In his eLetter George Hill asserts, of circumcision, that "The
evidence of injury to the child's sexual function is now conclusive".
However, this view is not supported by the literature he cites. He tells
us that Podnar found that the penilo-cavernosus reflex is harder to elicit
in circumcised men (or those with their foreskins retracted)1. So it is
harder to elicit a co...
In his eLetter George Hill asserts, of circumcision, that "The
evidence of injury to the child's sexual function is now conclusive".
However, this view is not supported by the literature he cites. He tells
us that Podnar found that the penilo-cavernosus reflex is harder to elicit
in circumcised men (or those with their foreskins retracted)1. So it is
harder to elicit a contraction of the anal sphincter by squeezing the
glans. What sexual functions are impaired by this?
Mr. Hill's third reference2 is unobtainable, beyond an abstract for a
conference presentation, making it impossible to judge its credibility.
The papers by Frisch3 and by Bronselaer4 that Mr. Hill cites both had
shortcomings. Being based on self-selected convenience samples, with
mediocre response rates, they were compromised by participant bias, in
addition to various other problems pointed out by critics5,6. In reply,
Frisch conceded that his study's findings "suggest, but by no means prove"
that a minority of individuals sometimes experience a few negative effects
from circumcision6. This is anything but "conclusive".
In his reply to his critics8, Bronselaer stated that the circumcision
rate in Belgium is 15 % as opposed to the 22.6 % of participants in his
study, but seemed not to appreciate the significance of this - his sample
cannot have been a representative one. A more recent commentary points
out that 12.1 % of his sample were homosexual9 leaving one wondering just
how unrepresentative this sample was.
For every study Mr. Hill might cite indicating a negative effect from
circumcision there are others finding no difference, or even an
improvement. Rather than list examples I refer readers to the recent meta
-analysis by Tian et al10 which finds no significant adverse consequence
of circumcision on male sexual function.
Mr. Hill also overstates his case when he asserts that the three
famous African HIV prevention trials "have been sharply questioned and
even debunked" and proceeds to cite three articles, one of them his own.
Unfortunately for Mr. Hill, each one of these articles has itself been
"sharply questioned and even debunked" in follow up critiques in the very
journals in which they were published. The one following his own was
particularly detailed and thoroughly rebuts the arguments he and his co-
author put forward11. The WHO, CDC, UNAIDS, and other professional bodies
dealing with this ghastly epidemic, also do not agree with Mr. Hill's
assessment.
It is worrisome that circumcision opponents overstate their case so
much. Telling circumcised males that they are sexually damaged can only
cause them anxiety and distress. And to tell them it when the evidence
does not support this view makes the distress entirely needless. And
claiming that the African trials are "debunked" when this is clearly not
so, whilst failing to acknowledge detailed rebuttals of the very articles
one cites in support of this claim, only invites accusations of denialism.
Finally, Mr. Hill writes as Vice-President of an activist
organization, "Doctors Opposing Circumcision", so has a clear interest in
promoting his organization's agenda. Fair enough, that is what a Vice-
President should do. However, this agenda extends to denying the
established benefit of circumcision in the context of African AIDS,
pitting it against major professional bodies and a large volume of peer-
reviewed research. It does not reflect mainstream medical opinion on this
matter. Furthermore, only two of its five officers are medically
qualified (Mr. Hill is not) which is a little surprising, given its name.
All this could easily tempt cynics to express doubts about its
credibility. Perhaps Mr. Hill could kindly allay such doubts please by
telling readers how many members this campaigning group has, and how many
are medical doctors?
References.
1. Podnar, S. Clinical elicitation of the penilo-cavernosus reflex in
circumcised men.BJU Int. 2011;209:582-5.
2. Solinis, I., Yiannaki, A. Does circumcision improve couple's sex
life? J Mens Health Gend. 2007;4(3):361.
3. Frisch, M., Lindholm, M., Gr?nb?k, M. Male circumcision and sexual
function in men and women: a survey-based, cross-sectional study in
Denmark. Int J Epidemiol. 2011;40(5):1367-81.
4. Bronselaer, G.A., Schober, J.M., Meyer-Bahlburg, H.F.L., et al.
Male circumcision decreases penile sensitivity as measured in a large
cohort. BJU Int. 2013;111(5):820-27.
5. Morris, B.J., Waskett, J.H., Gray, R.H. Does sexual function
survey in Denmark offer any support for male circumcision having an
adverse effect? Int J Epidemiol. 2012;41(1):310-2.
6. Morris, B.J., Kreiger, J.N., Kigozi, G. Male circumcision
decreases penile sensitivity as measured in a large cohort. BJU Int.
