Displaying 1-10 letters out of 395 published
Is Prostitution harmful? - a comment
I would agree with many of the points that Moen raises in his intersting journal especially that many of the problems prostitutes face are secondary to external factors.
Despite this I feel that the analogies he uses almost ridicule many of the sensitive points he argues. I do not feel you can compare hairdressing to prostitution because of the act involved. Our morals around sex form such an integral part of who we are and the act of having intercourse is far more personal and intrusive than having a haircut.
Conflict of Interest:
Response to Koch
Mr Koch is mistaken about the question of whether the Report by the Royal Society of Canada expert panel that I chaired was peer reviewed. It was extensively externally peer reviewed.
As to the journal's purported refusal to publish criticisms of the Report. We received only one request to publish an article critical of the Report. The author of said paper requested not only that we accept his manuscript without peer review but also that we display it prominently alongside the Report. The former violates basic publishing standards of peer reviewed international journals. We declined.
Conflict of Interest:
Re: Journals and "academic Freedom
in his recent article Bioethics Journal editor Udo Sch?klenk speaks grandly about academic freedom and bioethical journals "under seige". And yet, academic freedom and honesty must go together. His journal's website carries under a "new" banner a link to the 2012 Royal Society Expert Panel report on End of Life Decision Making. Mr. Sch?klenk was a principal author of this report. The report was not peer reviewed. Requests to Mr. Sch?klenk that balanced critical reviews be included have been politely declined. So his journal advances as new an old report he helped author as if it were the last and only word on a complexlly contentious subject This seems to make some hash of his calls for vigilance, balance, and forthrightness in journals.
Conflict of Interest:
The history of Jewish circumcision - a response to Lang
A recent Commentary piece by Lang1 contains a substantial historical error. He writes "Milah is merely a token clip of the very tip (the overhang flap or akroposthion) of the prepuce, which leaves most of the organ system (including all its essential functions) intact." No reference is cited, but the source appears to be Wallerstein2. Medical considerations make this unlikely, and the available historical evidence contradicts it. From the medical perspective, if the circumcision scar can migrate in front of the corona glandis it tends to shrink and create a secondary phimosis or a trapped penis. If treated early this can be remedied without further operation3 but re-circumcision may be necessary4. Leaving it untreated can have serious consequences5. Successful outcomes, with or without further surgery, result in a fully exposed glans. Deliberate removal of only the excess foreskin, without subsequent retraction and exposure of the glans, therefore poses a serious risk of creating an intractable secondary phimosis.
All available evidence suggests that Jewish circumcision did expose the glans. There is no pre-Hellenic representation of Jewish circumcision - there is almost no surviving early Jewish iconography, and the Jewish prohibition of exposing the genitals6 means that in any case penises would not be depicted. However, Egyptian circumcision long predates Jewish circumcision, and there is good reason to believe that the Jewish practice was derived from the Egyptian7. Iconography of circumcised Egyptians is abundant, and detailed7. One can see from these that the glans was completely exposed, though there could be a 'cuff' of residual inner foreskin behind the glans. This is exactly what would be expected from descriptions of the chituch operation (described by Lang1 as milah). The foreskin is forcefully stretched forward and severed in front of the glans. The outer layer springs back behind the glans and the residual inner foreskin is pushed back to meet it7. There is a 5,000 year old Egyptian illustration of the technique7, and the same technique is still used today in both medical and ritual circumcisions. There is also much textual evidence that Jewish circumcision exposed the glans. It is recorded that Jewish athletes competing in Graeco-Roman games wore a cap to cover the glans8.
The chituch type of circumcision does leave sufficient loose skin for foreskin reconstruction by stretching to be possible, and there is Biblical evidence that this did occur9. Roman surgeons wrote about techniques for foreskin restoration to re-cover the glans after circumcision8. Many Jews became Hellenised and wished to compete in athletic events9, for which a reconstructed foreskin was a more seemly solution than a cap (especially since the cap could be lost in the heat of competition8). It has long been accepted that periah - ablation of the inner foreskin - was a later introduction into Jewish ritual circumcision10. This technique is also still currently used in both ritual and medical circumcision7. Foreskin restoration would have been virtually impossible after the introduction of periah so periah could not have been part of the operation before the Hellenistic period, and it was a prescribed part of the rite in the Talmudic period three of four centuries later. It is therefore hard to escape the idea that periah was introduced to hinder circumcision reversal1,2,7. Following the destruction of Palestinian Jewish culture in AD 70 Jewish populations were dispersed. Since new ideas would not be adopted everywhere at the same time, it would be unlikely that periah was adopted by all Jewish communities at the same time. Circumcision reversal was still a topic of discussion late in the first century AD11. The important point is that periah did not affect the exposure of the glans penis, it just made circumcision reversal more difficult.
