Dear Sir,
I thank Dr Holland for his commentary [1] on my article [2]. I am replying to correct a possible misunderstanding he may have about the brain in people with prolonged disorders of consciousness.
He argues that there are people who are definitely permanently unaware without fluctuation because they have no brain, citing "Tony Bland, whose higher brain had effectively liquefied'". I assume that he bases this statemen...
Dear Sir,
I thank Dr Holland for his commentary [1] on my article [2]. I am replying to correct a possible misunderstanding he may have about the brain in people with prolonged disorders of consciousness.
He argues that there are people who are definitely permanently unaware without fluctuation because they have no brain, citing "Tony Bland, whose higher brain had effectively liquefied'". I assume that he bases this statement on two sentences in the original legal judgement in the Bland case. [3] They say "It is sufficient to say that it arises from the destruction, through prolonged deprivation of oxygen, of the cerebral cortex, which has resolved into a watery mass." and "There are techniques available which make it possible to ascertain the state of the cerebral cortex, and in Anthony Bland's case these indicate that, as mentioned above, it has degenerated into a mass of watery fluid."
Dr Holland has, naturally, interpret these legal statements to mean that there is no residual brain. He therefore argues both that there can be no awareness and that there can be no expectation of any recovery. If his understanding were correct, then his argument would be valid.
In reality people in a prolonged state of unconsciousness including people in the vegetative state still have some structurally intact brain albeit with considerable atrophy, [4] and this brain still shows electrophysiological activity [5] and changes in blood flow associated with stimuli. [6]
I suspect that in 1994 the experts made statements such as "the damaged brain has been replaced by cerebro-spinal fluid, which is mostly water". This simply explains that, within the fixed volume of skull, the space once occupied by the brain that has now atrophied is occupied by water; the statement does not say that there is complete absence of brain. However it has been interpreted to mean that all brain has been replaced by or transformed into 'a watery fluid'. In other words it was not made clear that there was still some structurally intact (albeit abnormally structured) brain present. This would have been known at the time. [7]
This may explain why some people believe it should be easy to determine consciousness. The difficulties in establishing consciousness on the basis of single signs has been shown in another recent publication. [8]
References.
1. Holland S. Commentary on Derick Wade's 'Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness' and Zoe Fritz' 'Can best interests' derail the trolley?' Examining withdrawal of clinically assisted nutrition and hydration in patients in the permanent vegetative state.Journal of Medical Ethics. 2016;0:1-2 doi:10.1136/medethics-2016-103739
2. Wade DT. Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness.
Journal of Medical Ethics. 2016;0:1-7 doi:10.1136/ medethics-2015-103140
3. Airedale NHS Trust v Bland (1993) http://www.bailii.org/uk/cases/UKHL/1993/17.html
4. Guldenmund P, Soddu A, Baquero K, Vanhaudenhuyse A, Bruno MA, Gosseries O, Laureys S, Gomez F. Structural brain injury in patients with disorders of consciousness: A voxel-based morphometry study. Brain Injury 2016;30:343-352
5. Sitt JD, King JR, El Karoui I, Rohaut B, Faugeras F, Gramfort A, Cohen L, Sigman M, Dehaene S, Naccache L
Large scale screening of neural signatures of consciousness in patients in a vegetative or minimally conscious state. Brain 2014;137:2258-2270
6. Vanhaudenhuyse A, Noirhomme Q, Tshibanda LJF, Bruno MA, Boveroux P, Schnakers C, Soddu A, Perlbarg V, Ledoux D, Brichant JF, Moonen G, Manquet P, Greicius MD, Laureys S, Boly M. Default network connectivity reflects the level of consciousness in non-communicative brain- damaged patients.Brain 2010;133:161-171
7. McLellan DR, Adams JH, Graham DI, et al. In: Papo I, Cohadon F, Massaroti M, eds. Le coma traumatique. Padova: Liviana Editrice, 1986:165-85.
