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

    Brian D. Earp University of Oxford


    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]


    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.


    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: 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.


    [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 -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 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 -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 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-

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  2. 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


    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: 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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  3. Ancient conceptions of dignity. The secular sacred.

    Dignity need not be coupled with theology. The South African offence of 'crimen injuria' is the offence defined as the act of "unlawfully, intentionally and seriously impairing the dignity of another."

    It is based on the 'Latin phrase crimen iniuriae, which should mean 'accusation of abusive behaviour' ( ).

    The search for an understanding of a secular basis for the notion of 'dignity' could benefit from an examination of Roman and South African case law.

    The word itself goes back to the Roman 'dignitas', a strongly related notion, that also may be worth examining to gain a secular picture ( ).

    This article ( bin/WebObjects/athensdialogues.woa/wa/dist?dis=22 ) on three types of dignity considers, inter alia, the Ancient Greek model, which would have informed the Roman.

    In support of the universality of the notion if dignity, it is wirth noting that it also appears in the Chinese and Japanese constitutions:

    The specific question of how dignity relates to the treatment of the dead is, I think, related, but separate. A corpse, in Roman law, is a res nullius, a thing that belongs to nobody, which attracts only duties, not rights. Organ transplant from corpses, of course, complicates this because a human organ can be possessed, and has value, possibly even monetary value, but this does not relate to dignity.

    The inarticulate, or instinctive, belief, or feeling, that corpses are special, and must be treated with respect, relates more to the notion of the 'sacred', which also exists in a secular sense. This sense relates to aesthesics and sentimental preciousness, rather than to dedication to the gods, but is a real and important human universal.

    The question of the treatment of the deceased might be considered as part of the wider question of what, in a secular world, is sacred - a question that most certainly does not have the answer 'nothing'.

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  4. For Drugs that Save Lives, a Steep Cost

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

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

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

    Conflict of Interest:

    None declared

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  5. Should Obesity Be a 'Disease'?

    Obesity being designated a disease recognizes its adverse effects on physical and psychological health. Pleas on behalf of the corpulent to not being judged and regarded without compassion are timely. However, obesity's classification as a disease could devolve the self-control needed to assume personal responsibility for the unhealthy dietary and sedentary choices we make. Dieting, weight consciousness, anxiety about body weight/shape and widespread hostility to obesity are fundamental themes in contemporary life. There is tension between trying to control our body weight in the midst of unprecedented access to unhealthy foods. The impulse to ridicule and publicly monitor the body shape has its basis in the highly visible markers of overweight transgressing aesthetic standards and signalling pathology and disease. Seeing fatness leads to the negative reading of fat bodies. More than ever, judgements about our own and others' worth is based on the morphological body as compared to the ideal. Although there is psychological toil from discrimination meted out to the obese, being insulated from the externally-imposed assessment of our weightiness imposes the inertial foundation to stay as we are. There is indeed a fine line between a stern reprimand that could avert a burgeoning public health disaster and abuse and derision that debases the esteem of others. Aside from being susceptible to more serious iterations of a whole range of chronic medical problems, the obese sustain higher risks of anaesthetic, pregnancy and post operative complications. They are more difficult to resuscitate in trauma and critical illness. Life- sustaining procedures such as intubation and central venous access pose an anatomical challenge. Due to their thickset habitus, even the longest chest drains could fail to reach large clots pressing on lungs in major trauma. The treat of loss of life and limb with acute injury and serious illness could be far more effective message than low grade hazard spread over years to decades .

    pleas on behalf of the corpulent to not being judged and regarded without compassion by society. Dieting, weight consciousness, anxiety about body weight/shape and widespread hostilty to obesity are fundamental themes in contemporary life. There is tension between trying to control our body weight in the midst of unprecedented access to unhealthy foods. The impulse to ridicule and publicly monitor the body shape has its basis in the highly visible markers of overweightedness transgressing aesthetic standards and signalling pathology and disease. Seeing fatness leads to the negative reading of fat bodies. More than ever, judgements about our own and others' worth is based on the morphological body as compared to the ideal. Shriver rightly protests the psychological toil from discrimination suffered by the obese. On the other hand, being insulated from the externally-imposed assessment of our weightiness imposes the inertial foundation to stay as we are. There is a fine line between a stern reprimand that could avert a burgeoning public health disaster and abuse and derision that debases the esteem of others.

    Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.

    Clinical senior lecturer, Division of Anaesthesiology and Critical Care, University of Queensland Medical School, Brisbane.

    Acute Care Programme, Mater Research Institute, The University of Queensland, and Division of Critical Care and Anaesthesiology, Mater Health Services, South Brisbane, QLD 4101.