2013;111(5):E269-70.
7. Frisch, M. Author's Response to: Brian Morris et al, Does sexual
function survey in Denmark offer any support for male circumcision having
an adverse effect? Int J Epidemiol. 2012;41(1):312-4.
8. Bronselaer, G. Reply. BJU Int. 2013;111(5):E270-1.
9. Wang, K., Tian, Y., Wazir, R. Male circumcision decreases penile
sensitivity as measured in a large cohort. BJU Int. 2013;112(1);E2-3.
10. Tian, Y., Liu, W., Wang, J-Z., et al. Effects of circumcision on
male sexual functions: a systematic review and meta-analysis. Asian J
Androl. 2013:1-5.
11. Wamai, R.G., Morris, B.J., Waskett, J.H. et al. Criticisms of
African trials fail to withstand scrutiny: Male circumcision does prevent
HIV infection. J Law Med. 2012;20(1):93-123.
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.
The paper by Hooper & Spicer and some of the responses to it raise an important debate about the hazards of safety legislation. It is wrong to assume that safety legislation will cause no harm and in line with principles of medical ethics public health professionals are obliged to take such harm into account.
The first level of harm may arise when the legislation actually mandates an unsafe act because all the consequences of...
The paper by Hooper & Spicer and some of the responses to it raise an important debate about the hazards of safety legislation. It is wrong to assume that safety legislation will cause no harm and in line with principles of medical ethics public health professionals are obliged to take such harm into account.
The first level of harm may arise when the legislation actually mandates an unsafe act because all the consequences of the act have not been taken into account. Although it is self evidently true that cycle helmets have a protective function in certain accidents the benefit that would be expected from the physics of the situation has not been demonstrated in population studies. What is offsetting it? Is it an increased risk of neck injuries? Is it that car drivers drive closer to cyclists who look less vulnerable? We need to know this before legislation could be regarded as ethical.
The second level of harm may arise when the legislation creates a false sense of security resulting in risk compensation. Cycle helmets do not offer anything like the degree of protection that is sometimes assumed so this is a serious potential problem. It is unethical to mislead.
The third level of harm may arise when people act in a dangerous or unhealthy way in response to legislation. This is an issue with cycle helmets because the evidence shows that the introduction of legislation will lead to a fall in cycling rates resulting in deaths from diabetes, heart disease, osteoporosis and mental illness. Excessive rail safety requirements can have the effect of reducing rail travel and substituting less safe road travel. For young men, who are safer cycling than driving, this issue arises with cycle helmets as well. It is unethical to create a situation which leads people to harmn themselves.
The fourth level of harm arises when we lose a sense of proportion in safety legislation so that people lose the capacity to weigh risks. In the Paddington rail disaster a large number of people were killed in a head on collision between two trains one of which had passed a signal at danger. This signal was badly sited and had been passed at danger a number of times previously but nothing was done. Nobody had convened a meeting of the Signal Sighting Committee. At this time the rail network was engaged in a major campaign to reduce deaths to zero and as part of this was developing safety cases about risks like passengers falling off the edge of station platforms. THSG asks a simple question - in the course of this process did the system lose sight of what is important, lose the capacity to prioritise and as a consequence of that neglect a major risk. The case for cycle helmets is weaker than the case for helmets when playing football and on a par with the case for helmets when driving. The added risks of cycling rather than driving on a local journey for a middle aged adult are comparable to the added risks of taking the car instead of the train or driving on an all purpose road instead of a motorway. If society attempts legislative control of risks of this order it will fail, and in doing so its failure will impact on much more significant issues as well. It is unethical to set up systems which will fail in such a way as to damage lifesaving activities.
The fifth level of harm comes when the legislation conveys a false message and as a result people make poor decisions. Cycling is a safe activity which benefits health. Yet the commonest reason given for not cycling is safety. If we compel cyclists to wear helmets we give out the message that it is on a par with riding a motorcycle or with working on a building site. It is unethical to mislead people into making harmful choices.
We must understand that safety legislation is not a free good. We can only handle so much of it and we must prioritise. We must reach out for a safe society, in which people who climb mountains use the right equipment, check the weather and tell people what route they are taking, not a risk averse society where people do not climb mountains. A morbid preoccupation with the dangers of normal safe activities limits lives and can kill people.
STEPHEN J. WATKINS
Chair, Transport and Health Study Group.
Conflict of Interest:
THSG has a policy of opposition to compulsory cycle helmets based on its understanding of the scientific evidence
The otherwise excellent paper by German law professors Merkel and Putze1 fails to sufficiently emphasize the prohibition against using Wisconsin v. Yoder (1972) to support physical injury to a child in the name of religion.