8. Fischer DB, Truog RD. What is a reflex? A guide for understanding disorders of consciousness. Neurology 2015;85:543-548
The JME's peer reviewers failed to press the clinical issues before
publication of this flawed paper(1). The unoriginal idea of a 'ritual
nick' performed by health professionals in a harm limitation approach to
female genital mutilation (FGM) was proposed by the American Academy of
Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the
face of worldwide condemnation(4) by the World Health Organisation...
The JME's peer reviewers failed to press the clinical issues before
publication of this flawed paper(1). The unoriginal idea of a 'ritual
nick' performed by health professionals in a harm limitation approach to
female genital mutilation (FGM) was proposed by the American Academy of
Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the
face of worldwide condemnation(4) by the World Health Organisation, and
the UK Royal Colleges of Obstetricians and Gynaecologists and Paediatrics
and Child Health, amongst others.(5)
Many mistakes slipped through: (i) the authors say the prevalence of
FGM is stable, but provide figures showing it falling; (ii) they claim to
medically recategorise all procedures (amateur, accidental or surgical) -
matters beyond the scope of ethicists to judge; (iii) they state the
impacts of surgery on male and female genitals can be assumed to be
similar - they cannot; (iv) likewise, comparisons with adult surgery
(including cosmetic female genital surgery) are not relevant to children;
(v) there is no such thing as a "nick that heals completely" without
leaving scar tissue; (vi) indeed, they later admit that "de minimus"
procedures will involve "tissue being removed", the amount being difficult
to regulate; (vii) controversially, they describe asymptomatic healthy
children as "patients" thus generating an overweaning sense that doctors
owe a duty of care regarding social matters; (viii) despite arguing for
autonomy they did not suggest leaving parents with responsibility for
performing the 'nick'; (ix) far from seriously considering the
utilitarian calculus, they have no insight into the damage their proposal
has on trust in the medical profession; (x) the concept of 'harm
limitation' need not be applied(6) to justify changing the present global
consensus, especially without evidence of rising harm in countries where
FGM is illegal; (xi) they neglect entirely physicians' conflicted
pecuniary interest when surgically altering healthy children's genitals,
even if by request of loving parents for socio-cultural benefits; (xii)
revealingly, they use a self-referential test for acceptability based on
one gynaecologist's previous defence of male circumcision(7).
Surgeons should respect the basic ethical principles of 'first of
all, do no harm' and informed consent to irreversible surgery on the basis
of medical necessity, particularly when performed on children. In the USA
(but less so in Europe), there may presently remain a 'liberal' tolerance
of male circumcision whose protection appears to be the article's real
purpose. The weak arguments presented might lead to the opposite
conclusion: far from condoning renamed non-therapeutic procedures (no
doubt performed for a fee on defenceless girls), why not turn the
spotlight onto medically sanctioned traditional 'ritual' practices on male
infants?
References
(1) Arora KS, Jacobs AJ. J Med Ethics Published Online First: 22nd
February 2016 doi:10.1136/
medethics-2014-102375
(2) American Academy of Pediatrics. Ritual genital cutting of female
minors. Pediatrics
2010; 125: 1088-93.
(3) American Academy of Pediatrics. Policy statement: ritual genital
cutting of female
minors. Pediatrics 2010; 126: 191.
(4) MacReady N. AAP retracts statement on controversial practice. Lancet
2010; 376: 15.
(5) Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 12 May
2010
https://www.rcog.org.uk/en/news/joint-rcogrcpch-statement-on-the-aap-
policy-statement-on-fgm/
(6) Pearce AJ, Bewley S. Medicalization of female genital mutilation. Harm
reduction or unethical? Obstet Gynaecol Reprod Med 2014;24(1):29-30
(7) Jacobs AJ. The ethics of circumcision of male infants. Isr Med Assoc
J. 2013;15:60-5.
A properly worded consent form must make risks transparent but if the
person has not even been asked to participate, discrimination is too
easily slipping in. Even giving the reason as duty of care can be mis/used
to eliminate some people - but their participation may be valuable as
well as ethical. There can be an unconscious bias to avoid difficulties
for researchers but discrimination will miss opportunities for the...
