I did enjoy this article for it canvassed much of the disquiet I have
felt over the Four. The problem arises when the principles are
extrapolated to being rules, like changing a dirt road to a railway line –
the user is no longer permitted to leave the track. Regrettably much of
medicine has been taught in this way, the principle of evidence based
practice, which has always been present (its just that th...
I did enjoy this article for it canvassed much of the disquiet I have
felt over the Four. The problem arises when the principles are
extrapolated to being rules, like changing a dirt road to a railway line –
the user is no longer permitted to leave the track. Regrettably much of
medicine has been taught in this way, the principle of evidence based
practice, which has always been present (its just that the quality and
accessibility got better), has been converted into a set of absolute
rules; Learning physical examination becomes a set of lists of signs and
symptoms to be “found” in a “case”. The other aspect so neatly covered is
the “professionalisation” of Medical Ethics with the growth of jargon to
establish academic cred.
To define that there will always be people who cannot make a decision and
will defer to an “expert” is an acknowledgement of reality, and our
failure in basic education. That there will be circumstances where
Autonomy cannot apply, where Justice is irrelevant, were beneficence and
non maleficence are simply inappropriate is inevitable and our students
will need both the intellectual and emotional skills to cope is also a
truism.
So how do we find the best way of discussing ethics in clinical problem
solving? Surely it is not in having “Medical Ethics 101” in the
University course database, with grades, success and failure. Is it not
better to consider ethics as a topic heading for every clinical problem we
use in PBL just as we have signs, symptoms, pathophysiology, behaviour
etc.
Ethics is just one aspect of clinical medicine, and like medicine it is so
diverse and complex that only broad classifications can be used – it is
certainly not a field for absolutism.
Fineschi et al. have recently commented on the recent Italian law on
assisted reproductive technology.[1] The Authors recognize that, with
respect to the previous completely uncontrolled situation, the law
represents a true step forward, by granting both better protection of the
rights of the children born through ART and necessary control of ART
centres. The Authors accurately describe the contents...
Fineschi et al. have recently commented on the recent Italian law on
assisted reproductive technology.[1] The Authors recognize that, with
respect to the previous completely uncontrolled situation, the law
represents a true step forward, by granting both better protection of the
rights of the children born through ART and necessary control of ART
centres. The Authors accurately describe the contents of the single
articles of the law; however, they seem to miss its spirit, thus being
unable to understand and explain its restrictions. Moreover, some of the
scientific premises of their discussion seem questionable.
The spirit of the law is expressed in article 1, which states that
“law” is to guarantee the rights of all involved subjects, including the
conceptus (art. 1). The protection of the rights of the conceived
generates subsequent restrictions, criticized by the Authors. We agree
with the Authors that infertility and sterility are negative health
conditions, and “ART must be dealt with from the point of view of
protection of health”. However, parents’ health and desires may not be the
only criteria. It is equally clear that “ART involves creating children
and building families, a fundamental social value”[2]; therefore,
protection of parents’ health must be balanced with the protection of
children and society.
Of course, if the protection of the rights of the conceived is
questionable, restrictions are questionable too; if not, restrictions are
clearly acceptable, and even rightful. In fact, protection of the rights
of the conceived is fully consistent with Italian jurisprudence, as
expressed also by a recent sentence of the Constitutional Court.[3] The
apparent conflict between the new law 2004/40 on ART and the previous
1978/94 on abortion arises from inappropriate application of the 1978/94,
as recently pointed out in an important sentence by the Court of Catania.[4] Notably, Italian law and jurisprudence on the rights of the conceived
is similar to the Embryonenschutzgesetz approved in Germany, and to
similar legislations of Austria and Switzerland.[5]
As for ART in couples carrying genetic transmittable anomalies, it
represents a eugenetic approach. Eugenetics is a complex subject, and it
can’t be dealt with in a few words. However, we just note that in Italian
law system eugenetic abortion is simply inadmissible[6], and such a
prohibition reflects a more general refusal of eugenetic principles and
practices, including embryo selection.[4]
With regard to the prohibition of any experimentation on human embryos,
the Authors state that “to discuss ART and embryonic stem cell research
together, in a single law, as if they were one subject, is to commit a
fundamental conceptual mistake”. This is true only if no rights are given
to human embryos, a position which is not that of the present law.
Furthermore, the Authors’ assertions on the presumed risks to women’s
health need some remarks. Firstly, their main source of data is an Italian
association of fertility centres, which has frankly opposed the law[7]
and a conflict of interest may exist. Secondly, reported incidence of
ovarian hyperstimulation-syndrome refers to the old protocols, aimed at
obtaining oocytes, regardless of their number. The new law promotes the
use of smoother (so-called “friendly”) ovarian stimulation protocols,
limiting to a maximum of three the number of generated human embryos;
these protocols are currently considered safer for both women and
children, are preferred by women and are therefore recommended by many
authors.[8-10] Finally, the previsions of dramatic fall of success and
increase of multiple pregnancy rates have been recently criticized by
Ragni et al., showing that success rate of cycles using fresh embryos and
risk of multiple pregnancies are not significantly influenced by the new
legislation.[11] The consequences of the prohibition to freeze embryos
remains to be determined, but it should be noted that in Italy less than
20% of couples undergoing ART have needed to use frozen embryos, and
freezing and in vitro maturation of oocytes may become useful
alternatives.