We would also add, as a postscript, that Lang's use of the sale of Viagra as a metric of erectile dysfuntion1 seems curious when many studies in the developed and developing countries have actually investigated the topic directly. Large-scale studies in the US12, Australia13 and Africa14 have shown that circumcised men are significantly less likely to suffer from erectile dysfunction. Sales of Viagra in the richest country of the world reflect nothing more than the ability to pay for it.
1. Lang DP. Circumcision, sexual dysfunction and the child's best interests: why the anatomical details matter. J Med Ethics 2013. (Epub ahead of print May 28. doi 10.1136/medethics-2013-101520).
2. Wallerstein E. Circumcision - An American Health Fallacy. New York: Springer, 1980:281pp.
3. Blalock HJ, Vemulakonda V, Ritchey ML et al. Outpatient management of phimosis following newborn circumcision. J Urol 2003;169:2332-4.
4. Patel H. The problem of routine infant circumcision. CAMJ 1966;95:576-581.
5. Sancaktutar AA, Kilincaslan H, Atar M et al. Severe phimosis leading to obstructive uropathy in a boy with lichen sclerosus. Scand J Urol Nephrol 2012;46:371-4.
6. Genesis 9, verses 20-24
7. Cox G, Morris BJ. Why circumcision, from prehistory to the 21st century. In: Bolnick DA, Koyle M, Yosha A (eds), Surgical Guide to Circumcision London: Springer. 2012:243-59.
8. Rogers BO. History of external genital surgery. In: Horton CE (ed). Plastic and Reconstructive Surgery of the Genital Area. Boston: Little Brown & Co. 1993:3-15.
9. 1 Maccabees 1, verses 15-16
10. Bryk F. Circumcision in Man and Woman. (tr. Felix Berger). New York: American Ethnological Press, 1934:342 pp. (Facsimile reprint New York: AMS Press, 1974)
11. 1 Corinthians 7, verse 18
12. Laumann EO, Maal CM, Zuckerman EW. 1997. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA 1997; 277:1052-7.
13. Richters J, Smith AMA, de Visser RO, Grulich AE, Rissel CE. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006;17:547-554
14. Krieger, JN. Circumcision, sexual function and sexual satisfaction. In: Bolnick DA, Koyle M, Yosha A (eds), Surgical Guide to Circumcision London: Springer 2012:233-239
Conflict of Interest:
Honourary authorship in Biomedical Journals.....
Sir, Waleed Al-Herz and colleagues have posed a common yet not so easy-to answer situation. No doubt, honourary authorship is to be discouraged in medical reporting, yet it's easier said than done.The authors have tried to delve in deep into the problem, however, the overbearing impact of the "publish or perish" conundrum has to be taken at the face of it. We have to evolve methods of evaluating the scientific contribution to biomedical research including an "Integrity Index". Now what all would be included in this index would require like-minded ethicists to put their heads together and evolve.
Conflict of Interest:
Member of Institutional research & Ethics Committeee
Post trial obligations, helthcare after research and the Declaration of Helsinki 2013 draft
I believe that the practical framework produced by Sofaer, Lewis and Davies, is the best document available for research ethics committees on post- trial obligations and responsible transition of research participants from the last visit of a study to the appropriate healthcare. This document should be taken into account for future discussion of the Declaration of Helsinki 2013 draft paragraph on post-trial obligations (see DoH, paragraph 34). I've written my PhD dissertation on the topic of these guidelines. And I've attended the seventh consultation at the Brocher Foundation in Geneva and translated into Spanish an advanced draft of "Care After Research" Guidelines, that it's available open access to download here: http://philpapers.org/rec/SOFADD I hope these materials reach the suitable audience in time.
Conflict of Interest:
Re:Infanticide and termination - an inexorable progression of logic
Infanticide has been practiced by humans throughout history and cultures. Human mothers are unique among primates in deciding whether to continue investing care in their offspring after birth. The reasons for this are many including the supply of resources, competing demands from siblings or the quality the child. (1)
Currently abortion takes the place of infanticide for the purposes of resource supply and competing demands and also at a lower cost to the mother. Prenatal testing meets some of the demand for quality of the infant. But some quality issues are not detected prenatal. With mothers today having fewer children a poor quality infant, one not expected to reach sexual maturity, is a threat to the mothers reproductive fitness.