A properly worded consent form must make risks transparent but if the
person has not even been asked to participate, discrimination is too
easily slipping in. Even giving the reason as duty of care can be mis/used
to eliminate some people - but their participation may be valuable as
well as ethical. There can be an unconscious bias to avoid difficulties
for researchers but discrimination will miss opportunities for the
unexpected to be revealed by the exclusion of risk. Intolerance of risk
means whole groups may not benefit from research carried out and they
subsequently may be treated incorrectly, that is in the same way as the
findings conclude for others with low risk.
Exeter University has carried out much ground breaking work to enable
wider participation in research by the public including via self referral
and genuine rather than tokenistic efforts to involve the wider community.
It has been promoted in other parts of the country by now but how much
the public is aware of it is questionable. (Patient and Public
Involvement Exeter web site) Open selection does not always happen
though as some projects still select participants via GPs acting as
gatekeepers. For example COBRA. (On Exeter web site) Researchers will
not always get it right and results can be skewed. It would be
interesting to see a comparison of the same or other studies conducted
both by self referral and via gatekeepers.
One area which could do more to become transparent to the public is,
although more loosely described as research , the issue of conferences and
events which are held by researchers/practitioners/professionals to debate
and share information with each other exclusively , any resulting write
ups are also exclusive. Many are not open to the public either because
admission is only for stated specialist groups or because the cost of
admission is entirely prohibitive for those who are not funded. These
events are using information given directly or indirectly by the public
and paid for by citizens. On these grounds as well as it being ethically
right to make debate inclusive to all citizens - events and conferences
which have an impact on or interest to the public should be made open
access.
Brennan offers an interesting strategy in "A libertarian case for
mandatory vaccination," though in form it is the common "devil's
advocate." The apparently least charitable bases for one's own position
(in this case libertarian premises) are granted for the sake of argument;
one's position is nevertheless found defensible (mandatory vaccination);
and thus the harshest critics are answered without having to pay out a
fu...
Brennan offers an interesting strategy in "A libertarian case for
mandatory vaccination," though in form it is the common "devil's
advocate." The apparently least charitable bases for one's own position
(in this case libertarian premises) are granted for the sake of argument;
one's position is nevertheless found defensible (mandatory vaccination);
and thus the harshest critics are answered without having to pay out a
full rebuttal. One need not endorse or condone the "devil" for this to
work; it is not sophistry to pick your battles - if libertarianism is
right, mandate vaccines; if it is wrong, mandate vaccines by a probably
more obvious argument than if it is right. No commitment necessary.
It should be noted, though, that Brennan's intended "devil" is
clearly a pro-vaccine libertarian. The anti-vaxxer audience is lost by
assumptions (A)-(D) that take for granted the efficacy, safety, and
obviousness of vaccines, plus a quip about Jenny McCarthy.
The damage here is not in directly insulting a particular reader (I
would be suprised if many anti-vaxxers read the JME), but in what such
disregard entails. For instance, the author briefly mentions that
libertarians can tolerate government advertisement campaigns, but he does
not feature this as a serious criticism, presumably because the anti-
vaxxer is not only irrational, but unreachable. While it is true that any
attempt to persuade a dogmatic believer can backfire and cause further
polarization instead, this danger applies also when outreach is forsaken
in favor of compulsion. It could be replied that, in the time it takes for
outreach to work, we will fail to stop harm to others, but in the time it
takes to debate each other about a mandate (and eventually to pass it),
there will also be infected. Force is seen as efficacious only after
diplomacy has been discarded.
By disregarding the anti-vaxxer as an agent with potentially
revisable beliefs, this article becomes about what "we" are to do about
"them." "We" are very diverse (so some devil's advocacy is required), but
"they" are demonized with words like "irrational," "stupid," and "self-
destructive." "They" aren't invited to this article, where the "them-
problem" is discussed and resolved (by government policy, no less).
Liberals and libertarians should be the first to get chills, at which
point Brennan also loses the very audience he attempts to court, who are
particularly wary of government-enforced marginalization.
