Peter Herissone-Kelly[1] makes the case that it would be morally
inappropriate for prospective parents to select their children based on
comparative judgments about their life quality. This view is in stark
contradiction with the view, advanced by Julian Savulescu [2], that
parents have a moral obligation to select the best possible children they
can have.
Peter Herissone-Kelly[1] makes the case that it would be morally
inappropriate for prospective parents to select their children based on
comparative judgments about their life quality. This view is in stark
contradiction with the view, advanced by Julian Savulescu [2], that
parents have a moral obligation to select the best possible children they
can have.
Herissone-Kelly argues that future lives can be assessed from two
mutually exclusive viewpoints: the external and the internal. The external
perspective, assumed by Savulescu in his Principle of Procreative
Beneficence, is according to Herissone-Kelly (pp. 167-168), "obligatory
for political decision makers selecting social policies that will
indirectly affect both who will come into existence in the future, and the
quality of those future persons' lives." It would, however, be (p. 168),
"unfitting ... for prospective parents to take up the external
perspective", indeed, "it would be morally inappropriate for them to do
so."
The use of the internal perspective in parental decision making
leads, Herissone-Kelly maintains, to the rejection of the Principle of
Procreative Beneficence, and to the assumption of an alternative axiom,
the Principle of Acceptable Outlook. This stipulates that possible
children are not compared with one another – the fact that child A could
have a better life than child B is not a fitting (or at least not a
binding) parental reason for choosing A. It also stipulates that parents
are not obliged to have children whose life quality would be at a level
that the parents deem to be unacceptably low.
Herissone-Kelly's principle is in many respects intuitively more
acceptable than Savulescu's. It states that as long as all our potential
children would have a reasonably good life, we may choose any one of them.
(Savulescu would insist that the best must be selected.) It also allows us
not to have children at all, if none of our potential offspring can be
expected to have an acceptable life quality. (Savulescu's principle would
morally oblige us to have a child with a truly miserable life, if there
are no better options).
The claim is interesting and skilfully defended, and the author has
made a considerable contribution to the current discussion on the use of
technology in reproduction. I have three questions concerning the
Principle of Acceptable Outcome, its implications, and its applications.
(i) Herissone-Kelly hovers in the paper between the view that it is
prima facie obligatory for parents to adopt his principle and the view
that it is merely admirable and permissible for them to do so. He is
explicitly (p. 168) "inclined to say that it is not" obligatory, but he
also says that "it would be morally inappropriate" for the parents to take
up the external perspective.
My question is this. If the external and internal perspectives are
the only options available, and if it is morally inappropriate to assume
the external perspective, how can it not be obligatory to take up the
internal view? The logic of moral sentences seems to be that if one of
only two alternatives is wrong, then the one remaining is right in the
strong sense of being a moral duty.
(ii) If what I have said is correct, what are the social and
political implications? Herissone-Kelly states that political decision
makers have an obligation to take up the external view, and in the present
context this means that they should aim for the "best" future population
they can, probably by using all available genetic and medical technologies
in the choice of prospective citizens. The parents, on the other hand,
have an obligation to adopt the internal view, which implies that they
should resist at least some of the authorities' attempts to influence
their reproductive choices. How can this potential tension be handled?
(iii) In the internal assessment of the life quality of possible
children, Herissone-Kelly allows the parents to consider whether their
offspring would suffer unacceptably. He goes on to say that (p. 169) "what
counts as unacceptable suffering, or precisely where the level of
acceptable outlook ought to be fixed, are not questions to which any very
definite answer can be supplied."
If this is so, what prevents a proponent of Savulescu's principle
from arguing that the acceptable level should be set higher, to the
standard suggested by procreative beneficence? Parents could (or should?)
arguably have the attitude that "I do not want any child of mine to have a
life that is worse than the best life a child of mine could have had". In
this case, the difference between the principles would seem to evaporate.
References
[1] Herissone-Kelly P. Procreative beneficence and the prospective
parent. J Med Ethics 2006;32:166-169.
[2] Savulescu J. Procreative beneficence: why we should select the best
children. Bioethics 2001;15:413-426.
I would like to thank Professor Häyry for his complimentary remarks
on my
paper, and for his three (characteristically) incisive questions. In what
follows,
I will attempt to answer each of those questions in turn.
(i) Häyry asks how I can consistently maintain the conjunction of the
following
three propositions:
(a) taken together, the external and internal perspectives exhaust...
I would like to thank Professor Häyry for his complimentary remarks
on my
paper, and for his three (characteristically) incisive questions. In what
follows,
I will attempt to answer each of those questions in turn.
(i) Häyry asks how I can consistently maintain the conjunction of the
following
three propositions:
(a) taken together, the external and internal perspectives exhaust
the
standpoints available to a prospective parent in thinking about the lives
of
her possible future children;
(b) it is morally inapproriate for a prospective parent to take up the
external
perspective; but
(c) it is not obligatory for a prospective parent to take up the internal
perspective.
Häyry's thought here is that, if it is morally inappropriate for a
prospective
parent to take up the external perspective, and if the internal
perspective is
the only other available, then it must surely be obligatory for her to
take up
the internal. Häyry has clearly detected that I simultaneously feel both
tempted and reluctant to take the hard-line position that adoption of the
internal perspective is a strict duty for prospective parents! But while I
admit
that my intuitions pull me in two directions here, I am not convinced that
this
causes me to fudge the issue.
That is, the opposite of "morally inappropriate" does not seem to me
to be
"obligatory", but rather "morally appropriate". In saying that a
prospective
parent does something morally inappropriate in adoting the external
perspective, I am not suggesting that she is thereby contravening a duty.
Rather, I am saying that she is not, as it were, being the prospective
parent
she might be, since she is not taking up the perspective that is
appropriate
for her qua prospective parent. Now, doubtless it is trivially true that
we
should do what it is morally appropriate for us to do, but it seems to me
that
this claim makes use of a weaker sense of "should" than attaches to
statements of strict obligation. Importantly for my argument in the paper,
however, what does follow from the claim that the external perspective is
morally inappropriate for prospective parents, is that prospective parents
cannot be obliged to follow any principle (such as that of procreative
beneficence) that is rooted in that perspective.
(ii) As Häyry goes on to note, I state in my paper that the external
perspective
is the proper one for political decision makers to adopt, when choosing
policies that will affect which people are born, and the expected quality
of the
lives those people will lead (as in Parfit's conservation/depletion
example,
cited in my paper). Given this, Häyry asks what is to be done about the
apparent clash between the perspectives fitting for parents and for policy
makers, and between the actions that will result from the adoption of
those
perspectives. My answer is that political decision makers will be obliged
not
to interfere with decisions that ought to be the sole preserve of
prospective
parents. I take it that the choice of a conservation or a depletion policy
is not
such a decision, whereas whether to choose a better life embryo or a worse
life embryo is. Häyry's point does me the service of drawing my attention
to
the fact that I ought not to have said that "adoption of the external
perspective ... is obligatory for political decision makers ...", but
rather that it
is prima facie obligatory. I am grateful to him for this.
(iii) Towards the end of my paper, I introduce a principle of
acceptable
outlook (PAO), which I maintain ought to guide prospective parents'
decisions
about which children to produce, in place of Savulescu's principle of
procreative beneficence (PPB). PAO, I say, will take a form similar to "'I
will not
allow any child of mine to have a quality of life below L', where L is a
level of
acceptable outlook ... PAO will typically find expression in such
attitudes as 'I
do not want any child of mine to suffer unacceptably' ...". I also claim
that no
definite answer can be given to the question of where exactly L (the level
of
acceptable outlook) should be fixed, and rather imply that it may differ
from
prospective parent to prospective parent (although I do say that a life
not
worth living will fall below any plausible candidate for L).
Now, given this last point, Häyry asks what is stop a proponent of
PPB from
setting L at "the standard suggested by procreative beneficence", and
holding
that prospective parents either could or should hold a principle of the
form "I
do not want any child of mine to have a life that is worse than the best
life a
child of mine could have had". This, as Häyry notes, would involve the
collapse of the distinction between PAO and PPB.
But that such a collapse would occur ought to give us pause. That is,
if any
prospective parent employed PAO in this fashion, she would, in doing so,
be
making an external perspective judgement about the lives of her possible
future children. Such a judgement is, my paper argues, morally
inappropriate
for a prospective parent, and it is precisely this fact that prevents our
being
able legitimately to flesh out PAO in the way Häyry mentions.
Of course, it may be that a prospective parent locates L at a
standard that, so
to speak, just turns out to equal that of the best life a child of hers
could
have. This might seem a curiously high standard to set, but so long as it
is
not chosen just because it is the level of the best life a child of hers
could
have, it would involve no external perspective judgement, and so no
illegitimate
application of PAO.
Asking “Can we justify eliminating coercive measures in psychiatry?”
underscores the importance of paying attention to our moral and political
presumptions and illustrates the social value and moral wickedness of
psychiatry as a system of social control. The question implies that
eliminating psychiatric deprivations of liberty needs to be justified but
continuing to inflict such deprivations in the name of mental illness...
Asking “Can we justify eliminating coercive measures in psychiatry?”
underscores the importance of paying attention to our moral and political
presumptions and illustrates the social value and moral wickedness of
psychiatry as a system of social control. The question implies that
eliminating psychiatric deprivations of liberty needs to be justified but
continuing to inflict such deprivations in the name of mental illness
needs not.
Psychiatry is presented to the public as a medical specialty “like
any other.” This is a lie. Physicians do not write papers asking “Can we
justify eliminating coercive measures in nephrology or ophthalmology?”
Asking “Can we justify continuing to use coercive measures in
psychiatry?” is like asking “Can we justify torture as a method of
judicial interrogation?” The question indicts the questioner.
"Freedom” declared Benjamin Franklin, “is not a gift bestowed upon us
by other men, but a right that belongs to us by the laws of God and
nature." Assuredly, freedom is not a gift bestowed upon us by arrogant and
ignorant psychiatrists who expect to justify its deprivation by
“controlled clinical trials.”
With respect to all authors, I have read the article and the comments
made in the e-letter. I agreed with Biggar to little extent. But one of
the important point here is the reason of following religion Vs following
the science. Religion is not only about the beliefs but also about the
practices. It teaches us 24 hours way of passing life by giving us the
heavenly or moral knowledge either with a concept of God or without...
With respect to all authors, I have read the article and the comments
made in the e-letter. I agreed with Biggar to little extent. But one of
the important point here is the reason of following religion Vs following
the science. Religion is not only about the beliefs but also about the
practices. It teaches us 24 hours way of passing life by giving us the
heavenly or moral knowledge either with a concept of God or without that.
Science is all about "profession" and social well being via technology and
services but yes all these technologies just can't change the fate.
Religion teaches us to how we can spend a good life but science teaches us
best way to use the neccesities around us in the form of technologies.
All religions teach us to be ethical, faithful towards our duties
under legal rules. Who so ever is a patient (birth control based to gays
or lesbians), a doctor must treat him/her as a "subject". The point is a
medical or paramedical staff at "duty" must follow their duty even what
ever religion they follow. But yes, I feel a good religious practicing
medical or paramedical staff will be ethically and morally will be better
than a religious non practicing staff. Religion can make us a better human
if we practice a religion and this will be reflected in our jobs and
strength of our moral ethics in dealing with the patients.
Its not the matter which religion we belong, but it does matter how
the world see us and how we treat the humans ethically and morally and
yes, if a non religious person with no ethics and no morals follow the
regulations and rules concerning with patient and communication skills, he
may be even better doctor than a religious doctor.
Way of passing life (religion) Vs profession must be treated
separately.
In his commentary on Francesca Minerva's paper 'Conscientious
Objection in Italy'[1], Roger Trigg writes, "mutual respect is easy for
people who agree", and, "it is against the spirit of democracy to ride
roughshod over other's [sic] beliefs"[2]. His point is apposite: in a
democratic society an individual's conscience in matters of ethical
controversy ought not to be compromised by popular sensitivities. Sharp
disagree...
In his commentary on Francesca Minerva's paper 'Conscientious
Objection in Italy'[1], Roger Trigg writes, "mutual respect is easy for
people who agree", and, "it is against the spirit of democracy to ride
roughshod over other's [sic] beliefs"[2]. His point is apposite: in a
democratic society an individual's conscience in matters of ethical
controversy ought not to be compromised by popular sensitivities. Sharp
disagreement and respect can and must co-exist.
Problems arise when conscience impedes the implementation of laws. In
her article, Minerva identifies an example of this in Italy, where a
women's access to abortion services is limited due to the high proportion
of doctors who, for conscientious reasons, forgo involvement in abortion
procedures. Minerva surveys the problem and suggests how it could be
mitigated, after a brief critique of the concepts of conscience absolutism
and what she terms the compromise position.
Minerva defines conscience absolutism as the healthcare
practitioners' right to decline a service, to the extent that it may
"compromise the right of the patient to be cured"[1]. It is possible that
some healthcare practitioners take this view with abortion, even if the
mother's life is immediately threatened. Many, however, as Minerva
acknowledges, hold the compromise position, whereby the healthcare
practitioner's right of refusal is respected, but he agrees to refer the
patient to a willing colleague. To most, this is preferable to conscience
absolutism. It is worth noting that UK law makes a concession for this in
Section 4 of the 1967 Abortion Act, which says, "no person shall be under
any duty... to participate in any treatment authorised by this Act to
which he has a conscientious objection", unless the mother's life is at
risk[3].
However, Minerva argues that such a set-up is inadequate in Italy;
intervention is needed to facilitate access to abortion because, "the
public health system has the responsibility and duty to guarantee to
citizens all safe and beneficial treatments they are entitled to
request"1. In response, I would argue that a woman's legal right to
abortion does not negate a physician's right to conscience. If the state
has a duty to protect both these rights, it cannot use one right to
supplant the other.
Finally, Minerva's second of three recommendations to redress the
issue of abortion access merits comment. She proposes that physicians
should be discouraged from conscientiously objecting by providing an
incentive - she suggests pay rises and holidays - to those who will
perform abortions. The right to conscience is ostensibly respected in
this case, though the moral agency behind it is insulted. At best, it is
profoundly patronising to incentivise doctors to compromise on personal
conscience for the sake of expediency.
In conclusion, regardless of one's view of abortion, the right to
conscientious objection must be maintained in a free society, even at the
expense of unmet requests. The physician is not a slave to the public's
demands. Minerva rejects conscience absolutism; we must reject demand
absolutism.
References:
1. Minerva F. J Med Ethics 2015;41:170-173
2. Trigg R. J Med Ethics 2015;41:174
3. Abortion Act 1697, Section 4
I think this is a very important article. Well written, well
researched and timely.
It seems that there is a large body of ancient wisdom locked away in
the Adab writings. I suspect that there will be material of great value to
Western, as well as Islamic medical practice.
I had, until now, been only vaguely of Adab, as a counter-balancing
ethic, to Sharia. I'm ashamed of my ignorance, and also surprise...
I think this is a very important article. Well written, well
researched and timely.
It seems that there is a large body of ancient wisdom locked away in
the Adab writings. I suspect that there will be material of great value to
Western, as well as Islamic medical practice.
I had, until now, been only vaguely of Adab, as a counter-balancing
ethic, to Sharia. I'm ashamed of my ignorance, and also surprised by it.
I've been making some effort to understand Islamic medical ethics and its
intersection with Western medical ethics for a couple of years now, as
part of the establishing the policy for King's College Hospital's clinic
in Abu Dhabi, where it has been important to recognise, and apply, both
the ethics of both countries and traditions. Throughout many discussions
of particular practical matters, and ethical decisions, the teachings of
Adab have not been mentioned.
The original sources are the right place to go for an understanding,
but I, and I think others, would find a guide to the field would be
extremely useful. Books that I can find in English on the subject appear
to be either historical, or literary, or to be concerned with non-medical
aspects of adab.
Conflict of Interest:
I am co-chair of the ethics committee of KCH Clinics Abu Dhabi - I'd hope more of a supporting, than a competing, interest, but I should mention it.
Recent attacks on the medical criteria for diagnosing death have, in
our opinion, reached such a degree of sophistry that the debate is in
danger of becoming irrelevant to doctors and patients alike1 2 .Doctors
have a job to do, to diagnose the dead.
Dying is a process, decay effects different functions and cells of
the body at different rates. Doctors must decide at what moment along this
pr...
Recent attacks on the medical criteria for diagnosing death have, in
our opinion, reached such a degree of sophistry that the debate is in
danger of becoming irrelevant to doctors and patients alike1 2 .Doctors
have a job to do, to diagnose the dead.
Dying is a process, decay effects different functions and cells of
the body at different rates. Doctors must decide at what moment along this
process there is permanence and death can be appropriately declared. This
is not a 'legal fiction', this is a doctor's solemn duty.
Here we feel obliged to correct a common misunderstanding. The
majority of deaths following cardiac arrest, as diagnosed in every
hospital worldwide, rest on the doctor's intention not to attempt
cardiopulmonary resuscitation and not a literal definition of
'irreversibility', that is a circulation that cannot be restored using any
currently available technology. Unless one is prepared to undertake
cardiac massage, direct cardiac defibrillation and perhaps extra-corporeal
membrane oxygenation prior to diagnosing anyone in hospital as dead, no
one can know that the heart has irreversibly ceased. DeVita's work
suggests that if a literal definition of irreversible loss of function is
used to define death, then brain death does not occur for one hour after
cerebral circulatory arrest, whilst for the heart it would be many hours 3
. This would lead to a death watch in which there would be no place for a
stethoscope and modern medicine would be turned back 150 years, to a time
when only the satisfaction of rigor mortis was accepted, yet still not
publically trusted.
Likewise the concept that doctors should not declare death in patients
confirmed deceased using neurological criteria, because a decapitated body
has living cells and the potential for function, has no relevance to our
duty to make a timely diagnosis of death whilst avoiding any diagnostic
errors.
What these attacks amount to is a request that death can only be
diagnosed if there is total cellular dis-integration, a process likely to
take many months, and will require hospitals for the dead as used in
bygone centuries. If it is the need for more organs that motivates this
continual undermining of diagnostic criteria for death, we would urge
philosophers to directly attack the donor rule, and leave the dead rule to
doctors.
References
1. Miller FG, Truog RD. Decapitation and the definition of death. J
Med Ethics. 2010;36:632-634.
2. Shah SK, Truog RD, Miller FG. Death and legal fictions. J Med Ethics.
2011.
3. DeVita MA. The death watch: certifying death using cardiac criteria.
Prog Transplant. 2001;11:58-66.
Thank you very much for highlighting the importance of ethics in
research. When I was at the Kathmandu University Medical Journal (KUMJ),
Journal of Nepal Medical Association (JNMA) and Journal of Nepal Health
Research Council (JNHRC), authors were required to submit ethical approval letter
from 2010. We started advertising and notifying authors of this from 2008.
Thank you very much for highlighting the importance of ethics in
research. When I was at the Kathmandu University Medical Journal (KUMJ),
Journal of Nepal Medical Association (JNMA) and Journal of Nepal Health
Research Council (JNHRC), authors were required to submit ethical approval letter
from 2010. We started advertising and notifying authors of this from 2008.
I left KUMJ and JNMA in 2011, but the ethical approval letter remains mandatory
for research articles. JNHRC and World Journal of Health Sciences (WJHS)
have also made it mandatory to submit an ethical approval letter.
There are five PubMed index journals, of which KUMJ, JNMA and JNHRC
have
already made the ethical approval letter compulsory two years ago, with initiation long
before, but the author fails to research this in depth.
Therefore, we, the editors from Nepal, felt that there is gap of
knowledge at various levels and we formed the Nepal Association of Medical
Editors (NAME) in order to provide education and to foster medical journal editors. It is also requesting all the
editors and journals to check for the correct ethical approval letter.
The Ethical Review Board (ERB) of Nepal Health Research Council
(NHRC) has continuously expanded its reach to the institutions and to
organizations setting up IRCs in the institutions. They are also providing
training at various levels.
NAME is collaborating with ERB to foster ethics in research in
Nepal.
Similarly NAME is a member of the Committee of Publication Ethics, UK,
through which it is fostering publication ethics as well.
However, there is room for development to improve the
scientific
community in developing countries.
The Article states "In health research, funding bodies and academic
institutions actively undertake patient and public involvement programmes
to ensure that studies adequately reflect the perspectives and input of
patients and citizens." I do not agree.
I have been a member of a research ethics committeee in England for
seven years. I do not recognise this statement, nor would my colleagues.
In very few cases...
The Article states "In health research, funding bodies and academic
institutions actively undertake patient and public involvement programmes
to ensure that studies adequately reflect the perspectives and input of
patients and citizens." I do not agree.
I have been a member of a research ethics committeee in England for
seven years. I do not recognise this statement, nor would my colleagues.
In very few cases does PPI (Patient and Public Involvement) in the
research applications we see "adequately reflect the perspectives and
input of ... citizens." The predominant reason for this is a n
unwillingness to go outside the institution and its familiar sources to
the public 'out there'. This is despite the regular requirement to do so
of funding bodies and the law.
If institutions were to comply on a regular and consistent basis, the
need for PLR would be confined to what, in my perception, is the very
limited number of occasions when it would be practicable.
Whilst it is right and proper that the circumcision issue be debated,
it is disturbing that many of those who oppose circumcision rely heavily
upon selective literature citations, untested speculations about foreskin
function, fear-mongering aimed at making circumcised males feel they have
been sexually damaged, and denialism about the proven benefits of the
procedure, while ignoring pub...
Whilst it is right and proper that the circumcision issue be debated,
it is disturbing that many of those who oppose circumcision rely heavily
upon selective literature citations, untested speculations about foreskin
function, fear-mongering aimed at making circumcised males feel they have
been sexually damaged, and denialism about the proven benefits of the
procedure, while ignoring published criticisms of their arguments.
Predictably all these academic sins are committed by circumcision
opponents in the current issue of the Journal of Medical Ethics. Rather
than rebut each author in turn, which would be tedious, I will concentrate
on just one, the article by David Lang, "Circumcision, sexual dysfunction
and the child's best interests: why the anatomical details matter"1. Most
of the usual academic sins are repeated in his opinion piece, making it a
good example of anti-circumcision polemic.
Part of the reason Lang's piece is so bad is his use of popular, non-
peer-reviewed, or biased sources. Lang is heavily reliant on an opinion-
piece by Fleiss in a popular magazine called "Mothering: the Magazine of
Natural Family Living"2. To anyone familiar with popular but unscientific
views, the word "natural" always sets alarm bells ringing, as it is so
often associated with the appeal to nature fallacy. Lang's reference list
also reads like a "Who's Who" of the anti-circumcision movement: Fleiss,
Cold, Taylor, Bollinger, Van Howe, Darby, Svoboda ... all well known to be
passionately anti-circumcision and therefore, it may be argued, not
impartial, and some of whom have clocked up impressive tallies of
rebuttals and critiques in the medical literature.
Proceeding now to the technical points, citing Fleiss2 Lang tells us
that the foreskin contains "more than 20000 nerve endings". Fleiss gives
no experimental data in support of this, but instead refers to an old
paper3 which does not give the 20000 figure, directly. It has to be
inferred by extrapolation, and exaggeration, from a single square
centimetre of a single foreskin which contained 212 nerve endings. It is
not clear where on the foreskin the sample came, which is important as the
distribution of nerve endings may vary. Nor is it stated how old the donor
was, which matters as nerve ending density may decline with age. It
includes nerve endings of any kind, including temperature receptors, but
there were only two of the touch receptors (Meissner's corpuscles) that
circumcision opponents harp on about. There is no indication of how
typical this particular sample was, nor any comparison with other body
parts to provide a control. And to arrive at 20000 one has to multiply by
94.3 square centimetres, which is a very generous foreskin, even assuming
both inner and outer surfaces are being counted. None of this mattered for
the purposes of the original study, but Fleiss' extrapolation is absurd
and, without a control, worthless.
Copying another of Fleiss's errors, Lang complains about,
"desensitisation of the glans ... due to successive layers of
keratinisation from constant exposure and abrasion". As before this is not
backed up by peer-reviewed science. Like the oft-repeated 20000 figure, it
is an urban myth. What scant evidence there is indicates no difference
between circumcised and uncircumcised members4.
Continuing with his theme of copying uncritically from Fleiss, Lang
lectures about drying of the glans and interruption of "the normal
circulation of blood". Without wishing to sound facetious one may retort,
"So what?" In the absence of evidence that these things matter, they are
irrelevant, although it could be argued that drying creates an environment
less conducive to pathogens.
The doctrine of the gliding motion is next. Circumcision immobilises
the remaining skin and thereby "destroys the mechanism by which the glans
is normally stimulated", Lang parrots Fleiss. It may be countered that
circumcision enhances the actual mechanism by which the glans is
stimulated - direct contact with the vaginal wall. Many men do find their
foreskins gliding back and forth during coitus, but others have short
foreskins that retract behind the glans upon erection. Where is the
research indicating how many men experience gliding, what they (and their
partners) think about it, and whether the greater contact with the vaginal
wall experienced by a bare glans compensates for its loss? What would a
condom do to it?
Finally breaking from echoing Fleiss, Lang begins copying
unquestioningly from Cold & Taylor5. Meatal stenosis, we are told,
occurs in "in 5-10% of circumcised males" citing these two circumcision
opponents, but theirs' is a secondary source, which in turn cites five
others. The first is an author (Van Howe) whose later more detailed study
on this topic was discredited6. Three others were studies of children
circumcised because of foreskin pathology, which may be associated with
meatal stenosis. The remaining study found an 8 % incidence but had no
control.
Some recent studies find dramatically lower figures. 0.55 % and 0.9
% in Iran7,8 and 0.01 % for English boys9. Another Iranian study found 6.6
%, but none at all when petroleum jelly was applied for 6 months post-
op10. Meatal stenosis has long been regarded as subjective and tricky to
define and diagnose consistently, with differences of opinion even as to
its significance11.
"The prepuce is primary, erogenous tissue necessary for normal sexual
function. The complex interaction between the protopathic sensitivity of
the corpuscular receptor-deficient glans penis and the corpuscular
receptor rich ridged band of the male prepuce is required for normal
copulatory behavior" Lang cuts and pastes from Cold & Taylor. But
others dismiss this as unproven speculation12. Although the sample size
was small, when men were asked to rank the different parts of their penis
with respect to sexual sensation, the glans was first, the prepuce last13.
Sexual sensation is mediated by genital corpuscles, which are absent from
the prepuce14.
In the recent African HIV prevention trials, thousands of men were
circumcised and compared to controls. These studies included sexual
function. In the Ugandan trial, 98 - 99 % of both the intervention and the
control groups reported satisfaction with their sexual function after two
years15. In the Kenyan trial, 64 % of men found that sensitivity improved
after circumcision, and 54.5 % reported greater ease of achieving
orgasm16. The most recent meta-analysis on the subject found that
circumcision has no adverse effect on male sexual function17. Circumcision
opponents greatly overstate the alleged erogenous merits of the foreskin.
Lang switches to a study by two other prominent, anti-circumcision
figures, Bollinger & Van Howe18 to claim that "circumcised men are 4.5
times more likely to use an erectile dysfunction drug than intact men."
Unfortunately, Lang ignores the subsequent criticism of this study19. Its
self-selected sample was recruited through advertisements on two websites
with strongly anti-circumcision content. It is hard to imagine a more
effective way of ensuring a biased sample, short of advertising
specifically for circumcision opponents. Indeed the loaded title of the
advertisement, "Male circumcision trauma survey" comes close to doing
exactly that. In their reply, Bollinger & Van Howe concede the
potential for bias, and that their results are "unconfirmed"20.
When Lang gets to his next point, "18% of adult American men (of whom
approximately three-fourths are circumcised) have erectile dysfunction" he
finally cites a credible source21. But it is a source that linked erectile
dysfunction to cardiovascular problems, diabetes, lack of exercise and
age, not to circumcision. The aforementioned meta-analysis found no
association between circumcision and erectile dysfunction17.
Lang concludes his section on the alleged harm of circumcision with
an extraordinary combination of speculation and barrel-scraping. The USA,
he tells us, "accounts for 46% of Viagra sales" and, whilst conceding that
this "could be explained by any number of factors unrelated to
circumcision", speculates that this is due to truncation of the perineal
nerve.
In the absence of any credible evidence that circumcision causes
erectile dysfunction, speculations about the perineal nerve are moot. And
the popularity of Viagra, which can be a recreational drug, in the
wealthiest country on earth, with a high consumption of all manner of
pharmaceuticals, can indeed be explained without recourse to baseless fear
-mongering about circumcision.
Done properly, circumcision does not damage sexual function. But
misleading claims put about by its opponents do damage the self-esteem of
circumcised males by needlessly making them feel they are damaged, and are
missing an important part of their anatomy. And they distress parents by
deceiving them into believing they have harmed their sons. This is
certainly an effective way to draw angry and motivated new recruits into
the anti-circumcision movement, and into "surveys" on "circumcision
trauma", but it is misleading and unethical.
Whether or not to circumcise should be decided on quality peer-
reviewed evidence that withstands scrutiny. Not urban myths, untested
speculations, and discredited "surveys" on biased samples by biased
authors. But that is all Lang offers us. It is ironic that the title of
Lang's opinion piece should state that "the anatomical details matter" and
he then proceeds to get them wrong, or to exaggerate their importance. His
details do not matter. The facts do, and they do not support the anti-
circumcision crusaders' claims about impairment of sexual function.
References.
1. Lang, D.P. "Circumcision, sexual dysfunction and the child's best
interests: why the anatomical details matter". J Med Ethics, 2013;39:429-
31.
2. Fleiss, P. The case against circumcision. Mothering: the Magazine
of Natural Family Living. 1997;Winter:36-45.
3. Bazett, H.C., McGlone, B., Williams, R.G., Lufkin, H.M., Depth,
Distribution and Probable Identification in the Prepuce of Sensory End-
Organs Concerned in Sensations of Temperature and Touch; Thermometric
Conductivity. Archives of Neurology and Psychiatry, 1932;27:489-517.
4. Szabo, R., Short,R.V., How does male circumcision protect against
HIV infection? BMJ, 2000;320:1592-4.
6. Schoen, E.J. Letter to the editor. Clin Ped., 2007;46(1):86.
7. Simforoosh, N., Tabibi, A., Khalili, S.A.R., Soltani, M.H.,
Afjehi, A., Aalami, F., Bodoohi, H. Neonatal circumcision reduces the
incidence of asymptomatic urinary tract infection: a large prospective
study with long-term follow up using Plastibell. J Ped Urol., 2012;8:320-
3.
8. Yegane, R-A., Salehi, N-A., Koshdel, J-A. Late complications of
circumcision in Iran. Pediatr Surg Int., 2006;22:442-5.
9. Cathcart, P., Nuttall, M., Meulen, J., Emberton, M., Kenny, S.E.
Trends in paediatric circumcision and its complications in England between
1997 and 2003. Brit J Surg. 2006;93:885-90.
10. Bazmamoun, H., Ghorbanpour, M., Mousavi-Bahar, S.H., Lubrication
of circumcision site for prevention of meatal stenosis in children younger
than 2 years old. Urol J., 2008;5(4):233-6.
12. Alanis, M.C., Lucidi, R.S., Neonatal circumcision: A review of
the world's oldest and most controversial operation. Obstet Gynecol Surv.,
2004;59(5):379-95.
13. Schober, J.M., Meyer-Bahlburg, H.F., Dolezal,C. Self-ratings of
genital anatomy, sexual sensitivity and function in men using the 'Self-
assessment of genital anatomy and sexual function, Male' questionnaire.
BJU Int., 2009;103:1096-1103.
14. Rhodin, J.A.G. Histology. 1974. Oxford University Press, London.
15. Kigozi, G., Watya, S., Polis, C.B., Buwembo, D., Kiggundu, V.,
Wawer, M.J., Serwadda, D., Nalugoda, F., N., Bacon, M.C., Ssempijja, V.,
Makumbi, F., Gray, R.H., The effect of male circumcision on sexual
satisfaction and function, results from a randomized trial of male
circumcision for human immunodeficiency virus prevention, Rakia, Uganda.
BJU Int., 2008;101:65-70.
16. Krieger, J.N., Mehta S.D., Bailey R.C., Agot, K., Ndinya-Achola,
J.O., Parker, C., Moses, S. Adult male circumcision: Effects on sexual
function and sexual satisfaction in Kisumu, Kenya. J Sex Med., 2008;5:2610
-22.
17. Tian, Y., Liu, W., Wang, J.Z., Wazir, R., Yue, X. & Wang,K.J.
Effects of circumcision on male sexual functions: a systematic review and
meta-analysis. Asian J Androl., 2013; in press.
18. Bollinger, D., Van Howe, R.S. Alexythmia and circumcision trauma:
a preliminary investigation. Int J Men's Health, 2011;10:184-95.
19. Morris, B.J., Waskett, J.H., Claims that circumcision increases
alexithymia and erectile dysfunction are unfounded: a critique of
Bollinger and Van Howe's "Alexithymia and circumcision trauma: a
preliminary investigation". Int J Men's Health. 2012;11:177-81.
20. Bollinger, D., Van Howe, R.S. Preliminary results are
preliminary, not "unfounded": reply to Morris and Waskett. Int J Men's
Health. 2012;11:181-4.
21. Selvin, E., Burnett, A.L., Platz, E.A. Prevalence and risk
factors for erectile dysfunction in the US. Amer J Med., 2007;120:151-7.
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