Since mothers are definitely persons and infants may not be persons, the mothers reproductive rights are greater than the right to life of the infant.
1. Hrdy, Sarah. Mother Nature: Maternal Instincts and How They Shape the Human Species, 2000
Conflict of Interest:
Quantitative analyses, ethical quandaries, and policy debates: A rejoinder
Javier Hidalgo's response to my commentary was unsatisfactory and is likely to mislead the readership of JME. First, biomedical journals often discourage authors from citing unpublished studies. After reading Hidalgo's response, one can see the wisdom of that rule. He quotes several incorrect assertions made by Michael Clemens in 2007 in an unpublished paper about my article with Frederic Docquier.
Second, Hidalgo repeats the misleading quote from page 6 of Clemens in his response: "Bhargava and Docquier note that the fraction of physicians abroad has a positive and significant effect on the number of adult deaths due to AIDS in general, while - interestingly--- it has a negative and significant effect on AIDS deaths in countries where HIV prevalence is low." In fact, I had spelled out how the net effect of physician emigration rate on adult deaths due to AIDS is computed in non-linear models and stated that: "Thus, the net effect at the sample midpoint was positive; net effect was very close to 0 (-0.005) when computed at the start of the sample in 1991." Thus, Clemens is wrong about the negative effect being significant-- it is not statistically different from zero at the start of the sample. In fact, to show that the negative net effect is statistically significant for countries with low HIV prevalence rates, one would have to evaluate its standard error that in turn depends on standard errors of two other estimated coefficients and their sample covariance. Such computations could not have been performed by Clemens since the covariance between the estimated coefficients was not reported by Bhargava and Docquier. Further, the net effect was positive at the sample midpoint where the expectation should be evaluated in such models. This is because the net effect is a function of the random variable HIV prevalence rates that varies across countries and over time. Thus, evaluating the net effect at the sample midpoint is a reasonable approximation for its mathematical expectation.
Third, I had made several points about the importance of micro data that are essential for "integrating the epidemiological evidence from developing countries with the results from analyses of country-level data". One of the problems in policy oriented research is that some authors may not be familiar with quantitative analyses necessary for extracting information from longitudinal data sets covering heterogeneous individuals over time. While it is easy to base one's claims on analyses of country-level data, the ethical quandary is whether to incorporate the findings from elaborate micro studies that may support or contradict the assertions. For example, I had cited our study in South Africa showing the benefits of uptake of healthcare services for AIDS patients' CD4 cell counts and quality of life indicators. There are numerous vacancies for nurses and physicians in South African clinics because many staff members have left for more lucrative venues in OECD countries. For a policy debate to be constructive, it is essential that the available evidence be examined. It would have been helpful if the micro evidence especially from sub-Saharan African countries received greater prominence in this discussion.
Finally, Clemens has claimed that our definition of emigrating physicians is "problematic"- a claim that Hidalgo repeats. Because the data agencies in OECD countries use three definitions, we compared the alternative definitions of emigrating physicians in a subsequent paper and found this issue to be unimportant. In fact, correlations between bilateral stocks of emigrating physicians on the basis of countries of birth and countries of training were very high for countries such as the U.S. (0.98), France (0.97), and Canada (0.94). Moreover, developing countries are justified in recovering the investments made in educating the emigrating physicians.
In summary, policy debates surrounding the emigration of physicians need to be conducted in a scholarly manner. This can be achieved to some degree by conducting several empirical or analytical studies and summarizing the findings for a policy readership. As I had noted previously, "the policy of regularly recruiting physicians from developing countries runs contrary to the ethos of technology transfer". Hidalgo's response avoids addressing many issues that are important from a policy viewpoint.
1. Hidalgo, J. Defending the active recruitment of health workers: a response to commentators. J. Med Ethics. Published online first: 31 may 2013. doi: 10.1136/medethics-2013-101325
2. Bhargava, A. Physician emigration, population health and public policies. J Med Ethics. Published online first: 26 January 2013. doi:10.1136/medethics-2012-101235.
3. Clemens, M. Do visas kill? Health effects of African health professional emigration. Center for Global Development Working Paper Number 114 2007:1-47.