So here is a "demon's advocate" portrait of an anti-vaxxer, based on
close friends of mine who have not vaccinated their children (though I do
not claim how far the portrait can be generalized): They are people. They
are firm in belief, and when I finish talking to them, I do have feelings
of frustration that one might express through name-calling (I have done so
privately). However, they are not those names; they are concerned mothers
and fathers who share many premises in common with me and probably with
you - for instance, a high regard for the welfare of their children. Their
premises diverge from mine on which sources of health information are most
trustworthy, as we have both a different religious and educational
upbringing, and they have felt (not unjustifiably) estranged from the
mixture of impersonal, corporate, and politicized healthcare that differs
strikingly from their intuitions on what "health" or "care" mean. They
prefer personal relationships with small-town doctors who spend time
taking their histories, and who typically engage in preventive, holistic,
minimally pharmaceutical, and minimally invasive forms of care (primum
nocere). Adverse events and side-effects are judged more heavily than
potential gains in health or improvements in one's natural history, so
most drug labels are off-putting and some minor maladies shrugged at;
preferences sometimes align with what evidence-based medicine would
prescribe and sometimes not. Drug and supplement companies who advertise
as being all-natural, small-scale (non-PHARMA) businesses have taken the
time to understand, magnify, and exploit some of these preferences to
share information "that the FDA doesn't want you to know," along with
conspiracy theories about FDA, Pharma, and government agendas (only
marginally more far-fetched when compared to confirmed events like the
Tuskegee or US Radiation studies, which, to use Brennan's phrase, "a
minimal amount of research" can easily uncover for any American worried
enough to look for it).
If we are both clever and patient enough to derive government
mandates from libertarianism, is our rhetorical distance from this
portrait so much greater? Couldn't some of their own premises favoring
preventive care and corporate transparency be used to expose the
misinformation?
*The opinions expressed in this letter are personal and do not
necessarily represent the views of my institution
There is a hierarchy of means to access opinions and information
published in journals. This is unethical in a democracy which uses
citizens' information to contribute to debates- from which they are then
excluded.
This to some extent mirrors my position that it is unethical to with hold
information from clients in therapy. It is taking advantage of
vulnerability however it is dressed up but also creates a hierarchy of...
There is a hierarchy of means to access opinions and information
published in journals. This is unethical in a democracy which uses
citizens' information to contribute to debates- from which they are then
excluded.
This to some extent mirrors my position that it is unethical to with hold
information from clients in therapy. It is taking advantage of
vulnerability however it is dressed up but also creates a hierarchy of
the informed. There are some prospective clients who will be more
informed by reading up on the practice and many others who will rely
mainly or only on what is disclosed by the therapist. There is also the
problem of the therapist him/herself deciding who will be given how much
information. Which can be discriminatory. Withholding information can
also be used defensively by therapists to hide their own insecurities.
The claim that it is acceptable to 'benignly' deceive clients
undermines what is the more important component - trust .To deceive as a
means to an end is unethical and more likely to be a component which adds
to dissatisfaction if the therapy is unsuccessful.
Dear Editors,
I read with interest the recent article on the ethics of doctor's
strikes.1 I accept most of the arguments expressed in the article,
however, there is one shortcoming to the framework: its under-analysis of
the role that the social context can have when evaluating the ethics of
doctors strikes.2 I contend that there is a need to contextualise
industrial disputes of this nature, namely, reflecting on and ev...
Dear Editors,
I read with interest the recent article on the ethics of doctor's
strikes.1 I accept most of the arguments expressed in the article,
however, there is one shortcoming to the framework: its under-analysis of
the role that the social context can have when evaluating the ethics of
doctors strikes.2 I contend that there is a need to contextualise
industrial disputes of this nature, namely, reflecting on and evaluating
the nature of the healthcare system, its values and vision, and its
relationship to the prevailing socio-political landscape. Such an approach
would offer a more integrated ethical understanding of doctors decision to
strike and extend the value of the ethical framework being proposed.