Then Chief Justice Burger wrote the majority opinion for the court and specifically exempted the case from application to physical harm. In his opinio...
The otherwise excellent paper by German law professors Merkel and Putze1 fails to sufficiently emphasize the prohibition against using Wisconsin v. Yoder (1972) to support physical injury to a child in the name of religion.
Then Chief Justice Burger wrote the majority opinion for the court and specifically exempted the case from application to physical harm. In his opinion, he wrote:
"This case, of course, is not one in which any harm to the physical or mental health of the child or to the public safety, peace, order, or welfare has been demonstrated or may be properly inferred."2
The court reaffirmed the earlier case of
Prince v. Massachusetts (1944) as the controlling case in situations in which a child is put at risk in the name of religion: 3
"To be sure, the power of the parent, even when linked to a free exercise claim, may be subject to limitation under Prince if it appears that parental decisions will jeopardize the health or safety of the child, or have a potential for significant social burdens."2
In the case of Prince v. Massachusetts, Justice Rutledge delivered the opinion of the court. The court said:
"The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death. People v. Pierson, 176 N.Y. 201, 68 N.E. 243. The catalogue need not be lengthened. It is sufficient to show what indeed appellant hardly disputes, that the state has a wide range of power for limiting parental freedom and authority in things affecting the child's welfare, and that this includes, to some extent, matters of conscience and religious conviction."4
The court then famously stated:
"Other harmful possibilities could be stated, of emotional excitement and psychological or physical injury. Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves."4
Therefore, the free exercise clause of the First Amendment to the United States Constitution cannot be used to support putting a child at risk in the name of religion.
Free exercise of religion is not only an adult right. Children also have a right to freely exercise their religious views when they reach "the age of reason."3 With particular application to the physical injury of circumcision, the child may make that decision for himself when he reaches the age of legal capacity, however neither the free exercise clause nor Yoder offers any support whatsoever for any alleged parental "right to circumcise."
References
Merkel R, Putze H. After Cologne: male circumcision and the law. Parental right, religious liberty or criminal assault? J Med Ethics Published Online First 22 May 2013. doi: 10:1136/medethics-2012-11284.
Wisconsin v. Yoder, 406 U.S. 205 (1972).
Adler PW. Is circumcision legal. 16 Rich. J.L. & Pub. Int. 2013;16: 439. Available at http://rjolpi.richmond.edu/archive/Adler_Formatted.pdf Accessed 9 June 2013.
"If circumcision is a net benefit to a child, parents do not violate his rights to bodily integrity or self-determination by circumcising him. Careful attention to (the evidence for) the costs and benefits of circumcision to the child himself is thus essential."1
The evidence of injury to the child's sexual func...
"If circumcision is a net benefit to a child, parents do not violate his rights to bodily integrity or self-determination by circumcising him. Careful attention to (the evidence for) the costs and benefits of circumcision to the child himself is thus essential."1
The evidence of injury to the child's sexual function is now conclusive. Podnar has demonstrated the adverse effect of circumcision upon the penilo-cavernosus reflex.2 Furthermore, several international studies demonstrate the injury of male circumcision to the sexual relations of both male and female.3-5
Benetar relies on "three major studies" as evidence of the efficacy of male circumcision in reducing HIV infection; however, those studies have been sharply questioned and even debunked.6-8
Therefore, the evidence against circumcision is conclusive, while the alleged evidence for circumcision has collapsed.
By Benetar's own standards, circumcision is not a benefit, but instead is a malefit; thus the circumcision of male children is an unethical operation.
References
Benetar D. Evaluations of circumcision should be circumscribed by the evidence. J Med Eth. 2013; published online first 31 May 2013.
Podnar S. Clinical elicitation of the penilo-cavernosus reflex in circumcised men.BJU Int. 2011;209:582-5. doi:10.1111/j.1464-410X.2011.10364.x
Solinis I, Yiannaki A. Does circumcision improve couple's sex life? J Mens Health Gend. 2007;4(3):361.
Frisch M, Lindholm, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol. 2011;40(5):1367-81.
Bronselaer GA, Schober JM, Meyer-Bahlburg HFL, et al. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. 2013;111(5):820-27. doi:10.1111/j.1464-410X.2012.11761.x
Van Howe, Storms MS. How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa 2011; 2:e4 doi:10.4081/jphia.2011.e4
Ncayiyana DJ. The illusive promise of circumcision to prevent female-to-male HIV infection - not the way to go for South Africa. SAMJ 2011;101(11):775-6.
Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med (Melbourne) 2011;19:316-34.