4. Bhargava, A., Docquier, F. HIV pandemic, medical brain drain and economic development. World Bank Econ Rev 2008: 22:345-66.
5. Bhargava, A., Booysen, F. Healthcare infrastructure and emotional support are predictors of CD4 cell counts and quality of life indices of patients on anti-retroviral treatment in Free State Province, South Africa. AIDS Care 2010:22: 1-9.
6. Bhargava, A., Docquier, F., Moullan, Y. Modeling the effects of physician emigration on human development. Econ Human Biol 2011:9: 172-83.
Conflict of Interest:
Lay REC members: patient and public
The Health Research Authority (HRA) is fully supportive of, and strongly encourages, the involvement of patients and the public as active partners in all aspects of the research process. Such involvement produces high quality ethical research consistent with the HRA's mission to 'protect and promote the interests of patients and the public in health research'. The HRA will shortly launch a three-month consultation on its public involvement strategy which sets out our proposed approach for involving patients and the public in our work, and how we can support and enable the research community to involve patients and the public more in their work.
The HRA agrees that patient involvement (PI) offers real benefits as described in this article. However, it does take issue with the author's central thesis that the role of lay members on research ethics committees (RECs) is to be understood as primarily providing a "patient perspective" involving "checking the accessibility of written materials" and ensuring that researchers produce "a summary for a lay audience". The HRA is proud of, and is grateful to all its volunteer REC members who give up their valuable time to review health research in the NHS in order to ensure that the rights, safety, dignity and well-being of research participants are protected. Whilst checking written materials and lay summaries are important aspects of that review we do not recognise this somewhat narrow conception of the lay member's contribution put forward in this article.
Staley correctly states that NRES (a Directorate of the HRA) identifies one aspect of the lay contribution as "taking a balanced view of the likely harms and benefits of a research project by bringing a lay perspective..." but neglects to point out that the Department of Health's 'Governance arrangements for research ethics committees - A harmonised edition' (updated April 2012), states that:
"4.2.2 RECs are expected to reflect current ethical norms in society as well as their own ethical judgement. REC members may come from groups associated with particular interests but they are not representatives of those groups. REC members are appointed in their own right to participate in the work of a REC as equal individuals of sound judgement, relevant experience and adequate training in research ethics and REC review. 4.2.3 A REC should contain a mixture of people who reflect the currency of public opinion ('lay' members), as well as people who have relevant formal qualifications or professional experience that can help the REC understand particular aspects of research proposals ('expert' members)."
The important role of lay members as "equal individuals of sound judgement" reflecting "the currency of public opinion" is thus an integral part of an ethics committee's function. Lay members are already charged with taking the very perspective that Staley argues will be necessary as a result of increasing levels of patient involvement, namely the contribution of "their views as a 'member of the public'" as a "general citizen - or reasonable person".
Staley suggests that "If the patient perspective is incorporated into research projects through early PI, then the quality of these PI processes will need to be assessed as part of the REC review". In fact RECs already assess the level of patient involvement through consideration of the answer given to question (A14-1) of the current Integrated Research Application System (IRAS) application form: "In which aspects of the research process have you actively involved, or will you involve, patients, service users, or members of the public?". This question draws the attention of both researchers and RECs to the importance of patient involvement with researchers being challenged to justify any absence of patient and/or public involvement to the committee.
The HRA welcomes and actively promotes the involvement of patients and public in the design of health research but this is, unfortunately, a long way from becoming standard practice, with some researchers still taking patient involvement to mean that patients are sufficiently 'involved' by virtue of their simply being research participants. So, whilst REC members do already assess and promote patient involvement in health research, reflect public opinion and ensure transparency and public accountability, the "patient perspective", brought not just by lay members but expert members too (who we should not forget are also patients and members of the public), will continue to play an important part in the ethical review of health research in the UK.
Joan Kirkbride (Director of Operations, Health Research Authority) & Prof. Andrew George (NREAP Chair)
Conflict of Interest:
Joan Kirkbride is the Health Research Authority's Director of Operations with responsibility for the operation of research ethics committees within the National Research Ethics Service. Prof. Andrew George is the Chair of the Health Research Authority's National Research Ethics Advisors' Panel (NREAP) and an expert member of the West London & GTAC REC
Re:The evidence demand protection of children from circumcision.
Case against circumcision overstated.