Roberts does attempt to contextualise the strike, by referring to the
'party line' adopted by various government officials and departments that
the junior doctor strike exposes patients to serious harm 1(p.3), and how
the media can be used to promote the government position. However, the
link between the doctors' actions and the social context is not properly
formulated. Healthcare systems can be categorised into four basic models-
Beveridge model (UK), the social insurance model (e.g. Germany), the
national insurance model (e.g. Canada) and a market driven model (e.g.
India).3 Each of these systems employ different principles of healthcare.
It would be worth incorporating this dimension of health care to an
ethical framework for evaluating doctors' strikes.
In this article the NHS and the Department of Health are framed as the
doctors 'employers'. While this is factually correct, it is worth
remembering that the Department of Health and the NHS are also significant
social institutions, key apparatuses of the UK welfare state and
custodians of its principles of universality, equality and justice.4 In
this particular case, it would be appropriate to check the actions of the
government and that of the doctors decision to strike against these
principles.5 The NHS has undergone a period of profound restructuring and
reorganisation under the austerity driven focus of a conservative
coalition government (2011-2016) and more recently a majority conservative
government (2016-present).6 The 'better outputs with fewer resources'8
logic of austerity calls into question whether equality, access and
quality of health services can be achieved when fiscal rectitude rather
than universality is the operational mode.7 9 In the UK the annual health
spend per capita in real terms is slowly recovering from -1.3% in
2010(compared with 0.1% for the OECD average for the same year). In 2013
the figure was 0.6 %, however, this was still behind the 1.0% average for
the OECD. 6 This concerted strategy to underspend in the area of
healthcare also included a two year policy of pay freezes and staff
redundancies.6 It is clear that these political decisions have had an
impact on the delivery of healthcare, impacting of the range of services
provided and the working conditions for staff. Austerity then not only
amplifies health inequalities of society and but also erodes at the 'the
very principle of relatedness and mutuality'10 that defines these public
health services and initiatives.
Incidentally, this belief in state responsibility for the health of UK
citizens has proved a rallying call for some of the striking doctors.
During the escalation of the industrial strikes in April 2016, a make-
shift banner was posted on the wall of a NHS hospital near my place of
work. It read: 'The NHS will last as long as there are folk left with
faith to fight for it- Aneurin Bevan'. This poster betrays the striking
doctors' sympathy with the ethical vision of the founding father of the
NHS and adds further legitimacy to their actions.
It would appear that the values of the healthcare system and the type of
priority it is given or not by a government are also important factors to
consider when evaluating the reasons why doctors strike. I think that this
amendment is worth making and highlighting for consideration.
REFERENCES
1 Roberts AJ. A framework for assessing the ethics of doctors' strikes, J
Med Ethics Published Online First: 20 May 2016 doi:10.1136/medethics-2016-
103395.
2 Weinstein BD. Dental ethics. Philadelphia: Lea and Febiger 1993.
3 Physicians for a National Health Program. Healthcare systems-Four Basic
Models, http://pnhp.org/single-player-
resources/health_care_systems_four_basic_models.php (accessed 8 Jun
2016).
4 Weir S. 2015. The welfare state is dead - what is rising from the
grave?. http://opendemocracy.net/ourkingdom/stuart-weir/welfare-state-is-
dead-%E2%80%93-what-is-rising-from-grave (accessed 7 Jun 2016).
5 Pearse N. 2015. Welfare debate marks opportunity to renew Beveridge's
legacy. http://opendemocracy.net/ourkingdom/nick-pearse/welfare-debate-
marks-opportunity-to-renew-beveridge%E2%80%99s-legacy (accessed 7 Jun
2016).
6. OECD. Country Note: How does health spending in the United Kingdom
compare? 7 July 2015. OECD Heath Statistics http://www.oecd.org/health
(accessed 7 Jun 2016).
7 Quaglio GL, Karapiperis T, Van Woensel L, et al. 2013. Austerity and
Health in Europe. Health Policy 2013; 113: 13-19.