In conclusion, the new Italian legislation is consistent with the aim
to guarantee the rights of all involved subjects, unborn included.
Restrictions are consistent with this principle, and at present they do
not appear to have negatively influenced success and complication rates;
in contrast, they are likely to promote an implementation of safer
practices. After hot debate, in June 2005 the four referenda aiming at abrogating
some of the most significant articles of the law have failed. Italian
Parliament will modify the law according to these results and to
scientific advancements in the field. In doing this, we hope that the
recommendation by R.M.L. Winston and K. Hardy will be kept in mind:
“Patient desperation, medical hubris and commercial pressures should not
be allowed to be the key determining features in this generation of
humans. Bringing a child into the world is the most serious human
responsibility”.[12]
Andrea Dovio1, Andrea Manazza1, Clementina Peris2, Anna Maria Poggi1, Carlo Campagnoli2.
1University of Turin; 2Endocrinological Gynecology, Sant'Anna
Gynecological Hospital, Turin, Italy.
References
1. Fineschi V, Neri M, Turillazzi E. The new Italian law on assisted
reproduction technology (Law 40/2004). J Med Ethics 2005;31:536–539.
2. [No authors listed]. ART into science: regulation of fertility
techniques. ISLAT (Institute for Science Law, and Technology) Working
Group. Science. 1998;281:651-2.
3. Corte Costituzionale della Repubblica Italiana, Sentenza 35/1997,
Gazzetta Ufficiale 12.02.1997; also available at:
http://www.cortecostituzionale.it (last access: 9.10.05).
4. Tribunale di Catania, I Sezione Civile, 03.05.2004. In: Bioetica
2004:2:278-341.
5. Casini C, Di Pietro ML, Casini M. La normativa italiana sulla
“Procreazione medicalmente assistita” e il contesto europeo. Medicina e
morale 2004;1:17-52.
8. Edwards RG, Lobo R, Bouchard P. Time to revolutionize ovarian
stimulation. Hum Reprod. 1996;11:917-9.
9. [No authors listed]. ESHRE Capri Workshop Group (report by Collins
J and Crosignani PG). Mono-ovulatory cycles: a key goal in profertility
programmes. Hum Reprod Update 2003;9:263-74.
10. Hojgaard A, Ingerslev HJ, Dinesen J. Friendly IVF: patient
opinions. Hum Reprod. 2001;16:1391-6.
11. Ragni G, Allegra A, Anserini P, Causio F, Ferraretti AP, Greco E,
Palermo R, Somigliana E. The 2004 Italian legislation regulating assisted
reproduction technology: a multicentre survey on the results of IVF
cycles. Hum Reprod. 2005;20:2224-8. Epub 2005 Apr 7.
12. Winston RM, Hardy K. Are we ignoring potential dangers of in
vitro fertilization and related treatments? Nat Cell Biol. 2002;4
Suppl:s14-8.
Fox and Thomson found it "striking" that male and female genital
cutting are treated so very differently in law. One explanation for
this is that men are expected to endure pain whereas women
should be sheltered and protected.
Such an assertion is easy to dismiss as academic theorising.
However, the effect of this cultural blindness can be demonstrated
in the reports of the Sydney Morning H...
Fox and Thomson found it "striking" that male and female genital
cutting are treated so very differently in law. One explanation for
this is that men are expected to endure pain whereas women
should be sheltered and protected.
Such an assertion is easy to dismiss as academic theorising.
However, the effect of this cultural blindness can be demonstrated
in the reports of the Sydney Morning Herald to the forcible
circumcision of men, women and children in Ambon, Indonesia, on
27 January 2001 http://www.cirp.org/news/morningherald01-27-
01/
Dominating the Herald report was a courageous woman,
Christine Sagat. She revealed the atrocities that she and others
had suffered at the hands of the fanatics, and was even willing to
be photographed.
'They told me to undress and sit on a chair which was covered with
white cloth. "Open your legs," they said. I saw under the chair a
coconut shell filled with water and a kitchen knife. I said, "Oh My
god, what would happen to me?" I was so scared, upset too. But I
did not dare to resist them. I didn't want to be killed.
"At first the woman soaked her fingers in the water and then
inserted them into my vagina as she looked for the clitoris. After
she found it she pulled it out, took out the kitchen knife and cut it.
That hurt very much. I shed tears. They left just like that without
giving me any medication."
She was not the only one who suffered this brutal assault. Her
niece, who was eight months pregnant, and her mother who is in
her 70s were also circumcised.
