as life shortens, it becomes more precious (particularly for the atheist, who believes that this is all we get!), so it may be more wrong kill people with less time left to live.

In discussing violations of the dead donor rule, the authors miss the mark in clearly establishing what death is. Brain death is merely a surrogate marker for determining death proper. What we actually care about is whether the organism itself, the person, is dead. We use brain death as a marker for the organism's inability to maintain cohesion of its various systems to the benefit of itself. According to Maureen Condic, a neurobiologist at the Universty of Utah, when an organism can no longer "act in a coordinated manner for the continued health and maintenance of the body as a whole," it's considered dead (Condic, M. Life: Defining the Beginning by the End. First Things. 2003). This appears to be the most intuitive, holistic definition of death. The reason why we look for brain death is because we care whether we're using machines to artificially prolong the survival of an organism that can no longer perform this fundamental function; it is not strictly to determine whether higher-order brain function is lost. Thus Condic explains:

"It is often asserted that the relevant feature of brain death is not the loss of integrated bodily function, but rather the loss of higher- order brain activities, including consciousness. However, this view does not reflect the current legal understanding of death. The inadequacy of equating death with the loss of cognitive function can be seen by considering the difference between brain death and "persistent vegetative state" or irreversible coma. Individuals who have entered a persistent vegetative state due to injury or disease have lost all higher brain functions and are incapable of consciousness. Nonetheless, integrated bodily function is maintained in these patients due to the continued activity of lower-order brain centers. Although such patients are clearly in a lamentable medical state, they are also clearly alive; converting such patients into corpses requires some form of euthanasia."

Therefore if one is brain dead, one is properly dead because brain death is a marker for the organism's permanent inability to coordinate the maintenance of all its various sub-systems into a cohesive whole. The authors' ignore the implication that brain death is being used as a surrogate marker for the death of the organism in light of the fact that we can use machines to keep the cellular processes of the organism going without the organism ever being able to recover its coordinated manner by which it sustains its life. To procure organs from these individuals is not a violation of the dead donor rule; they're dead.

They raise a second example in which they believe the dead donor rule is violated, yet they fail to point out that the decision has been made to not resuscitate these individuals, just like anyone else with a "do not attempt resuscitation" order in their chart. Obviously it's philosophically inconsistent if a patient goes through vital organ donation but has an advanced directive still in place to attempt resuscitation. Irreversibility isn't included in the legal definition of death because plenty of people who die could be resuscitated but are not because of their advanced directive, yet we still declare them dead when they enter into that state because we will not prevent them from naturally progressing to the point at which their body loses the capacity to maintain cohesion amongst its sub-systems.

Interestingly, Dr. Miller co-authored a paper in the New England Journal of Medicine on the topic of the dead donor rule, and a point was made that seems to stand contrary to the central argument of the article in question (Truog and Miller. The Dead Donor Rule and Organ Transplantation. 2008. NEJM):

"At the dawn of organ transplantation, the dead donor rule was accepted as an ethical premise that did not require reflection or justification, presumably because it appeared to be necessary as a safeguard against the unethical removal of vital organs from vulnerable patients. In retrospect, however, it appears that reliance on the dead donor rule has greater potential to undermine trust in the transplantation enterprise than to preserve it. At worst, this ongoing reliance suggests that the medical profession has been gerrymandering the definition of death to carefully conform with conditions that are most favorable for transplantation. At best, the rule has provided misleading ethical cover that cannot withstand careful scrutiny. A better approach to procuring vital organs while protecting vulnerable patients against abuse would be to emphasize the importance of obtaining valid informed consent for organ donation from patients or surrogates before the withdrawal of life- sustaining treatment in situations of devastating and irreversible neurologic injury."

The question, it seems, is irrelevant as long as strict adherence to informed consent and the advanced directive of the patient (if present) is upheld. Those are our guiding principles in choosing to withdraw aggressive care, whether it be from the patient with multi-organ failure in the intensive care unit or the patient with metastatic cancer in the outpatient setting who just wants to live his last two weeks free from the burden of chemotherapy and other aggressive interventions. The valid concern is that organs would begin to be harvested from people who have reasonable chances of survival or are not even in imminent danger of death. Yet we seem to navigate this labyrinth fairly well when patients or their families request a cessation of aggressive care apart from concerns of organ transplantation; the additional piece that must be added to it in matters of transplantation is the avoidance of euthanasia and physician- assisted suicide, the ethics of which will not be discussed here, but for the sake of this discussion I take for granted as wrong. I suspect it would be very difficult to determine a general rule that could apply to all cases, but that each patient must be approached individually.

Interestingly, Dr. Truog and Dr. Miller identify that, at worst, "this ongoing reliance [on the dead donor rule] suggests that the medical profession has been gerrymandering the definition of death to carefully conform with conditions that are most favorable for transplantation." It seems that is exactly what is being done in this paper Dr. Sinnott- Armstrong and Dr. Miller have submitted to the Journal of Medical Ethics and the applications reach beyond the field of transplantation. The authors are trying to figure a way to broaden the population that would be available to donate their organs. With the precedent set, each following step becomes easier to take and before long we really are harvesting organs from people who are in no imminent danger of death. Indeed, the reductio ad absurdum would be the harvesting of organs from individuals who are disabled in some capacity and do not even want their organs harvested. The authors attempt to stave off this objection by stating, "We can hold the line for vital organ donation by continuing to restrict it to those in a state of total (universal and irreversible) disability. It is only these donors who would not be harmed or wronged by vital organ donation, since all other donors have abilities to lose." Yet they are not holding the current line (i.e., the dead donor rule). So the line is moved this time and, perhaps even after the authors themselves are dead, still others will desire to move the line and will make arguments in favor of it. And another argument will be made to move the line further. This is the power of precedent setting. Why should we trust those who move the line to hold the line?

"What makes killing wrong" is a transparent attempt to do what Dr. Miller denounces in his paper in the New England Journal of Medicine: "gerrymander the definition of death," or in this case, gerrymander those circumstances about which one might be declared suitable for transplantation. The scope of this argument extends beyond organ transplantation, however, and into the broader world of medicine. If adopted, this view would color for the worse how we perceive the weak, the sick, the aged and the unborn.

Conflict of Interest:

None declared

Giubilini and Minerva, in their article "After-birth abortion: why should the baby live?", have been trying to justify the moral legitimacy of the infanticide posing well-known theories in bioethics and bringing out the analogy with abortion. Such intention has raised reactions of protest and disagreement coming from different sides. Criticisms have been sometimes uttered in the deprecable forms of threats and insults, which is surely not suitable to rational confrontation and scientific research. However if we reckon that the civilization and justice rate of a society can be measured in the way its children are treated and welcomed, this bewilderment, in its peaceful statements, is significant and can be shared and vindicated through considered judgments and rational argumentation. In fact the "children" of a society, being totally helpless and vulnerable, need someone who, especially in the first days of life, takes care of them so that they can survive. Consequently the way they are treated becomes paradigmatic because it represents a precious index to understand in what extent a society respects human beings in every phase of their existence, since every man is first of all "child". Anyway, referring to the article at issue it is noteworthy to recall Michael Tooley[1] and Peter Singer[2]?s well-known contributions. Although they were the first to advocate the moral legitimacy of infanticide in bioethics, a twofold originality is ascribable to the two Italian authors in facing this issue. On the one hand, although admitting its contradictoriness, they have coined a new term i.e. "after-birth abortion" to distinguish the action they attempt to legitimate from infanticide. The term is actually an oxymoron, because for "abortion" we understand an interruption of pregnancy and consequently it is easy to understand that we cannot talk of "abortion" in the case of a newborn. Notwithstanding it is still to prove if the action defined "after-birth abortion" is really a different practice than infanticide or if it is just a linguistic legerdemain to legitimate an old discriminatory one. On the other hand they structure their argumentation maintaining that if the baby is "unwelcome" after-birth abortion would represents a better solution compared to a possible baby's adoption - albeit this assertion seems to be confirmed by psychological studies, it certainly needs to be discussed again. However these two new elements have as their premiss a functionalist concept of person, not at all new. According to this notion a person can be considered such and consequently a moral subject having right to life, only when he/she is able to recognize some sort of value to life that would lead him/her to perceive the own existence deprivation as a loss. Only by beginning with a similar concept - which is clearly restrictive of human being - they can argue, with a coherence that has to be unquestionably acknowledged, the legitimacy of abortion before and after birth and lean toward the killing the baby instead of the possibility of adoption. Nevertheless before considering the conclusions it is interesting to analyze how Giubilini e Minerva develop their argumentation and to value its foundation. The article begins giving for granted that voluntary abortion is a morally acceptable practice since if carried out under certain conditions it is legally allowed in many countries. Fortified by this concept, the two authors don?t waste a word to argue the legitimacy of voluntary interruption of pregnancy. They should have at least partially explained the notion, since it is the premiss from which their following argumentation is structured. Beginning with the observation that abortion can be justified when a baby's birth can cause physical or psychical impairments to a woman, the two authors wonder if these factors, remaining undetected until the delivery, can be equally valid to justify killing a baby once he/she is born. The cases they cite as an example are those in which some delivery complications intervened, from not diagnosed pathologies to the ones not diagnosable before the delivery, from changes of both sentimental and economic situation of the parents, who will condemn them to be responsible of "an unbearable burden" they are not able to carry: the offspring in a not desirable condition. Their answer is affirmative: a child can be killed both before and after his/her birth as he/she is not a person yet, but just a potential person who is not able neither to attach value to his/her own life (being unaware of it), nor to express desires nor to make plans for the future. In this way the analogy between abortion and what they name "after-birth abortion" is easily accepted as valid in order to legitimate the second term of the same analogy according to a sort of "transitive property". Often analogies entail the risk to stress common elements of the compared terms, hiding those aspects which differentiate the two categories. Instead in this case the analogy is perfectly structured. However if we question the concept of person at the bottom of their reasoning and consider it in the most proper manner, this analogy cannot lead us but to the diametrically opposed conclusion. In fact it is not difficult to find also among the argumentations of those who deem abortion as illegitimate, the reasoning which stresses the similarities between abortion and infanticide, taking into account that the letter is an action considered shameful by most people. Nevertheless Giubilini and Minerva's article is basically coherent in its reasoning, except for some details. Yet it is based on a notion of person that has to be necessarily discussed if we want to analyze the conclusions to which it leads with intellectual honesty. The definition of person proposed by the two authors has to be rejected not because of a "bottom option" which on the contrary would aim at protecting every person they consider potential, but because it is not able to catch in every possible facet what is specific of the human person. In fact a person is such because needs time to develop, i.e. needs some conditions to express at its fullness the qualities and abilities recognized and empathized by the two authors as necessary to acknowledge the right to life to an individual. The ability to be self-aware, to relate to others, to communicate through a language, to make plans for the future are surely qualities which reveal us the human value and which give reasons for its protection. However a similar protection takes root in the ontological condition that allows such exceptional expressions and that characterizes every human being. In fact such ontological condition distinguishes every man in every stage of growth and represents the not sufficient but necessary condition of those abilities so much stressed by the two authors. Consequently in order not to give an arbitrary definition of person, which puts Giubilini and Minerva in the uncomfortable position of "exactly determining when a subject begins or ceases to be person" and that leads them to unsolved problem of identifying an age until which after-birth abortion can be performed, the only alternative is to grant to human beings the right to life so as they are as such. Furthermore relating the protection of a human being to the quality/quantity of his interests appears restrictive and letting the adults' interests prevail on the repeatedly underestimated newborn's ones represents an arbitrary decision. What's more the two authors don't precisely explain the concept of "interest" which they continually refer to. Nevertheless we can accept that adults' interests have a wider significance but it is undeniable that a newborn has interests too. Although these are not verbalized, they become apparent in his vital dynamism, in his request for food and in the interaction with those who take care of him since the first days of life. Although interests are obviously proportional to the individual's stage of growth, the infant' s ones deserve a special consideration also because the satisfaction of the most fundamental interests, such as those emerging in the first weeks of life, represents the necessary condition to facilitate the expressions of more complex interests in the future. Going back to the analogy of fore and after-birth abortion: they are both morally equivalent since newborn and fetus are ontologically equivalent, but consequently these actions have to be claimed as illegitimate because interrupting the life of the involved subject - a human being - they are prejudicial to the right to life. Such conclusion is fundamental not just because this right represents the basis for all the others, but also because its acknowledgement in these terms avoids every kind of discrimination towards human beings: either they are protected in every condition or they are inevitably at the mercy of the strongest. In fact Giubilini and Minerva deem that the moral status of the unborn child or of the newborn depends on the value assigned by the mother, i.e. an adult human being, who has as such an absolute power on the individual who totally depends on her. If these are the terms through which the human procreation is connoted, the meaning of relationship parents-children is twisted because in this way the child is conceived as an object whose value (understood in purely utilitarian terms) depends on the interest of the people who brought him into the world. Parents should take care of their own child abiding by what they "have started", whether one likes it or not, instead of claiming the right to life or death over him. Such a duty is rooted "in the total absence of self-sufficiency of what is begotten [in which] it is ontologically programmed that the begetters protect him from the risk of falling back into nothing and look after him in his further becoming"[3] like Jonas writes about the "figure" of the newborn. Giubilini and Minerva try to defend their thesis affirming that it cannot be talked of a damage towards someone if this someone is not able to perceive the action as a damage. The concept of damage that they use is not proper: in order to carry on a damage it is not necessary that the damaged person realizes it, but it is necessary that one of his/her interests is harmed. Such interest does not have to be intended as something emotionally perceived by the subject, but as the objective relation between the subject and a goods that belongs to him/her. In the case of abortion or after-birth abortion the goods which is not only damaged but even destroyed in a not-reversible way is that of life. This is the necessary condition for every other goods so its liquidation cannot but be a severe damage. In order to better understand the existence of a damage despite a person's unawareness, it is useful to cite as example the condition of a person whose human rights are offended without he/she realizes it. This happen because of a particular psychic or socio- cultural condition which doesn't permit the person to be aware of his/her human stature and consequently of his/her rights: if such rights are offended the damage exists anyway. The two authors go on with two terminological clarifications. First of all they specify that they use the term "after-birth abortion" and not "infanticide" to stress that the killed person's moral status is more comparable to the fetus' one that to that of a child. Consequently they ask to legitimate the killing of a newborn in all the cases in which abortion is permissible. Such "request" cannot be accepted since the human being's growth process is not characterized by qualitative differences and therefore it cannot be affirmed that a fetus-newborn-child have a different moral status. As a result it has to be granted them the same moral protection since these definitions don't identify distinct entities, but are just denominations indicating different growth stages of the same human being, who deserves always protection. Second of all they admit to have chosen the term "after-birth abortion" to distinguish the action identifiable through such expression from the one identifiable with "neonatal euthanasia" so to stress the fact that the interest of who dies is not necessarily the first choice criterion. The latter is basically represented by the protection of adults' interests which can be jeopardized by the baby's existence. The strategy of solving problems resorting to redefinitions rarely works and the arbitrary decision to name differently same actions does not succeed in backing a praxis averting its connection with an expression: "neonatal euthanasia"; a problematic practice for the public opinion. Even though both actions could be carried on for the sake of different reasons, such goal is not met because they remain illegitimate as they equally pursue the killing of a human being during the days following his/her birth. The two authors end their article upholding an innovative thesis: after- birth abortion would be preferable than the option of giving an undesired baby in adoption since it would be less traumatic for the mother. In what extent the own child's voluntary killing, whether the baby is considered a person or just a potential person, could be thought as a better choice than the adoption also from the point of view of emotional impact on a person's psychical balance, is a mystery that could maybe being clarified only by the deepening of psychological studies the two authors appeal to. From a moral point of view a similar practice cannot certainly be accepted as legitimate and results out of proportion because, although according to the two authors the newborn's life enjoys a low reputation, it is surely not so worthless to let prevail the egoism of the strongest on the life of the weakest. The events following the publication of this article deserve to be mentioned. The two Italian authors, surprised by the outcry caused by their words, explained on the blog of the "Journal of medical ethics" that their intervention is not to be intended as a draft bill but as a "pure exercise of logics". Moreover they affirmed that it is necessary and right to distinguish among what can be object of academic discussion and what can be legally permitted. The scientific community's obtained outcomes will surely be communicated to the "great public" through proper language and proportional to the comprehension skills. However this statement cannot be supported because of two reasons: first of all because it would provoke a retrenchment of the Academy's conception and of its task and of its role in the society. It is not a merely gathering of intellectuals, who, pour parler, play to sharpen their argumentative skills analyzing the most paradoxical and provocative issues. On the contrary the Academy is a place where the culture of a society should (at this point the conditional is obligatory) flourish and where reasoning should find its fully development in order to be in service of the scientific and civil community. Second of all the restrictive way to consider the work carried out in the bosom of the University appears naive, because it does not take into account that, owed to quicker and quicker means of communication, what is "produced" inside it reaches more easily the wide public. Henceforth the academical impact on the society is greater and requires more responsibilities as the academical debate often prepares the public one even without wanting to and consequently could create the presuppositions for a possible legislative intervention.