    TEL : +61 07 3843 2541

    CELL: 0404 826 650

    Conflict of Interest:

    None declared

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  6. The Unrealized Horrors of Population Explosion-Increased longevity and enhanced reproductive capacity

    To the Editor: The threat posed by human "population explosion" goes beyond that capable of being supported by the earth's diminishing food and natural resources. The long standing but recently dormant debate on the sustainability of population growth is an integral topic that complements recent media focus on global warming and catastrophic weather events. There needs to be balanced discussion on the societal and health impact of overcrowding, water and food depletion as well as heightened risk of conflict fueled by competition for limited resources. Beyond mass starvation, environment degradation, critical destruction of animal habitat and accelerated loss of biodiversity needs to be foregrounded. When all living beings are interdependent and inextricably linked, this omission is remiss.

    Proponents of human population growth contend the declining impetus to have children jeopardizes human prosperity and societal well-being. The dilemma lies in matching the subsidized needs of a burgeoning number of retirees and the long living elderly (the demand) with children raised to tax-paying independence (the supply). However, this co-dependency holds potential to generate an accelerating demand-supply loop. Today's children will grow old and in turn seek their due from generations raised to adult productivity that come after them. The cost of raising a child to independence, an increasingly deferred milestone, is not just met by the parents and families but also the rest of society.

    Exponential human population growth is not just constrained by the depletion of food stocks and rapid environmental degradation. Although food production has kept pace with recent population growth through better yield crops, improved farming practices and more efficient food distribution, shortage of safe drinking water in many parts of the inhabited world remains a threat to all life. The successful cultivation of crops and animals for human consumption are contingent upon adequate supplies of water. Water is the font of life on earth; no life (including sources of human food) can take root without it. Indeed we search for it in outer space as a harbinger of life.

    Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.

    Clinical senior lecturer, Division of Anaesthesiology and Critical Care, University of Queensland Medical School, Brisbane.

    Acute Care Programme, Mater Research Institute, The University of Queensland, and Division of Critical Care and Anaesthesiology, Mater Health Services, South Brisbane, QLD 4101.

    TEL : +61 07 3843 2541

    CELL: 0404 826 650

    Conflict of Interest:

    None declared

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  7. Research fraud thrives in today's competitive science endeavour

    It does us all well to recognize that despite only a minority of scientists engaging in dishonest means to achieve academic gains, their disrepute will unfortunately taint the hard work of the honest majority. The greater harm will be loss of faith in publicly funded research and the waste of resources on non-credible work. Provided one evades detection, contemporary academia's unbridled publish or perish imperative breeds and rewards ethical lapses, leading to an irreparable breach of trust.

    Deliberately misleading research could be unwittingly adopted into daily life and even be incorporated as detrimental advances in medical treatment, putting all of us at risk. The issue should be deemed to go beyond research misconduct to the material risk of harming people. This occurs by giving false hope, patients receiving non-beneficial treatment and forgoing therapies that do work, and incurring unnecessary side- effects. When standards are not adhered to, we depend on personal ethics and morals to avoid research misconduct. It is high time that all researchers were trained in ethical approaches to career advancement, preferably in their formative years.

    Science fetishes the published paper as the gold medal of prestige and achievement, more so if it is headline grabbing, hosted in a top journal and concentrates on a hot topic such as sex and race. The perverse academic promotion and incentive system that view high-profile journals as the pinnacle of success corrupt us by rewarding those who cut corners, or worse, cheat for a shot at glory. The pressure to publish or perish has become the sole currency of tenure, grants, prestige and promotion. The scientific endeavour is dysfunctional with cheating in scientific papers growing ever deeper roots. Recent headlines of misdemeanours suggest exaggeration, fraud and manipulation to enhance academic standing and competitive funding have only has gotten worse, or that we are better at detecting problems that would have gone unnoticed in the past.

    Falsified or erroneous results have forced authors and editors to retract papers from journals whose peer reviewers have failed to detect conclusion-altering biases and misrepresentations. In the same week that gay marriage was legalised by popular vote in Ireland, Science retracted a paper that purportedly showed gay political canvassers to be better at influencing conservative voters' views on same-sex marriage. Diederik Stapel's sensational findings that garbage-strewn train platforms made racial prejudice worse made for great press. The hope that cleaning up our environment could set free the better angel of our natures was dashed when a whistle blower revealed the social psychology experiments to have never taken place. Tilburg University defended him to the last, and Stapel continues to defend his actions as being driven by "a quest for aesthetics, for beauty-instead of the truth." Yoshiki Sasai, a senior author of a 2014 Nature paper that claimed to have developed an easy method to create multipurpose stem cells, was found hanging in his office stairwell. Vaccination rates tumbled and a rash of measles cases followed Andrew Wakefield's published contentions that thiomerisal vaccines could lead to autism. Wakefield is now in jail and deregistered as a medical practitioner. Authors submit fake peer reviews under assumed false identities, often ones they themselves have written in praise of their own work.