Christine's body healed, but the emotional scars remained:
"I was lucky. I had some money and went to the store immediately
to get antibiotics. My scar healed quite fast, but the sad, humiliated
feeling stayed until today."
She elaborated: " I feel like I'm no long 'complete' both as a person and a woman."
However, she also acknowledged something else: "I know the
men suffered more than us women. The circumcision hurt them
more than it did to us because their scars could not heal fast.
Several of the men I knew got serious infections after suffering
from severe bleeding."
What happened to Kostantinus Idi was much less prominently
reported, tucked in an article entitled, 'Terror attacks in the name of
religion'
"I could not escape," he said. "One of them held up my foreskin
between pieces of wood while another cut me with a razor ... the
third man held my head back, ready to pour water down my throat
if I screamed.
"But I couldn't help but scream and he poured the water. I kept
screaming aloud and vomited. I couldn't stand the pain."
However, there was another indignity.
'Idi said one of the clerics urinated on his wound, saying it would
stop infection.
"All of the men at the house were cut using the same razor," he
said. "That night they circumcised about 60 men. I was bleeding all
over and had nothing to cover my wound. I was told to take a bath
but it kept bleeding until the next day. I could not imagine any
greater pain. One of my friends got infected and was taken to
hospital when we arrived in Ambon."
Without doubt, men and women and children suffered terribly at
the hands of their assailants. All suffered physical, emotional and
sexual assault. All were exposed to infection. However, the men
had the added danger of excessive bleeding, for the human
foreskin has an exceptionally rich blood supply.
While no one should minimise the sufferings of women, the
reporting of this atrocity consistently underplayed the suffering of
the men. Both Christina Sagat and, Kostantinus Idi showed
enormous courage in telling their story to Herald reporters.
Christina was exceptionally brave in agreeing to be photographed.
However, Christina's story was told in an article of that name with a
heading an inch high, Kostantinus's story was tucked into a
secondary article on the same page entitled 'Terror attacks in the
name of religion'.
The Herald's leading article began: "Islamic extremists are
committing atrocities against women and children" An illustration
of Christine Sagat praying before a statue of Jesus
had the caption: "Fear and pain Christina Sagat, one of hundreds
of Christians forcibly circumcised by Muslim clerics."
Almost the entire attention has been directed towards Christina, so
forced circumcision was presented as an outrage against woman
rather than an abuse of both sexes.
Letters published the following Tuesday (30 January) didn't even
mention the men's suffering:
'[W]hen "religious" action means forced female circumcision we
need to ask whether this is religious freedom or criminal
behaviour.'
Dave Burrows,
Marrickville
'The most vile and abhorrent act must be female circumcision in
the name of religion, happening on our doorstep in Ambon.'
Alastair Browne,
Cromer Heights
This last comment so impressed the editor, that it was used as a
caption for all the letters about the situation in Ambon.
Christine Sagat stated that the men suffered even more than the
women did. However, this point was not followed up. Why?
One reason could be that the acceptance of infant circumcision
blinds us to atrocities such as the forced circumcision of the men in
Ambon. Infants are frequently circumcised without anaesthesia
when only a few days old. Like Kostantinus Idi, these tiny babies
also scream and show other signs of distress. And, despite our
best efforts, some suffer infections, too.
If we allow this to happen to tiny babies, what moral ground have
we to protest against the same thing happening to grown men?
In our society, there is an enormous indifference to men's health.
Male death rates during the working years are double and even
triple the comparable female death rates. Male suicide rates are
much higher than comparable female suicide rates.
Enormous efforts are made to prevent, treat and cure breast,
uterine and ovarian cancer in women. By comparison, prostate
cancer is a poor relation, and testicular cancer, though it is mainly
afflicts young men, is almost ignored in the media. There is far
more attention to road fatalities (a general problem) than to
workplace fatalities (a predominantly male problem), even though
workplace incidents kill more people overall.
Thus, the reporting of forced circumcisions in Ambon, Indonesia,
threw a harsh light on our cultural blindness, and of our
disregard of male health and welfare. It is this cultural indifference
to men's suffering that helps to account for the vast difference in
our view of male and female genital cutting.
Some points made by Appel in the recent essay “Defining death: when
physicians and families differ [1]” merit comment.
First, it is stated that critics of brain death (BD) are most
significantly in Japan and in certain religious groups. However, there is
a long list of secular commentators who point out the many problems with
the BD criterion of death.[2-11]
Some points made by Appel in the recent essay “Defining death: when
physicians and families differ [1]” merit comment.