We read with great interest Daoust and Racine's contribution to the
ongoing debate about brain death and its ethical and medical implications
[1]. The authors argue that little is known about how the public
understands the concept of death determined by neurological criteria
(DNC). They set out to trace common sources of public confusion about DNC
and seek to "better define the relationship between expert and lay views...
We read with great interest Daoust and Racine's contribution to the
ongoing debate about brain death and its ethical and medical implications
[1]. The authors argue that little is known about how the public
understands the concept of death determined by neurological criteria
(DNC). They set out to trace common sources of public confusion about DNC
and seek to "better define the relationship between expert and lay views
of death". We wish to comment on the issue of whether or not public
confusion "reflects public confusion in the media or perhaps a more
profound insight into the nature of academic debates among experts".
Although the authors recognize that "recent critiques have made any clear
meaning of DNC more challenging and even counterintuitive", they position
themselves, with no further explanation, on one side of the debate by
stating that "landmark contributions and guidelines of professional
societies have brought clarity and credence to the standard definition of
DNC". With that, they imply that current determination of death and organ
transplantation practices are rigorous and that media coverage distorts
the actual process of declaring a person dead based on neurological
criteria.
The two premises-- that the standard of DNC has clarity and credence
and that producing a clear meaning of DNC is both challenging and
counterintuitive-- are logically irreconcilable. The authors,
nevertheless, conclude that all discussions in the media and with patient-
families should "reinforce the genuine nature of neurological
determination of death as a criterion to establish death...". Either (a)
the philosophical rationale proposed in the President's Council on
Bioethics "White Paper" [2] seeking to validate the concept of DNC, and
the criteria and tests for determining DNC outlined in the guidelines by
professional societies, definitively settled the issue, or (b) the critics
have been raising legitimate concerns and have successfully challenged the
validity of this concept. Regarding the President's Council of Bioethics'
philosophical validation of DNC, the debate is ongoing and indeed has
intensified [3-5]. In regard to professional societies' guidelines, the
American Academy of Neurology has assigned level "U" (i.e., unknown,
conflicting or insufficient evidence) to several recommendations in the
DNC [6]. Generally, for clinical practice guidelines to be trustworthy,
the Institute of Medicine requires the recommendations to be supported by
a much higher level of evidence than "U" [7].
The authors also mention that some articles refer to the brain-dead
patient as being "kept alive" by artificial methods rather than as being
dead. Yet this brings out the fact that it is odd to declare an individual
with functioning circulation and respiration (in the sense of cellular
exchange of oxygen and carbon dioxide-- ventilator-dependence is
irrelevant to the issue of whether a person is alive or dead) dead as is
done in brain-dead patients. Even though the authors ostensibly
acknowledge the academic debate about the validity of brain-death
criteria, de facto they ignore it, claiming (though not arguing) that both
discussions between the patient's family (note the use of the word
"patient," which does not make sense if the patient is dead) and
information shared with the general public should reflect the view that
brain death criteria are "genuine". Therefore, Daoust and Racine's
recommendation to reinforce the genuine nature of neurological
determination of death is not only premature but, if followed through,
would deprive the public of informed decision making about organ donation
following DNC. More importantly, merely repeating the claim that brain-
death criteria are "genuine" does not make them so.
Maintaining the professional integrity of medicine and public trust
is a responsibility shared by the global medical community. This
responsibility demands honesty, truthfulness and transparency with the
general public regarding healthcare issues (e.g., organ donation at the
end of life). Daoust and Racine report that critics of DNC have argued
that DNC "merely represents a convenient 'redefinition' of death solely
for the purpose of transplant medicine." Many in the medical community
would agree with the critics. After several decades, the cumulative
clinical experience with many kinds of brain-dead patients over decades,
combined with logic has disproved the neurologic criterion of death.
Persistent denial of caveats that donors are not certainly dead may be
leading to grievously unethical medical practice namely: (1) the lack of
truly informed consent in the donation process, (2) the strategic campaign
of rhetoric, partial information, and misinformation designed to induce
people to check the donor box on drivers licenses and to induce families
to authorize donation from a "brain-dead" loved one, (3) the nondisclosure
of financial conflict of interest on the part of organ procurement
representatives whose job is to convince grieving families to donate.
The media have been fulfilling their primary duties of disclosing to
the general public scientific, ethical and cultural controversies about
neurologic criteria [8,9]. The conclusion of Daoust and Racine that
"public discussions should reinforce the genuine nature of neurological
determination of death as a criterion to establish death" and "scholarly
debates need to be contextualized to avoid undue collateral damage to
public confidence in DNC and organ donation practices" can also be
construed as a call for censorship of media and suppression of scholarly
debates. Costas-Lombardia and Castiel have criticized the control of
information in Spain by the transplantation industry: "disinformation of
society is an indispensable condition for the success of the 'Spanish
Model'" [10]. Organ procurement and transplantation practice generate
billions of dollars in a commodified US health care system annually [11].