    The dog-eat-dog competition to be published in prestigious journals, weak oversight by supervisors or study monitors, the rush by journals to publish ground-breaking press-worthy studies, cursory appraisal by reviewers juggling the demands of their own wor, the secrecy and unavailability of original data for inspection all lead to sloppy or even unethical research. However, most researchers are honest to their calling, despite the career and competitive gains that become their due from disseminating their work in high profile journals. Of 2 million papers published each year, only a single paper a day is withdrawn from journals because of misconduct, ranging from plagiarism to fabrication of results. If we accept that only 2% of researchers commit deliberate or false misrepresentation, then 98% of the scientific research remains above board. However, the rare occurrence of fraud taints the whole scientific community, incurs loss of public trust on whom most funding depends, embeds erroneous findings in health care (resulting in patient harm), incurs the adoption of ineffective social policy and undermines future research underpinned by false premises.

    There are ways to minimise fraud, but it will require changing the process, from how scientists share their data to how their peers review it and who is allowed to enforce academic standards. Surveillance and regulatory oversight, such as that provided by Retraction Watch and Office of Research Integrity in the United States, police for fraud after it has occurred. Although sanctions, official reprimand and even jail serve as deterrents for potential offenders, could the problem be weeded out at an earlier stage, when a study manuscript is appraised by peer reviewers for suitability to be published? A journal's peer reviewers are supposed to detect errors, but they often do not have the critical data needed to check the findings, nor the time to do so, particularly since they are seldom paid.

    The scientific community clearly needs to build a better safety net, more so in biomedical research involving human subjects. Institutional review boards are only delegated to assess and approve a clinical trial protocol for participant safety and methodological validity, with no remit to monitor a researcher's adherence to safety standards during the conduct of the study. Although misrepresentation of findings leading to biased, exaggerated and fraudulent claims can be discerned by independent re- evaluation of full outcome data that are made available after publication of a clinical trial, this process does not protect a patient from harm and coercion for the duration they are enrolled in a clinical trial.

    I have previously advocated for the important role of data monitoring and safety committees in conferring protection to participants and detect fraud whilst the trial is in progress. With their in depth understanding of the study objectives and protocol, as well as access to fully disclosed results as they accumulate, these committees are well placed to gauge breaches in safety mechanisms, coercive recruitment and fraudulent behaviour from the start of a trial to its completion. Data monitoring committees are independent and widely perceived to be extremely competent. Using these committees to review and approve the completeness of outcomes reported before publication would also enhance the trustworthiness and credibility of clinical studies. The DAMOCLES Study Group recommends that data monitoring committees "ensure that trial results are published in an unbiased, correct and timely manner" and that the committee discusses final data and their interpretation with study investigators. The ability to monitor for errors, whether deliberate or not, while the study is being conducted improves the validity and credibility of submitted manuscripts, eliminates the need for resource intensive post-publication re-evaluation, and averts disseminating erroneous studies to journal audiences in the first place.

    Conflict of Interest:

    None declared

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  8. When Doing Everything Is Way Too Much

    To the Editor: It is crucial that hospital staff have ready access to background health care information about patients who come into their care -- including end- of-life care preferences -- that allow better decisions to be made. However, it is important to incorporate the reality that chronically ill and debilitated patients can at best, only achieve a return to the level of health or function they had before they became really sick. If they were previously housebound with significant cognitive impairment, I would be reluctant to start aggressive treatment and then have to deal with the difficult decision of whether to continue. To do everything for a non- communicating bed-ridden patient confers legal protection to the treating team but does the patient fearful of meeting his maker a gross disservice. Such measures prolong physiological viability at the expense of meaningful life.

    Unlike the inhumanely excessive and overly aggressive treatment demanded by desperate patients, and complied with by the ICU, there is often all-round agreement that symptom alleviation, with a focus on pain reduction, maximising physical comfort and support of the psychological well-being of both patient and family, is the clinically rational and humane course to pursue. Before the acute worsening, and in consultation with their usual treating physician, partners, children and families will have had to opportunity to discuss and contemplate at length a fundamental shift of objective to comfort care, preservation of dignity and symptom palliation.

    There is usually time to come to a realization that premorbid or disease-related quality of life is poor and more aggressive treatment would be futile. Most of us believe that dying at an old and infirm age is not something to be raged against or resisted at all cost. For all of us and every day, life dies at a varied pace. Some race into the abyss of oblivion and the healthy are inching towards the precipice. Alastair Reid yields a truthful rebuttal to Dylan Thomas' "Do not go gentle into that good night." "Curiosity", alluding to a cat's nine lives and a dog's contentment with its allocated years, is an enjoinder to life as the prelude to death.

    " tell the truth; and what cats have to tell

    on each return from hell

    is this: that dying is what the living do,

    that dying is what the loving do,

    and that dead dogs are those who never know

    that dying is what, to live, each has to do."