Reference list

1 Tooley M., Abortion and infanticide, Philosophy & Public Affairs, Vol. 2, No. 1 (Autumn, 1972), pp. 37-65. 2 Singer P., Practical Ethics, Cambridge University Press, 1979. 3 Jonas H., Il principio responsabilit?. Un'etica per la civilt? tecnologica, trad. it. Einaudi, 2009, p. 167.

Conflict of Interest:

None declared

I read Robert Card's recent paper entitled "Is there no alternative? Conscientious objection by medical students" with great interest.1 That Muslim students in America are able to conscientiously object (and this was entertained) to the cross-gender consultation is somewhat startling. I have just left the Middle East, where I worked as a medical educator for five and half years (2006-2011), and, to the best of my knowledge, even in the conservative, gender-segregated traditional Muslim culture of the United Arab Emirates, not once did a male or female student refuse to examine a patient of the opposite sex.

Several issues, many of which have been described by Padela and del Pozo,2 should be taken into consideration in relation to Muslim students' conscientious objection to the cross-gender consultation on religious grounds. Although Islam prohibits touching or physical contact by the opposite gender, unless appropriate (e.g. by a spouse), in some circumstances, the "prohibited becomes permissible".3 Medicine is one such circumstance. Islam does not preclude a doctor from examining the opposite gender where a same gender physician is not available or in life and death situations.2-6 Islam recommends first a same gender Muslim physician, followed by a same gender non-Muslim and, failing their availability, a Muslim of opposite gender, and lastly an opposite gender non-Muslim doctor. 3,5 In cross-gender consultations, however, Muslim women generally need to be accompanied by a same gender third party.3-5 The ancient literature on medical care attests to the possibility of and necessity for cross-gender examinations. In the eighth century, Ibn Quaddama wrote that it was permissible for a male doctor to inspect whatever parts of the woman's body warranted during the medical examination.4 Similarly, Ibn-Muflih stated that "A man doctor may inspect the awra of a women's body as far as the medical examination warrants if only a male doctor is available to treat her, even if he has to look at her private parts. The same would be true if a man is ill and there is but the woman doctor to treat him. She may inspect his body even his private parts" (p. 3).4 Furthermore, this literature attests to the need for Muslims to seek the most qualified practitioner for their medical treatment. Some 600 years ago, Ibn Qayyim Al Jawziyya wrote in The Prophetic Medicine that Muslims should seek the best authority in each matter and field because such expertise will ensure that the task is done with excellence.7 Implicit in this hadith (narrative originating from the words or deeds of Prophet Muhammad) would be the need to consult an opposite gender physician if he or she was the most qualified. The insistence of modern Muslim patients for the same gender physician or for Muslim medical students conscientiously objecting to the cross-gender consultation is interesting considering the Islamic history of medicine during Prophet Muhammad's life. During that time, the medical corps comprised "lady healers" or asiyaat, who were responsible for treating wounded soldiers, irrespective of the injuries. Cross-gender medical care was established during the battles of Badr and Uhud, and so according to the Prophet's tradition, the rule governing covering of areas of the body was waived in the interest of medical treatment.3,4

During interviews with final year male and female clerks about the cross-gender consultation in a society (United Arab Emirates) where women are generally not free to travel without a member of their mahram (non- marriageable male chaperone), some female students (more so than their male colleagues) had initially been apprehensive about touching a male body. Their mutawa (religious leader) reassured them that as medical students, they had to treat both male and female patients and were therefore allowed to touch males. From this study, it also emerged that although students became more "comfortable" with cross-gender touching in the clinical consultation, Emirati female patients in Obstetrics and Gynecology and Emirati male patients in Urology often refused male and female students, respectively. As little has been published in this regard, a group of local female students surveyed Emirati women's attitudes towards male and female medical students as well as canvassed their physician preference. While their general preference was for a female student or physician, other factors such as physician certification and patient education impacted on what parts of the body the women would or would not allow a male student or physician to examine.8,9

As I indicated at the start of my response, it was startling that Muslim students in America could conscientiously object to the cross- gender consultation. This is difficult to reconcile how Muslim students living in a conservative, gender-segregated and traditional Middle Eastern society were able to accept that in Islam medical care should supersede religious teachings and how Muslim students living in a Western country do not share the same understanding.

References 1. Card RF. Is there no alternative? Conscientious objection by medical students. J Med Ethics 2012;38:602-4. 2. Padela A, del Pozo PR. Muslim patients and cross-gender interactions in medicine: an Islamic bioethical perspective. J Med Ethics 2011;37:40-4. 3. Aldeen AZ. The Muslim ethical tradition and emergent medical care: An uneasy fit. Acad Emerg Med 2007; 14(3): 277-8. 4. Hathout H. The male gynaecologist. Medical examination of the other sex. 1986. http://www.islamset.org/bioethics/obstet/examin.html (accessed 21 November 2012). 5. Hedayat KM, Pirzadeh R. Issues in Islamic biomedical ethics: A primer for the pediatrician. Pediatrics 2001;108: 965-71. 6. Hammoud MM, White CB, Fetters MD. Opening cultural doors: Providing culturally sensitive healthcare to Arab American and American Muslim patients. Am J Obstet & Gynecol 2005;193: 1307-11. 7. El-Qadar A. trans. Ibn Qay'em El-Jozeyah on The Prophet Medicine, 2007. http://www.islamhouse.com/p/51834 (accessed 21 November 2012). 8. McLean M, Al Ahbabi S, Al Ameri M, Al Mansoori M, Al Yahyaei F, Bernsen R. 2010. Muslim women and medical students in the clinical encounter: A United Arab Emirates study. Med Educ 44:306-15. 9. McLean M, Al Yahyaei F, Al Mansoori M, Al Ameri M, Al Ahbabi S, Bernsen R. 2012. Muslim women's physician preference: Beyond Obstetrics and Gynecology. Health Care Women Internat 2012;33:849-76.

Conflict of Interest:

None declared