First, it is stated that critics of brain death (BD) are most
significantly in Japan and in certain religious groups. However, there is
a long list of secular commentators who point out the many problems with
the BD criterion of death.[2-11]
Second, there seems to be a conflation of criterion and concept of
death in the discussion. As Evans points out in his reply, a definition
(concept) of death must “stand prior to the particular sets of criteria
and evidence [12].” This means that there must be a definition of death
for which brain death follows as the criterion.[13] The definition of
death in North America is the loss of integrative unity of the
organism.[13,14] The statement that “the boy’s heart may continue to beat
for weeks or even months on ‘life support’”[1] shows that the integrative
unity of the organism is not lost, as Shewmon has elegantly argued [15]
and shown.[16] Therefore, the criterion of BD does not fulfill this
definition of death.
Third, there seems to be a suggestion of the ends justifying the
means. One concern mentioned is that there may be “long term societal
damage by undermining the perceived validity of brain death.[1]” Another
concern is the “expenditure necessary to maintain lifeless bodies.[1]”
However, as Evans points out, the cost and the need for organs should be
“irrelevant to whether or not the patient on the machine is alive or dead
while still connected to it.[12]” If BD is death, it should be because it
really is death, and fulfills a definition of death; it should not be
death because we need more organs or need to save money.
There are many other inconsistencies in the criterion of BD, and to
discuss them further is beyond the scope of this letter.[2-11] As stated
by others, “the general acceptance of the practice [BD and organ donation]
since 1968 (in the US) is irrelevant to its moral rightness or
wrongness.[11]” Like the parents in the Koochin case, it may be time for
the medical community to reconsider whether BD is equivalent to death of
the patient.
References
1. Appel JM. Defining death: when physicians and families differ. J Med
Ethics 2005; 31: 641-642.
2. Truog RD. Is it time to abandon brain death? Hastings Center Report.
1997; 27(1):29-37.
3. Potts M. A requiem for whole brain death: a response to D Alan
Shewmon’s ‘The Brain and Somatic Integration’. Journal of Medicine and
Philosophy. 2001;26:479-491.
4. Youngner SJ, Bartlett ET. Human death and high technology: the
failure of the whole-brain formulations. Annals of Internal Med. 1983;
99:252-258.
5. Zamperetti N, Bellomo R, Defanti CA, Latronico N. Irreversible
apnoeic coma 35 years later: towards a more rigorous definition of brain
death? Intensive Care Med. 2004; 30:1715-1722.
6. Shewmon DA. Recovery from “Brain Death”: a neurologist’s apologia.
Linacre Quarterly. 1997; 64(1):30-96.
7. Veatch RM. Impending collapse of the whole-brain definition of death.
Hastings Center Report. 1993; 23(4):18-24.
8. Kerridge IH, Saul P, Lowe M, McPhee J, Williams D. Death, dying and
donation: organ transplantation and the diagnosis of death. J Med Ethics.
2002; 28:89-94.
9. Halevy A, Brody B. Brain death: reconciling definitions, criteria,
and tests. Ann Intern Med. 1993; 119:519-525.
11. Potts M, Evans EW. Does it matter that organ donors are not dead?
Ethical and policy implications. J Med Ethics. 2005; 31:406-409.
12. Evans HM. Reply to: Defining death: when physicians and families
differ. J Med Ethics 2005; 31: 642-644.
13. Bernat JL, Culver CM, Gert B. On the definition and criterion of
death. Annals of Internal Med. 1981;94:389-394.
14. President’s Commission for the Study of Ethical Problems in Medicine
and Biomedical and Behavioral Research. Defining Death: Medical, Legal
and Ethical Issues in the Determination of Death. Washington, D.C.; U.S.
Government Printing Office, 1981.
15. Shewmon DA. The brain and somatic integration: insights into the
standard biological rationale for equating brain death with death.
Journal of Medicine and Philosophy. 2001; 26:457-478.
16. Shewmon DA. Chronic “brain death”: meta-analysis and conceptual
consequences. Neurology. 1998;51:1538-1545.
The discussion of Global Medical Ethics, by D F-C Tsai, “Human
embryonic stem cell research debates: a Confucian argument" (1), fails to
justify the gradualist view of human personhood.
He begins with a list of flawed arguments concerning the current
status of the human embryo which fail in the following ways:
1. Many women do undergo hormonal support of early pregnancy, for
th...
The discussion of Global Medical Ethics, by D F-C Tsai, “Human
embryonic stem cell research debates: a Confucian argument" (1), fails to
justify the gradualist view of human personhood.
He begins with a list of flawed arguments concerning the current
status of the human embryo which fail in the following ways:
1. Many women do undergo hormonal support of early pregnancy, for
threatened miscarriage or in the case of habitual miscarriage.(2) For
those women who do not choose to do submit to such therapy, society is
refrained from assault of their bodily integrity by forcing the ingestion
or injection of medication. We do not do evil to do good. In fact, the
interest of society only becomes relevant at the point of intervention by
the mother or a third person or when the child is purposefully placed in
harm’s way. In human embryology terminology, there is no such thing as a
“fertilized ova.” The human female has oocytes which cease to exist at
fertilization, when the zygotic embryo begins to exist.
2. It is interesting that, in the footnotes ("i"), the author
dismisses those cases where the parents do grieve and hold ceremonies for
the loss of unborn children. The loss of a pregnancy is experienced the
same way that all other grief is experienced: in relation to the
attachment to the one who dies. In the same way, individuals do not grieve
for thousands of strangers across the world in the same way that they
grieve for someone known for years. The fact that some murder close
relatives after birth without grief does not excuse killing and does not
define the moral status of the one killed.
3. Most, like the author, do not understand the mechanism of the
IUD.(3) In fact, it does work to inhibit fertilization by obstructing the
movement of sperm and increasing the immunological reaction to both the
sperm and (unfertilized) oocyte. When and if the device causes the death
of an embryo, it is an abortifacient. Again, Tsai uses poor terminology:
the embryo is “pre-implantation,” not a “pre-embryo” and the “egg” is
actually an “oocyte” which ceases to exist when it is fertilized and
becomes the embryo.
4. Recent publications indicate that the usual “morning after pill”
protocols work primarily to prevent ovulation, without post-fertilization
effect, although this is still in dispute.(4) As in the case of the IUD,
to the extent, if any, that such protocols are active interventions in the
normal lifespan or place the child in harm’s way, they are wrong.
5. It is irrelevant to the moral status that laws do not prohibit
abortion, since laws vary from government to government and many illicit
acts are allowed by laws in different nations. Would you excuse the
harvesting of organs for transplantation from death row inmates, since it
is legal in China? Where is the place for reform in any government if the
actions of the government make those actions licit?
6. Again, the fact that something is done does not make that action
excusable and the author is either unaware or unconcerned with the
reality that some ethicists, such as Dr. Leon Kass, have objected to the
practice of IVF all along.
The discussion of philosophers points out the problem with using
ancient knowledge, religious notions or common knowledge in determining
the moral status of the embryo: increased understanding of human
embryology informs us of the biological life span of human organisms. The
more recent philosophers mentioned, including Fletcher, Singer and
Engelhardt, give criteria (recognition of which cannot be met by the most
precocious child until 3 to 7 years of age. In fact, Singer is notorious
for his views which would push the legal status of the child up to one
year of age, depending on the wishes of his parents. Mencius’ description
of person fails all too often: Ted Bundy either never had or lost the
capacities of shame, commiseration and the feeling of right and wrong. Was
Bundy never a person or did he lose his personhood?
Tsai does not succeed in his justification of the division of human
lives into those who are persons and those who are not. He would actually
increase the confusion and dissent between those persons who are assigning
value. Remember, toddlers and young children do not meet the definitions
of personhood referenced by the author, and he admits that others such as
those with developmental impairment or other neurological abnormalities
who are counted as persons under most legal systems would have unclear
status under the “strict” personhood according to abilities criteria.
History gives us examples of definitions of personhood that were more
dependent on pigmentation and the legal status of (human) parents than on
the level of functioning or development that Tsai advocates.
The very capacity to develop "jen" as described by Tsai, and
attributed to Confucius, will always be variable, in process, and subject
to the effects of a mixture of genetics and environment, as well as valued
and measured differently in diverse cultures and according to actual
knowledge. "Jen" and "yi’" should inspire greater caution at all times
rather than the decreasing license over time and as a function of
perceived development which the author would allow for the destruction of
humans lives according to their benefit or usefulness to other humans.
The only prudent, justifiable and consistent definition of personhood -
the only one which would demonstrate "jen" and "yi'" is that which would
give full protection from active intervention in the life cycle of all
whose parents were human or whose species or nature has the capacity to
demonstrate "jen. ."
The author should consider his understanding about why Shun would
carry his father on his back rather than violate justice or cause a death,
even though it would mean the loss of a kingdom. Since the author used a
New Testament Bible quote, I'll use one, too: “For what is a man profited,
if he shall gain the whole world, and lose his own soul? or what shall a
man give in exchange for his soul?”(Mat 16:26 KJVR. E-sword.com)
References
(1) D F-C Tsai. "Human embryonic stem cell research debates: a
Confusian argument." Journal of Medical Ethics 2005; 31:635-640.
http://jme.bmjjournals.com/cgi/content/full/31/11/635 (accessed November
4, 2005)
Allen B Shaw suggests that individuals commenting on the BMA Guidance
on male circumcision should declare if they are bereft of, or the proud
possessors of a prepuce. He also says that 'surely there must be some
bold spirits among the circumcised, articulate enough to protest about the
violation of their own rights in childhood. Yet no sound is heard.'
Allen B Shaw suggests that individuals commenting on the BMA Guidance
on male circumcision should declare if they are bereft of, or the proud
possessors of a prepuce. He also says that 'surely there must be some
bold spirits among the circumcised, articulate enough to protest about the
violation of their own rights in childhood. Yet no sound is heard.'
First therefore I will declare that I was circumcised for no medical
reason and have no memory of having an intact body. I consider that I
have been genitally mutilated. Unlike Allen B Shaw however, I am fully
aware of my loss. I do not need to have lost a limb to know that I would
be at a disadvantage if I was without one. The same reasoning applies to
a foreskin.
With regard to his comments that 'No sound is heard', I am the
General Manager of NORM-UK, a registered charity formed to help men who
have been damaged either physically or psychologically by circumcision.
We have now handled in excess of 5,000 enquiries. The sound is there if
people are prepared to listen.
Following the publication of the Fox and Thomson report, our Chairman
Dr John Warren has written to the All Party Group on Men's Health asking
them to investigate the situation. We agree that the Medical Ethics
Committee of the BMA has more work to do in this respect.
I do not consider that circumcision has in itself protected me from
HIV. Frankly I would rather have kept my foreskin and taken my chances
with the virus.
The paper of K. Devolder[1] is very interesting and stimulating.
Unfortunately, the author takes for granted some value premises,
which are not so widely accepted.
The first one is that embryos are just lumps of cells, biological
matter without any dignity apart from being of some utility to us. If this
is true, the consequences are obvious. Their coming to life will be
justified only...
The paper of K. Devolder[1] is very interesting and stimulating.
Unfortunately, the author takes for granted some value premises,
which are not so widely accepted.
The first one is that embryos are just lumps of cells, biological
matter without any dignity apart from being of some utility to us. If this
is true, the consequences are obvious. Their coming to life will be
justified only by the benefits we can derive from them. If no benefit can
come to us (no possible HLA-matching), they can be destroyed. Or perhaps
used for other any other (possibly lucrative) purpose.
The second one is that everything, which is technically possible, may
be done, if economically profitable and if no major risks (valued
according to the first assumption) derive for the involved subjects. The
fact that embryos are not accorded any moral status and that newborn
children (derived or not from pre-implantation HLA typing) are incompetent
and can not oppose any refusal (while adults are free to refuse to become
bone-marrow or simply blood donors) opens the doors to alternative ghastly
scenarios. So, banking of HLA typed embryos, which foreshadows a sort of
embryos supermarket where anyone can buy, "adopt the embryo and carry it
to term, ... or use the embryo in vitro as a source of stem cells", is
presented as "a valuable option". And the insurance policy scenario
("using preimplantation HLA typing to ensure that all of one's children
will be HLA identical, in case one of them needs a transplant") is laid
aside (for the time being) only because of its financial costs.
The whole paper leaves the bitter taste of a view of science in which
those who can are allowed to do almost everything, and in which the rights
of the weakest are much less important than the interests of the
strongest.
We believe that the new tools that medicine continues to offer must be
used with extreme prudence and attention, and only for the wellbeing and
in the interests of all the subjects involved. In case of incompetent
subjects (as in the case of the newborn, and - for many of us - even
embryos), prudence should be much greater.
Centuries ago, Immanuel Kant taught us to treat no one merely as a means
to an end, but only and always as an end in his/herself. We believe that
this is still the only way in which medicine and science can really serve
humanity and not the other way round.
References:
1. Devolder K. Preimplantation HLA typing: having children to save
our loved ones. J Med Ethics 2005;31:582-586.
Author Address:
Nereo Zamperetti, MD
Department of Anesthesia and Intensive Care Medicine
San Bortolo Hospital, Via Rodolfi, 37
36100 Vicenza
Italy
e-mail: zamperetti.n@medicivi.org
Rinaldo Bellomo, MD
Department of Intensive Care,
Austin & Repatriation Medical Center,
Heidelberg, Victoria
Australia
e-mail: Rinaldo.bellomo@austin.org.au
I am delighted that Trevor Perry agrees that the debate about the
medical aspects of male circumcision is not closed, because most
correspondents think that it is.
One correspondent argues that removal of the richly innervated
prepuce delays ejaculation. Now rapid ejaculation may have had
evolutionary benefit, when wild animals or rivals often interrupted
coitus. In more civilised times we wo...
I am delighted that Trevor Perry agrees that the debate about the
medical aspects of male circumcision is not closed, because most
correspondents think that it is.
One correspondent argues that removal of the richly innervated
prepuce delays ejaculation. Now rapid ejaculation may have had
evolutionary benefit, when wild animals or rivals often interrupted
coitus. In more civilised times we would wish to prolong coitus to enhance
female satisfaction. Perhaps it is a sacrifice that man should make for
his mate, if not his maker. On the other hand removal of the clitoris
reduces female sexual pleasure, its unjustifiable purpose. Those
circumcised for medical reasons, whose predilection is variety not
constancy, should also remember that circumcision offers some protection
against HIV. Students will forgive an old doctor for reminding them that
yesterday’s dogma is today’s anathema, and may yet be dogma tomorrow.
I am also grateful to Trevor Perry for following my lead in coming
out of the closet. But our frankness is useless until all contributors
follow suit. I am also grateful to him for reminding me that the important
issue is whether those circumcised for religious, not medical reasons,
object to what was done. Unless he can show that many of those object,
then Fox and Thomson are indeed patronising them, however learned they
might be.
Otherwise Trevor Perry is misguided. I quoted Fox and Thomson, when I
said that men may wish their sons to resemble them, and they quoted four
other authors. Perhaps he should read their article.
Finally Fox and Thomson are not just unwise, they are unrealistic. No
government in Europe, with its Moslem population, nor in America, with its
Jewish population, would ban circumcision. You cannot compare it to
slavery, because the slaves never willingly enslaved their sons. They are
not just unwise and unrealistic, they are unethical. Proscription would
cause more distress than it could possibly relieve. Why do they not return
to the ethical path of persuading parents that currently the benefits of
circumcision are questionable, and forget proscription?
Allen Shaw's suggestion, that Fox and Thomson have made an "unwise"
proposal in urging legal sanctions against male circumcision, is poorly
founded.
His first premise is muddled. In hypothetical language, Shaw
suggests that the presence or absence of an author's prepuce "may" lead
papers to be "rationalisations of emotional attitudes." Primarily, this
argument should be discounted becaus...
Allen Shaw's suggestion, that Fox and Thomson have made an "unwise"
proposal in urging legal sanctions against male circumcision, is poorly
founded.
His first premise is muddled. In hypothetical language, Shaw
suggests that the presence or absence of an author's prepuce "may" lead
papers to be "rationalisations of emotional attitudes." Primarily, this
argument should be discounted because he provides no substantial evidence
that males do indeed "all wish others of our sex to resemble us." This,
the lynchpin of the premise, is an assumption. Shaw's argument would be
better served if he could cite actual subjectivity on the part of the
authors in the text, instead of conjecturing about the possibility of
subjectivity.
Shaw's second premise is as wanting. He misconstrues the authors as
assuming "that the medical case against circumcision is beyond doubt."
First, the authors have not made this assumption. Instead, they have
cited authoritative evidence, based on empirical observations, that at
best, the harm to benefit ratio is difficult to ascertain, and at worst,
the harms outweigh the benefits. Included in Fox and Thomson's analysis
is the link to medical responsibility with regard to surrogate consent.
Shaw's own words, that "it is hard to know the balance," confirm the
authors' message: there is not enough medical justification for surrogate
consent to be acceptable. At the very least there ought to be a
moratorium on infant circumcision until substantial and clear knowledge is
gained. Again we find that Shaw has not proven Fox and Thomson's proposal
to be "unwise."
His next opposition to legal restrictions is as conjecturally
misguided as his first. The perpetuation of the practice of genital
mutilation is not self-justifying. Considering that unnumbered voices,
contrary to Shaw's assumption, are being heard condemning circumcision,
that the majority of males living today are not circumcized, and that
annual circumcision rates are declining in the United States, we have
reason to believe, using Allen's logic, that people, including males, are
recognizing the ethically questionable nature of circumcision, including
its harms. Shaw is even welcome to consider me "some bold spirit among
the circumcised, articulate enough to protest about the violation of their
own rights in childhood." As for Fox and Thomson being "patronising," it
is fair to consider them as learned bioethicists whose duty is to inform
popular opinion, medicine, and law. Their criticism of the BMA is within
this duty.
Shaw's last point includes an unjustified attack against Fox and
Thomson. The relationship between law, religion, and invasive procedures
has already been outlined, and Fox and Thomson have properly included
analysis on this. While it may be
true that further discussion about the acceptance, by religious persons,
of outlawing circumcision is merited, this alone is simply not enough to
justify the status quo, particularly when the entire dilemma of genital
mutilation is considered. In sum, Fox and Thomson's proposal is very wise
indeed.
Holms, writing in June 2004, laments that there is a “singular lack” of medical evidence regarding the harm of early circumcision on which to form an opinion regarding the ethical status of child circumcision.[1]
We submit that that is not the case. We affirm there was enough evidence in 2004 regarding the inherent harm of circumcision on which to make a decision. We furth...
Holms, writing in June 2004, laments that there is a “singular lack” of medical evidence regarding the harm of early circumcision on which to form an opinion regarding the ethical status of child circumcision.[1]
We submit that that is not the case. We affirm there was enough evidence in 2004 regarding the inherent harm of circumcision on which to make a decision. We further submit that additional evidence has emerged in the past year to further support the sexual harm of child circumcision.
Winkelmann, as early as 1959, showed that the prepuce is a “specific erogenous zone” with nerve endings arranged in rete ridges.[2] Moldwin & Valderrama (1989) reported “an extensive neuronal network within prepucial tissue.”[3] Taylor et al. (1996) further described the tissue that is excised by circumcision, finding that more than one-half of the skin and mucosa of the penis is excised by circumcision and, moreover, that this includes a highly innervated and vascularized circular band of ridged tissue, which he named the ridged band.[4] With so much sensory tissue extirpated, one would expect to find decreased sensory input to the central and autonomic nervous systems with adverse effects on sexual function.
Demonstrated adverse effects of circumcision on erection and ejaculation supply proof of injury. A survey from South Korea (where circumcision has been practiced since the Korean War as a result of American cultural influence) found that men were twice as likely to report “diminished sexuality rather than improved sexuality.”[5] Coursey et al. report that the adverse effect of circumcision on erectile function is equivalent to that of anterior urethroplasty.[6] Fink et al. report a statistically significant reduction in erectile function after circumcision and a loss of sensitivity.[7] Shen et al. report weakened “erectile confidence” and prolonged intercourse after circumcision.[8] Senkul et al. report statistically significant increase in ejaculatory time after circumcision.[9] Masood et al. report degraded erectile function.[10]
Circumcision also causes changes in sexual behaviour. Laumann et al. report higher incidence of oral sex, anal sex, and masturbation in circumcised men.[11] Dave et al. report circumcised males are more likely to have homosexual experience and partners from abroad.[12]
Nineteenth century doctors were well aware of the sexual nature of the prepuce, therefore they promoted circumcision in hope of eliminating masturbation.[13]
Coursey et al., Fink et al., and Masood et al. argue that men should be told of the probable adverse effect on sexual function as part of pre-circumcision informed consent counseling.[6] [7] [10]
Although Holm attempts to draw a distinction between adult circumcision and childhood circumcision, [1] there is no reason to believe that the age at the time of circumcision has any effect on the reported sexual changes associated with extirpation of sensory tissue from the penis.
Dear Editor,
I did enjoy this article for it canvassed much of the disquiet I have felt over the Four. The problem arises when the principles are extrapolated to being rules, like changing a dirt road to a railway line – the user is no longer permitted to leave the track. Regrettably much of medicine has been taught in this way, the principle of evidence based practice, which has always been present (its just that th...
Dear Editor,
Fineschi et al. have recently commented on the recent Italian law on assisted reproductive technology.[1] The Authors recognize that, with respect to the previous completely uncontrolled situation, the law represents a true step forward, by granting both better protection of the rights of the children born through ART and necessary control of ART centres. The Authors accurately describe the contents...
Dear Editors,
Fox and Thomson found it "striking" that male and female genital cutting are treated so very differently in law. One explanation for this is that men are expected to endure pain whereas women should be sheltered and protected.
Such an assertion is easy to dismiss as academic theorising. However, the effect of this cultural blindness can be demonstrated in the reports of the Sydney Morning H...
Dear Editor
Some points made by Appel in the recent essay “Defining death: when physicians and families differ [1]” merit comment.
First, it is stated that critics of brain death (BD) are most significantly in Japan and in certain religious groups. However, there is a long list of secular commentators who point out the many problems with the BD criterion of death.[2-11]
Second, there seems t...
Dear Editor
The discussion of Global Medical Ethics, by D F-C Tsai, “Human embryonic stem cell research debates: a Confucian argument" (1), fails to justify the gradualist view of human personhood.
He begins with a list of flawed arguments concerning the current status of the human embryo which fail in the following ways:
1. Many women do undergo hormonal support of early pregnancy, for th...
Dear Editor
Allen B Shaw suggests that individuals commenting on the BMA Guidance on male circumcision should declare if they are bereft of, or the proud possessors of a prepuce. He also says that 'surely there must be some bold spirits among the circumcised, articulate enough to protest about the violation of their own rights in childhood. Yet no sound is heard.'
First therefore I will declare that I...
Dear Editor,
The paper of K. Devolder[1] is very interesting and stimulating.
Unfortunately, the author takes for granted some value premises, which are not so widely accepted.
The first one is that embryos are just lumps of cells, biological matter without any dignity apart from being of some utility to us. If this is true, the consequences are obvious. Their coming to life will be justified only...
Dear Editor
I am delighted that Trevor Perry agrees that the debate about the medical aspects of male circumcision is not closed, because most correspondents think that it is.
One correspondent argues that removal of the richly innervated prepuce delays ejaculation. Now rapid ejaculation may have had evolutionary benefit, when wild animals or rivals often interrupted coitus. In more civilised times we wo...
Dear Editor
Allen Shaw's suggestion, that Fox and Thomson have made an "unwise" proposal in urging legal sanctions against male circumcision, is poorly founded.
His first premise is muddled. In hypothetical language, Shaw suggests that the presence or absence of an author's prepuce "may" lead papers to be "rationalisations of emotional attitudes." Primarily, this argument should be discounted becaus...
Dear Editor:
Holms, writing in June 2004, laments that there is a “singular lack” of medical evidence regarding the harm of early circumcision on which to form an opinion regarding the ethical status of child circumcision.[1]
We submit that that is not the case. We affirm there was enough evidence in 2004 regarding the inherent harm of circumcision on which to make a decision. We furth...
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