    We need to bear in mind Kafka's "The meaning of life is that it stops." The question arises of health resources wasted in futile clinical care being made available elsewhere, and the substantial opportunity costs entailed in expensively futile critical care.

    The algorithm for equitable distribution of expensive health care should include probability of meaningful survival, quality adjusted life years of remaining alive from medical treatment, and the loss of scarce critical care beds to a competing patient with better prognosis.

    Conflict of Interest:

    None declared

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  9. Freedom of speech risks inciting race based abuse and vilification

    To the Editor: The rights to unrestrained free speech in Australia, including the abolition of the ban on hate speech in the Racial Discrimination Act that makes it it unlawful to "offend, insult, humiliate or intimidate" a person or group on the basis of their "race, colour or national or ethnic origin," could incite race based abuse.

    Racial discrimination and vilification remains a prescient worry for the recently arrived, with children at higher risk of its long-term adverse effects. As a child growing up in 1980s Australia, I was daily branded ''ching chong Chinaman''. As an intern in the early 1990's, I looked after the child of a fellow student who had repeatedly hurled racial abuse and spat at me as I left for home from school on the bus. During the week of typhoon Haiyan in late 2013, a man mimicked paddling a kayak to a Filipino colleague while heckling him to ''row back to where you came from''. A would-be parliamentarian declared that asylum seekers were clogging up traffic in western Sydney in the lead up to our most recent Federal Elections (2013).

    None of these personal or very public instances of race-based vilification were taken seriously enough to court on the basis of injury to reputation and defamation. The effort and expense required to instigate and follow through legal proceedings compels most non-majority non-white Australians to take such insults and threats on the chin. This aids and abets strong electoral support for Australia's already curtailed foreign aid to be redirected from Indonesia if it did not allow boats to be turned away from Australian shores. The inhumane treatment of asylum seekers remains the biggest elephant in the room, racial prejudice implemented in a systematic rollout.

    How is an immigrant child to deal with unbridled permission to express hateful abuse? Would its vehemence not be seared into his soul, just as the vilification 30 years ago at a bus stop remains fresh and alive in my memory? I am all for free speech, but racially motivated abuse is threatening and hurtful to the progress of hardworking minorities who just want to make a go of it in a new country.

    Conflict of Interest:

    None declared

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  10. Lost in Clinical Translation: Difficult communication in futility

    Getting your message across to a patient and their family is difficult and fraught with misunderstanding. Aside from not having enough time and patience to explain complex diagnoses and sophisticated treatment plans as well as ensuring that understanding has occurred, English may not be the patient's first language.

    As a hospital doctor, even when using non-technical terms, I wonder whether a family member or a professional interpreter is capably relaying acute concerns and nuances of complicated discussions to patients from a non-English speaking background. The medical team cannot be sure that questions posed by a patient in return are being faithfully rendered.

    As communication is an iterative and interactive process, far more is "lost in translation" in health care encounters when the several spoken languages are necessary. Body language can be misinterpreted, with cross- cultural diversity in health-seeking behavior and beliefs pose further obstacles to effective communication.

    There is no doubt that the ethical, moral and legal quandaries of whether to withdraw ventilator-support from a child and pregnant adult clearly dependent on machine-assisted breathing are stressful for, indeed provoke strong emotions in, families and critical care staff.

    Ongoing physiological support as decisions on treatment withdrawal are being deliberated in courts of law necessarily delay the availability of scarce intensive care beds to other seriously ill or injured patients with far better prospects of meaningful recovery. These patients cannot afford to wait for all-round resolution between families, clinicians and courts. Surely the high cost of intensive care and the diversion of hundreds of thousands of dollars from other health care programs bears serious thought even in times of immense crisis. The health system cannot afford the thousands of dollars spent each day in the support of a brain- stem damaged person for whom futility is the eventual outcome. In the unlikely event that one is weaned off the ventilator, the patient is still condemned to full nursing care for the rest of her natural life.

    I recently cared for an elderly man who had sustained a large brain hematoma. The son, who had cared for an ailing father for years, stroked his shock of white hair as he declined neurosurgical treatment on his father's behalf. As he tearfully looked upon the face of his uncomprehending father, the son was unwavering in his refusal. He believed that the great man his father had once been was no longer there. We agreed that surgery was not going to change that and they went home.

    A truthful rendition of diagnosis, treatment and prognosis, as well as ensuring that the family has understood, were necessary for my patient's son to confidently make a decision aligned to his father's wellbeing and priorities. My job was easier without the self-imposed burden of trying to dictate treatment trajectory. I was satisfied that I had not, by deception or persuasion, imposed what I believed to be in the best interest of the patient. Doctors are human after all, with even our most well-intentioned recommendations susceptible to the the beliefs and values we hold dear.

    Conflict of Interest:

    None declared

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