8 Thomas S, Burke S, Barry S. 2014. The Irish health-care system and
austerity: sharing the pain, Lancet, May 3, 2014; 383: 1545-1546.
9 Suhrcke M, Stuckler D. 2012. Will the recession be bad for our health?:
it depends. Soc Sci Med 2012; 74: 647-653.
10 Lynch, K. 'New managerialism' in education: the organisational form of
neoliberalism, Open Democracy, 16 Sept 2014.
https://opendemocracy.net/kathleen-lynch/'new-managerialism'-in-education-
organisational-form-of-neoliberalism (accessed 7 Jun 2016).
A major conceptual problem this paper suffers from is the suggestion
that those whose views do not accord with the majority are, by default,
not tolerable.
Such people, whom the authors assume are exclusively religious, are
twice said to possess an idiosyncratic view of the universe. These remarks
exclude the possibility that there might be good, even non-religious,
reasons for conscientious objections. Moreover...
A major conceptual problem this paper suffers from is the suggestion
that those whose views do not accord with the majority are, by default,
not tolerable.
Such people, whom the authors assume are exclusively religious, are
twice said to possess an idiosyncratic view of the universe. These remarks
exclude the possibility that there might be good, even non-religious,
reasons for conscientious objections. Moreover, they betray a contempt for
religious views.
These people are also said to have "ultimately arbitrary" views, and
that because it is "ultimately up to society to determine the scope of
professional practice", those who wish to conscientiously object should
leave the profession. Two things here are cause for alarm. The first,
relating to the previous point, is: the authors suggest that off-beat
views are nonsensical. This is a disrespectful posture which colours the
entire argument.
The second is the largely undefended assumption that society defines
the scope of the medical profession. This is intellectually untenable.
Professions have always enjoyed a degree of independence from the State.
This degree of autonomy prevents certain conflicts of interest, and allows
a profession to develop its own aims and standards. Professional standards
are not determined by plebiscite, but by rational reflection.
Of course, the professions are accountable to the State and the
nation, but not dictated by them. Only tyranny contradicts this. Simply,
it is not in the general interest for the professions to be merely a tool
of the government. Since the authors appear to suggest the opposite, that
the professions should acquiesce entirely to others' demands, their
attempted ethical argument is built upon political presuppositions. If
their argument is to stand, so must these political assumptions be
defended.
In conclusion, doctors of all stripes and beliefs should be most
distressed by the proposals laid out in this paper. Morality and medicine
are not issues to be settled, in the final analysis, democratically. The
professions should resist unreasonable interference from other bodies. It
would be most undesirable for them to bow to the absolutism of public
demand or government decree. Though the authors dismiss all analogy with
historic totalitarian regimes, they seem to suggest that conscientious
objection is never appropriate. And this is manifestly false.
The JME's peer reviewers failed to press the clinical issues before
publication of this flawed paper(1). The unoriginal idea of a 'ritual
nick' performed by health professionals in a harm limitation approach to
female genital mutilation (FGM) was proposed by the American Academy of
Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the
face of worldwide condemnation(4) by the World Health Organisation...
The JME's peer reviewers failed to press the clinical issues before
publication of this flawed paper(1). The unoriginal idea of a 'ritual
nick' performed by health professionals in a harm limitation approach to
female genital mutilation (FGM) was proposed by the American Academy of
Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the
face of worldwide condemnation(4) by the World Health Organisation, and
the UK Royal Colleges of Obstetricians and Gynaecologists and Paediatrics
and Child Health, amongst others.(5)
Many mistakes slipped through: (i) the authors say the prevalence of
FGM is stable, but provide figures showing it falling; (ii) they claim to
medically recategorise all procedures (amateur, accidental or surgical) -
matters beyond the scope of ethicists to judge; (iii) they state the
impacts of surgery on male and female genitals can be assumed to be
similar - they cannot; (iv) likewise, comparisons with adult surgery
(including cosmetic female genital surgery) are not relevant to children;
(v) there is no such thing as a "nick that heals completely" without
leaving scar tissue; (vi) indeed, they later admit that "de minimus"
procedures will involve "tissue being removed", the amount being difficult
to regulate; (vii) controversially, they describe asymptomatic healthy
children as "patients" thus generating an overweaning sense that doctors
owe a duty of care regarding social matters; (viii) despite arguing for
autonomy they did not suggest leaving parents with responsibility for
performing the 'nick'; (ix) far from seriously considering the
utilitarian calculus, they have no insight into the damage their proposal
has on trust in the medical profession; (x) the concept of 'harm
limitation' need not be applied(6) to justify changing the present global
consensus, especially without evidence of rising harm in countries where
FGM is illegal; (xi) they neglect entirely physicians' conflicted
pecuniary interest when surgically altering healthy children's genitals,
even if by request of loving parents for socio-cultural benefits; (xii)
revealingly, they use a self-referential test for acceptability based on
one gynaecologist's previous defence of male circumcision(7).
Surgeons should respect the basic ethical principles of 'first of
all, do no harm' and informed consent to irreversible surgery on the basis
of medical necessity, particularly when performed on children. In the USA
(but less so in Europe), there may presently remain a 'liberal' tolerance
of male circumcision whose protection appears to be the article's real
purpose. The weak arguments presented might lead to the opposite
conclusion: far from condoning renamed non-therapeutic procedures (no
doubt performed for a fee on defenceless girls), why not turn the
spotlight onto medically sanctioned traditional 'ritual' practices on male
infants?
References
(1) Arora KS, Jacobs AJ. J Med Ethics Published Online First: 22nd
February 2016 doi:10.1136/
medethics-2014-102375
(2) American Academy of Pediatrics. Ritual genital cutting of female
minors. Pediatrics
2010; 125: 1088-93.
(3) American Academy of Pediatrics. Policy statement: ritual genital
cutting of female
minors. Pediatrics 2010; 126: 191.
(4) MacReady N. AAP retracts statement on controversial practice. Lancet
2010; 376: 15.
(5) Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 12 May
2010
The authors submit an ethical theory which rejects categorical
conceptions of right and wrong, and adopts a scaled view of rightness,
believing that it can depolarise the debate over the use of human
embryonic stem cells (hESC) in medical research. I will argue that their
proposal is unsuccessful.
They argue that binary ethics must be forgone in preference of a non-
binary understanding of rightness and wrongnes...
The authors submit an ethical theory which rejects categorical
conceptions of right and wrong, and adopts a scaled view of rightness,
believing that it can depolarise the debate over the use of human
embryonic stem cells (hESC) in medical research. I will argue that their
proposal is unsuccessful.
They argue that binary ethics must be forgone in preference of a non-
binary understanding of rightness and wrongness: pro and contra reasons
cannot be reduced to a binary moral conclusion, and a single pro or contra
reason should ever rule out acts which go against it (and vice versa). If
it were otherwise, an illegitimate "deontic leap" is made, and a binary
conclusion (e.g. action X is right/wrong) is forced. Below I offer one
major reason why this theory cannot do what the authors claim it can.
Crucially, "right" and "wrong" remain (apparently) undefined, though
they are essential to the debate. Those who oppose to the use of hESC
often assume that embryocide is murder--a belief not easily trumped even
by the forceful argument of medical research.1 So, if the means to an end
are seen as absolutely wrong, the "non-binary" analysis will mean nothing
to those whose ethic includes deontological considerations such as "do not
kill".
The authors do not seem to recognise this. Hence, they imply that
"right" and "wrong" are synonyms of "pro" and "con" respectively; they
assume a quantitative view of ethics. Thus, they reveal that their ethic
is utilitarian. Regardless of whether utilitarianism is valid or not, it
is na?ve to think that it could resolve a debate so bound up in religion
and politics.2 Simply, it is a different ethical language to that of some
of the major voices in the debate.
Espinoza and Peterson's non-binary ethical theory falls short of its
promise to depolarise the ethical debate. Its utilitarian design sidesteps
other ethical considerations in order to redefine the terms of the debate,
making it unconvincing to many.
1. Meilaender, G. 2013. Bioethics: A Primer for Christians.
Cambridge: Eerdmans
2. Green, R. M. 2008. "Embryo as epiphenomenon: some cultural, social and
economic forces driving the stem cell debate". Journal of Medical Ethics,
34, pp 840-844.
I feel a huge debt of gratitude towards the Journal of Medical
Ethics for showing that it can be possible for outsiders to contribute to
what can seem like a closed circle of people talking to themselves. Just
to point out though that there is not an equality of democracy when the
Journal of Medical Ethics and others are still largely unknown to the
public; that work carried out in the name of 'the public good' is unkn...
I feel a huge debt of gratitude towards the Journal of Medical
Ethics for showing that it can be possible for outsiders to contribute to
what can seem like a closed circle of people talking to themselves. Just
to point out though that there is not an equality of democracy when the
Journal of Medical Ethics and others are still largely unknown to the
public; that work carried out in the name of 'the public good' is unknown
until it trickles down into policies; that they still has a pay policy
which bars many from reading most complete articles and therefore the
opportunity of making their own authentic views heard. Is there maybe a
fear of 'lowering the tone' of the more academic publications? Funding is
an issue but does it need to cap the right to equality of access to
debates about issues which effect society as a whole? For outsiders such
as myself it can seem at times that specialist publications can act like
some exotic society composed of those who can afford to pay, can speak
the language of academia - to each other - and /or have free access
through institutions from which most members of the public again are
excluded.
He argues that there are people who are definitely permanently unaware without fluctuation because they have no brain, citing "Tony Bland, whose higher brain had effectively liquefied'". I assume that he bases this statemen...
The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation...
A properly worded consent form must make risks transparent but if the person has not even been asked to participate, discrimination is too easily slipping in. Even giving the reason as duty of care can be mis/used to eliminate some people - but their participation may be valuable as well as ethical. There can be an unconscious bias to avoid difficulties for researchers but discrimination will miss opportunities for the...
Brennan offers an interesting strategy in "A libertarian case for mandatory vaccination," though in form it is the common "devil's advocate." The apparently least charitable bases for one's own position (in this case libertarian premises) are granted for the sake of argument; one's position is nevertheless found defensible (mandatory vaccination); and thus the harshest critics are answered without having to pay out a fu...
There is a hierarchy of means to access opinions and information published in journals. This is unethical in a democracy which uses citizens' information to contribute to debates- from which they are then excluded. This to some extent mirrors my position that it is unethical to with hold information from clients in therapy. It is taking advantage of vulnerability however it is dressed up but also creates a hierarchy of...
Dear Editors, I read with interest the recent article on the ethics of doctor's strikes.1 I accept most of the arguments expressed in the article, however, there is one shortcoming to the framework: its under-analysis of the role that the social context can have when evaluating the ethics of doctors strikes.2 I contend that there is a need to contextualise industrial disputes of this nature, namely, reflecting on and ev...
A major conceptual problem this paper suffers from is the suggestion that those whose views do not accord with the majority are, by default, not tolerable.
Such people, whom the authors assume are exclusively religious, are twice said to possess an idiosyncratic view of the universe. These remarks exclude the possibility that there might be good, even non-religious, reasons for conscientious objections. Moreover...
The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation...
The authors submit an ethical theory which rejects categorical conceptions of right and wrong, and adopts a scaled view of rightness, believing that it can depolarise the debate over the use of human embryonic stem cells (hESC) in medical research. I will argue that their proposal is unsuccessful.
They argue that binary ethics must be forgone in preference of a non- binary understanding of rightness and wrongnes...
I feel a huge debt of gratitude towards the Journal of Medical Ethics for showing that it can be possible for outsiders to contribute to what can seem like a closed circle of people talking to themselves. Just to point out though that there is not an equality of democracy when the Journal of Medical Ethics and others are still largely unknown to the public; that work carried out in the name of 'the public good' is unkn...
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