In his eLetter George Hill asserts, of circumcision, that "The evidence of injury to the child's sexual function is now conclusive". However, this view is not supported by the literature he cites. He tells us that Podnar found that the penilo-cavernosus reflex is harder to elicit in circumcised men (or those with their foreskins retracted)1. So it is harder to elicit a contraction of the anal sphincter by squeezing the glans. What sexual functions are impaired by this?
Mr. Hill's third reference2 is unobtainable, beyond an abstract for a conference presentation, making it impossible to judge its credibility.
The papers by Frisch3 and by Bronselaer4 that Mr. Hill cites both had shortcomings. Being based on self-selected convenience samples, with mediocre response rates, they were compromised by participant bias, in addition to various other problems pointed out by critics5,6. In reply, Frisch conceded that his study's findings "suggest, but by no means prove" that a minority of individuals sometimes experience a few negative effects from circumcision6. This is anything but "conclusive".
In his reply to his critics8, Bronselaer stated that the circumcision rate in Belgium is 15 % as opposed to the 22.6 % of participants in his study, but seemed not to appreciate the significance of this - his sample cannot have been a representative one. A more recent commentary points out that 12.1 % of his sample were homosexual9 leaving one wondering just how unrepresentative this sample was.
For every study Mr. Hill might cite indicating a negative effect from circumcision there are others finding no difference, or even an improvement. Rather than list examples I refer readers to the recent meta -analysis by Tian et al10 which finds no significant adverse consequence of circumcision on male sexual function.
Mr. Hill also overstates his case when he asserts that the three famous African HIV prevention trials "have been sharply questioned and even debunked" and proceeds to cite three articles, one of them his own. Unfortunately for Mr. Hill, each one of these articles has itself been "sharply questioned and even debunked" in follow up critiques in the very journals in which they were published. The one following his own was particularly detailed and thoroughly rebuts the arguments he and his co- author put forward11. The WHO, CDC, UNAIDS, and other professional bodies dealing with this ghastly epidemic, also do not agree with Mr. Hill's assessment.
It is worrisome that circumcision opponents overstate their case so much. Telling circumcised males that they are sexually damaged can only cause them anxiety and distress. And to tell them it when the evidence does not support this view makes the distress entirely needless. And claiming that the African trials are "debunked" when this is clearly not so, whilst failing to acknowledge detailed rebuttals of the very articles one cites in support of this claim, only invites accusations of denialism.
Finally, Mr. Hill writes as Vice-President of an activist organization, "Doctors Opposing Circumcision", so has a clear interest in promoting his organization's agenda. Fair enough, that is what a Vice- President should do. However, this agenda extends to denying the established benefit of circumcision in the context of African AIDS, pitting it against major professional bodies and a large volume of peer- reviewed research. It does not reflect mainstream medical opinion on this matter. Furthermore, only two of its five officers are medically qualified (Mr. Hill is not) which is a little surprising, given its name. All this could easily tempt cynics to express doubts about its credibility. Perhaps Mr. Hill could kindly allay such doubts please by telling readers how many members this campaigning group has, and how many are medical doctors?
1. Podnar, S. Clinical elicitation of the penilo-cavernosus reflex in circumcised men.BJU Int. 2011;209:582-5.
2. Solinis, I., Yiannaki, A. Does circumcision improve couple's sex life? J Mens Health Gend. 2007;4(3):361.
3. Frisch, M., Lindholm, M., Gr?nb?k, M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol. 2011;40(5):1367-81.
4. Bronselaer, G.A., Schober, J.M., Meyer-Bahlburg, H.F.L., et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;111(5):820-27.
5. Morris, B.J., Waskett, J.H., Gray, R.H. Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol. 2012;41(1):310-2.
6. Morris, B.J., Kreiger, J.N., Kigozi, G. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;111(5):E269-70.
7. Frisch, M. Author's Response to: Brian Morris et al, Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol. 2012;41(1):312-4.
8. Bronselaer, G. Reply. BJU Int. 2013;111(5):E270-1.
9. Wang, K., Tian, Y., Wazir, R. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;112(1);E2-3.
10. Tian, Y., Liu, W., Wang, J-Z., et al. Effects of circumcision on male sexual functions: a systematic review and meta-analysis. Asian J Androl. 2013:1-5.
11. Wamai, R.G., Morris, B.J., Waskett, J.H. et al. Criticisms of African trials fail to withstand scrutiny: Male circumcision does prevent HIV infection. J Law Med. 2012;20(1):93-123.
Conflict of Interest: