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 s...
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]
Conclusion
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.
Acknowledgments
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:
http://blogs.bmj.com/medical-ethics/2015/06/17/prostitution-harm-and-
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.
References
[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 http://dailynous.com/2015/08/13/philosophers-on-prostitutions
-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 https://www.academia.edu/12055156/Born_this_way_How_high-
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
https://www.academia.edu/10270196/Female_genital_mutilation_and_male_circumcision_Toward_an_autonomy
-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
http://blog.practicalethics.ox.ac.uk/2014/03/things-ive-learned-so-far-
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-
enrich.com/pe_main_site_content/pdf/research/national_survey.pdf.
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' (
https://en.wikipedia.org/wiki/Crimen_injuria ).
The search for an understanding of a secular basis...
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' (
https://en.wikipedia.org/wiki/Crimen_injuria ).
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
(https://en.wikipedia.org/wiki/Dignitas_(Roman_concept) ).
This article ( http://athensdialogues.chs.harvard.edu/cgi-
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:
http://www.chinahumanrights.org/cshrs/Developments/t20130206_1037860.htm
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'.
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...
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.
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
bo...
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.
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...
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.
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 breed...
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.
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 becam...
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.
"...to 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.
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 rece...
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.
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 p...
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.
Schuklenk and van der Vathorst's feature paper articulates powerful
and persuasive arguments to the effect that denying patients with
treatment-resistant depression (TRD) assistance in dying results in
unnecessary suffering and amounts to unfair discrimination against TRD
patients.
Beyond TRD, the same arguments can readily (and in my view
appropriately) be used to support assisted dying...
Schuklenk and van der Vathorst's feature paper articulates powerful
and persuasive arguments to the effect that denying patients with
treatment-resistant depression (TRD) assistance in dying results in
unnecessary suffering and amounts to unfair discrimination against TRD
patients.
Beyond TRD, the same arguments can readily (and in my view
appropriately) be used to support assisted dying more generally, wherever
intractable severe mental distress pertains. This point is also made by
psychiatrist Colin Brewer in his letter in response to the paper [1].
In establishing the case that patients with depression should not
necessarily be considered incompetent, Schuklenk and van der Vathorst's
paper contains the assumption that mental competence is a prerequisite for
access to assisted dying. While most prochoice ethicists take this
position to be axiomatically correct, I suggest that an insistence on
competence - at least as it is usually conceived in medicine - may lead to
unfair discrimination and unnecessary suffering amongst patients suffering
from a particular class of psychiatric disorder, namely those deemed to be
'psychotic'.
As Schuklenk and van der Vathorst describe, even the most prochoice
jurisdictions stipulate mental competence as a prerequisite for assisted
dying. So in the Netherlands, while patients suffering from TRD can obtain
assistance in dying, those with psychotic depression do not qualify,
because treatment decisions by these patients are considered to be often
'not arrived at competently and should be overridden/ignored'. The
fundamental assumption here - and it is a commonplace notion in medical
ethics - is that psychosis equates with mental incompetence. Presumably,
the basis for this position is that psychosis entails disordered or
delusional modes of thought.
TRD can be very severe, as is made very clear by Schuklenk and van
der Vathorst's paper; however, various forms of intractable psychosis can
be at least as -and in some cases possibly even more- difficult to endure.
Psychotic depression, as above, might be one such case; treatment-
resistant severe schizophrenia would also appear to be an extremely
difficult to endure form of psychosis, entailing great suffering - indeed
many of those affected end up committing suicide. While such patients (by
definition) suffer from disordered or delusional thinking, it is not clear
that the desire to end their lives should be deemed irrational.
As with TRD, denial of assisted dying to patients enduring
intractable psychosis is responsible for a great deal of unnecessary
suffering and amounts to unfair discrimination. I suggest that the
assumption 'psychotic = incompetent' should no longer be accepted
axiomatically. Prochoice medical ethicists ought to explore principled
ways by which our conceptions of 'competence' may be refined such as to
permit fair access to assisted dying for those afflicted by intractable
psychotic disorders.
REFERENCES.
1. Brewer, C. Depression is not the only treatment-resistant psychiatric
condition. eLetter, Journal of Medical Ethics, 2 June 2015.
Brian D. Earp University of Oxford
Introduction
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 s...
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' ( https://en.wikipedia.org/wiki/Crimen_injuria ).
The search for an understanding of a secular basis...
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...
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 bo...
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...
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 breed...
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 becam...
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 rece...
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 p...
Dear Editor.
Schuklenk and van der Vathorst's feature paper articulates powerful and persuasive arguments to the effect that denying patients with treatment-resistant depression (TRD) assistance in dying results in unnecessary suffering and amounts to unfair discrimination against TRD patients.
Beyond TRD, the same arguments can readily (and in my view appropriately) be used to support assisted dying...
Pages