The call for control of media and scholarly debates to avoid collateral
damage to organ transplantation practice may indeed violate public trust
in the medical profession and the First Amendment of the United States
Constitution.
Michael Potts, Ph.D., Department of Philosophy, Methodist University,
Fayetteville, North Carolina, USA
Joseph L. Verheijde, PhD, MBA, PT, Department Physical Medicine and
Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA
David W. Evans, MA, MD, FRCP, Queens' College, Cambridge, UK
Mohamed Y. Rady, MB BChir MA MD (Cantab), Department of Critical Care
Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
D. Alan Shewmon, MD Olive View-UCLA Medical Center, Sylmar, CA, USA
References
1. Daoust A, Racine E. Depictions of 'brain death' in the media:
medical and ethical implications. J Med Ethics.2013:Published Online
First: 12 April 2013 doi:2010.1136/medethics-2012-101260
2. The President's Council on Bioethics. Controversies in the
determination of death. A White Paper of the President's Council on
Bioethics. 2008; http://bioethics.georgetown.edu/pcbe/reports/death/.
Accessed 10 April 2013.
3. Shewmon A. Brain Death: Can It Be Resuscitated? Hastings Cent
Rep.2009; 39(2):18-23.
4. Joffe AR. Brain death is not death: a critique of the concept,
criterion, and tests of brain death. Rev. Neurosci.2009; 20(3-4):187-198.
5. Nair-Collins M. "Brain Death, Paternalism, and the Language of
"Death"." Kennedy Inst Ethics J.2013; 23(1):53-104.
6. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM. Evidence-based
guideline update: Determining brain death in adults: Report of the Quality
Standards Subcommittee of the American Academy of Neurology.
Neurology.2010; 74(23):1911-1918.
7. Institute of Medicine (IOM) -National Academy of Sciences.
Clinical Practice Guidelines We Can Trust. 2011;
http://www.nap.edu/openbook.php?record_id=13058. Accessed 10 April, 2013.
8. Rady MY, McGregor JL, Verheijde JL. Mass media campaigns and organ
donation: managing conflicting messages and interests. Med Health Care
Philos.2012; 15(2 ):229-241.
9. Rady M, McGregor J, Verheijde J. Transparency and accountability
in mass media campaigns about organ donation: a response to Morgan and
Feeley. Med Health Care Philos.2013:Published online: 25 January 2013. DOI
2010.1007/s11019-11013-19466-11014.
10. Costas-Lombardia E, Fereres Castiel J. The Easy Success of the
Spanish Model for Organ Transplantation. Artif Organs.2011; 35(9):835-837.
11. Bentley TS, Hanson SG, Hauboldt RH. Milliman Research Report.
2011 U.S. organ and tissue transplant cost estimates and discussion. 2012;
http://publications.milliman.com/research/health-rr/pdfs/2011-us-organ-
tissue.pdf. Accessed April 1, 2013.
We would like to thank Professor Stewart Justman for his thoughtful
paper "Placebo: the lie that comes true", in which he highlights the
often neglected deception in research on placebos and points out the
potential harms related to half-truths or exaggerated claims about the
"power of the placebo" (1). We agree strongly with his conclusion that "it
is necessary to root the placebo effect in the attentive practice of
me...
We would like to thank Professor Stewart Justman for his thoughtful
paper "Placebo: the lie that comes true", in which he highlights the
often neglected deception in research on placebos and points out the
potential harms related to half-truths or exaggerated claims about the
"power of the placebo" (1). We agree strongly with his conclusion that "it
is necessary to root the placebo effect in the attentive practice of
medicine itself". We also agree with his other conclusion that the
"appropriate response to this dilemma is first of all to consider the
placebo effect as a therapeutic benefit arising from the conscientious
performance of the rituals of good medicine, and not as a resource to be
tapped by the use of trickery (with equivocations counting as trickery) or
dispensed in the form of pills."
As Justman also remarks, much of the confusion related to placebos
and placebo effects is related to the ambiguous nature and many
understandings of these concepts. We'd like to develop this point further
and repeat our earlier suggestion to replace the ambiguous "placebo
effect" with a new term "care effect" in the clinical context (2). In the
research context, the term "placebo effect" could be replaced by the
expression "the effect in the control group" when the outcome of the
research is discussed. The equivocal concept "impure placebo" confuses
more than it clarifies and should be abandoned totally. If a method of
treatment is ineffective in its own right, it should be called an
ineffective treatment for a particular patient or problem.
References:
1. Justman S. Placebo: the lie that comes true. J Med Ethics 2013;39:243-
248.
2. Louhiala P, Puustinen R. Rethinking the placebo effect. J Med Ethics;
Medical Humanities 2008;34:107-109.
Authors:
Pekka Louhiala, Hjelt Institute, University of Helsinki, Finland,
pekka.louhiala@helsinki.fi
Raimo Puustinen, Medical School, University of Tampere, Finland,
raimo.puustinen@uta.fi
For full disclosure, I should begin by saying that I read this paper because I am personally acquainted with one of the authors, Johann Roduit, with whom I had a brief exchange about the paper and who encouraged me to submit my few critical thoughts to this site. Also, I should say that I am not an expert in bioethics, but simply an interested layman.
As a layman, I read the paper with pleasure. The thoughts were clearl...
For full disclosure, I should begin by saying that I read this paper because I am personally acquainted with one of the authors, Johann Roduit, with whom I had a brief exchange about the paper and who encouraged me to submit my few critical thoughts to this site. Also, I should say that I am not an expert in bioethics, but simply an interested layman.
As a layman, I read the paper with pleasure. The thoughts were clearly articulated, and I learned something about the current debate within this particular field of ethics. The paper does a good job at laying out the respective positions of bioconservatives and bioliberals and pointing out "the crucial question of the ultimate goals of biotechnological interventions."
In our exchange about the paper, Mr. Roduit told me that his main criticism is directed against people who "refuse to speak of an ideal at all," although they "cannot avoid having an ideal influencing the way they wish to enhance." This point is well taken, but in my view, the paper goes too far in charging bioconservatives with an "untenable ambiguity between criticising and endorsing ideas of human perfection" (p. 1). I am also inclined to think that the paper goes too far in charging bioliberals with an "unconvincing" denial of the relevance of perfection, but here I will restrict my comments on the criticism of bioconservatives.
Of course, the authors of the paper are right that anyone who makes any kind of proposition in regard to human behavior has some kind of ideal in mind. Otherwise the person would not make a proposition at all. People who say that everyone should do as they please have the ideal of individual autonomy in mind. People who say that human perfectibility is not desirable thereby say that another human state is more desirable and hence, in a certain sense, more perfect.
But this observation, as true as it is, seems to me little more than a tautology. It says little more than, "People who make a normative statement, no matter of what kind, have a certain norm in mind." Naturally. But does that merit the charge that certain bioconservatives have an "untenable ambiguity" in regard to human perfectibility? I doubt it.
To make clearer why I doubt the merit of this charge, let me use a few examples from other fields. Take political philosophy, for instance. According to the thinking of the paper, one may charge Machiavelli's realpolitik with the same kind of "untenable ambiguity" as the authors charge bioconservatives, because Machiavelli makes the prescriptive (=idealistic) statement that a ruler should not be too idealistic but rather use whatever methods work to maintain order and keep society running in a reasonably safe state. One could then take the criticism of Machiavelli's ambiguity further and claim that his Prince is really just as idealistic as Plato's Philosopher-King, because he makes just as many normative statements about him as Plato does about his explicitly ideal ruler. Therefore, one might say, Machiavelli should bring his implicit idealism into the light of explicit discussion instead of pretending that he is abandoning the political idealism of the likes of Plato.
However, to my mind, such a charge is more sophistic than helpful and blurs the very important distinction between the idealism of Plato's Philosopher-King and the realpolitik of Machiavelli's Prince. Plato is clearly an idealist, and Machiavelli is clearly a realist, and making normative statements about being flexibly realistic does not turn him into an idealist.
To give another example, this time from the earliest literature we possess, which already deals with the big themes of the human condition and the ideal human life, let us take the Epic of Gilgamesh. Gilgamesh, an ancient king of Uruk (modern-day Iraq), loses his best friend and realizes that he, too, shall one day die. Hence, he goes on a quest to find immortality, but in vain. Not only does he learn that immortality is reserved for the one couple that survived the Great Flood in a boat, because it was a unique situation that led the gods to bestow immortality on them, but the rejuvenating Plant of Life is also stolen from Gilgamesh by a serpent. Gilgamesh therefore has to accept his mortality, and he proceeds to engage in great building projects in order to make a lasting name for himself in that way.
The Epic of Gilgamesh seems to make the point that, in order for a human to flourish, he or she needs to accept their mortality. In other words, the story can be said to set up a kind of ideal of what the good life is, but at the same time the story conveys the strong message that the good human life is far from perfect. "Ideal under the very imperfect circumstances" is not the same as perfection.
To give third and last example, the Greeks were instructed to "know thyself," that is, to know the limits of the human condition, and this self-knowledge can be said to have been an ideal. But the ideal consisted precisely in the acknowledgment that, under the circumstances, humans are not and can never be perfect.
In my view, it would be confusing to say that recognizing the existence of imperfection as a precondition for many good things is to erect another standard of perfection, as the paper seems to charge certain bioconservatives with doing. It is not another standard of perfection but simply the recognition that certain good things hinge on the existence of imperfection.
That's the two cents from a layman for now, written with much ignorance about the details of today's bioethical debate.
For clarity's sake, however, I would like to point out in reply that
I do not cite Ahsan to 'legitimize' any claim. Rather I present it as
legal authority for a claim about legal principle. The principle is clear,
though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies
to patients...
For clarity's sake, however, I would like to point out in reply that
I do not cite Ahsan to 'legitimize' any claim. Rather I present it as
legal authority for a claim about legal principle. The principle is clear,
though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies
to patients individually, and thus necessarily varies from patient to
patient. I do not for a moment consider that best interests supports the
measures discussed in the paper for all patients; rather I suggest that it
does so in some cases.
The respondents to my paper seem to suggest that a preponderance of
relgious opinion renders my interpretation of the law impossible.
Their argument rests on a fundamental failure to appreciate that the
law respects a plurality of distinct values. Many systems of beliefs are
respected.
It would not be true that it would be in everyone's best interests,
as that idea is understood in English law, to become organ donors. But it
is wrong to suggest that this means that it can be in no-one's best
interests.
In a recent article by Walter Sinnott-Armstrong and Franklin G.
Miller, the argument is made that ability should be the metric of value
among human life and thus the determining factor on what constitutes moral
harm when killing. Someone who has permanently lost all abilities no
longer has value and killing them would not only fail to add more harm and
it would also fail to take away any more value.
In a recent article by Walter Sinnott-Armstrong and Franklin G.
Miller, the argument is made that ability should be the metric of value
among human life and thus the determining factor on what constitutes moral
harm when killing. Someone who has permanently lost all abilities no
longer has value and killing them would not only fail to add more harm and
it would also fail to take away any more value.
In the authors' case, to say that "Betty is not worse of dead" is to
presume knowledge about death. It's taken for granted what the authors
believe about death is true: a descent into non-existence and nothingness.
However, we cannot say whether it is better to become nothing than to be
conscious and totally and irreversibly disabled mainly because we have
experienced neither, and we have no ability to comprehend what it would be
like to "be nothing" (a contradictory phrase, but one that captures the
farce in making the claim that someone is "not worse off dead" if one
presupposes nothing after death). I certainly don't believe that we
descend into nothingness when we die, and indeed the things that happen
after we die could be much worse than our present life, but I'm only using
the authors' own views to determine that they aren't justified to say that
Betty is not worse off dead; even if she were, it would be a matter of
personal preference toward either nothingness or total and irreversible
disability.
Furthermore, the authors divorce morality from truth when they say
"one advantage of this position is that it simplifies the structure of
morality." Either that which is most simple is always true, or else
morality and truth have no relationship and we pursue that which is most
useful to us, regardless of its veracity. Why should simplicity win on the
merit of simplicity alone? The authors identify the simplification of
morality as an advantage of this perspective, regardless of whether that
simplification is born out of truth: is it actually true that it is wrong
to kill a universally and irreversibly disabled person? The truth, it
seems, doesn't matter as much as the simplicity of the moral system.
The authors also assume that it is worse to cause a person to be deaf
and blind rather than only blind. However, this begs the question, for
this is only worse in their system of morality in which abilities are the
metric of value. In that system, it makes sense that it is worse to
deprive a person of two abilities rather than one. However, in other
systems, depriving a person of any abilities ("without adequate reason")
reaches maximum heinousness and to add increasing quantities of ability
deprivation to that doesn't make it any more wrong, but only more tragic.
The authors' example here, then, isn't helpful to them because it assumes
the system of value they're trying to establish.
The rebuttal to the objection regarding God's commandment is
superficial. First, it assumes that the strength of God's commandment is
in the reason that justifies his commandment and not the command itself.
This is not evidenced throughout Judeo-Christian theology, the theology
that I would be prepared to assert and defend; instead, God should be
obeyed because he is God. This is why Lot's wife was turned into a pillar
of salt: because she disobeyed God. It doesn't matter what God's reasons
were for commanding her not to look back on the destruction of Sodom and
Gomorrah. What matters is that he commanded it at all and his commands are
self-justifying because he is God. This leads us into a discussion
regarding the sovereignty of God and epistemology, which isn't the main
topic at hand, but suffice it to say that the authors dismiss this
objection without actually rebutting it.
The authors go on to further establish, in their rebuttal of the
anticipated objection by secular theorists, how they are begging the
question in their argument. The main question of their paper may be, "Why
is life valuable in this extreme case when it includes no ability?"
They're trying to show in their argument that killing people in this state
is not wrong because lack of ability constitutes total loss of value. To
dismiss this objection by assuming that the metric of value is ability is
to beg the question in the rebuttal.
They reduce moral theory to a matter of preference when they write,
"these arguments will have no force at all for those of us who prefer our
moral theories to be independent of religion." Therefore, it doesn't
matter what is actually true; what matters is what one prefers. They
further support this idea by stating that it is problematic to depend on
religious belief in philosophical theory as well as public policy. They
imply that what is good is an agreeable solution for all, even if that
means that the agreeable solution isn't what's actually true. Is this
right or even good? Unfortunately that small question alone is irrelevant
to those who do not care about what's right but instead only what serves
their preferences! Thus this discussion cannot even begin until we deal
with moral relativism, a discussion unto itself.
They go on to nearly refute their entire argument when addressing
concerns regarding whether using ability as the metric of value would lead
to the assignment of variable values to humans with non-zero quantities of
ability.
For their first response regarding possession of abilities greater
than plants, why would that be the case? Why plants in particular? If one
is going to hold the "minimal ability threshold" stance, does that mean a
human with, say, one ability is equivalent to a chimpanzee with one
ability? Indeed, under this view, why aren't chimpanzees and humans
equivalent, or any non-plant life? The authors fail to flesh out this
rebuttal to make it consistent with the rest of their argument.
Furthermore, they establish earlier in their argument that if it is wrong
to remove one ability, it is more wrong to remove two, and maximally wrong
(indeed, equivalent to murder) to totally and irreversibly disable
someone. Their argument cannot be paired with this objection because this
objection assumes that abilities do not have individual value but only the
trait of "ability possession" (in which a person may only possess one
ability) is what actually grants value.
Their second response (that it would be morally wrong to treat people
differently based on their different abilities) does a good job of
overturning the argument for which the paper was written. Are we not
treating the totally and irreversibly disabled person differently based on
their lack of ability? Yet the authors argue that one could rebut the
aforementioned objections by declaring that it's wrong to do just that.
The third response is antiquated: quality- and disability-adjusted
life years (QALYs and DALYs) are already used to compare people with
different disabilities and sets of abilities. This is not a perfect
system, but it's what's being used for any number of purposes now. If one
is going to respond in this way, one would have to make the point of doing
away with QALYs and DALYs.
The fourth response is essentially what the authors are doing in this
paper. They're insisting that ability should be the metric of value, yet
they haven't established why that should be the case and they've done a
poor job of dealing with the anticipated objections. Indeed, if ability is
the metric of value, then a myriad of questions are raised that the
authors don't address: for someone who is reversibly disabled, how many
abilities must they recover to gain value again and thus pull themselves
from the chopping block? What if they can follow simple commands? Write
their name? Speak? Maintain urinary and bowel continence? Do abilities
differ in value, as this would become a real concern in determining
whether to harvest someone's organs? If not, would it be accurate to say
all who are disabled at all are equally disabled?
The fifth and final response is essentially selling the agenda;
somehow get people to believe that what is wrong isn't that wrong, or what
is wrong is actually good. When variable value is assigned to humans, such
that some are worth less than others, that is the stuff out of which
tyrannies, discrimination, eugenics and persecution are made. It is not
hyperbole to indicate this because that is precisely the philosophy of
historical figures like Adolf Hitler: some people were worth more than
others during the Third Reich and some people were worth so little and so
detrimental to society that they were better off exterminated. This, of
course, is the extreme conclusion of the authors' argument, but the
authors' argument sets the precedent for it; it paves the way for other
arguments to march, one step at a time, toward that conclusion.
In stating that it is bad to shorten life and thus worse to shorten
it more in killing younger or healthier individuals, the authors assume
that quantity is what gives life value; in this particular point, not just
quantity of abilities, but quantity of years left to live. They neglect
the possibility that life, regardless of the quantity remaining, maintains
maximum value until death. An analogy would be currency: whether you have
$1000 or $1, a dollar is still worth a dollar (putting aside inflation and
other economic confounders). Thus, as you spend your money, your money
doesn't lose value. By the time you're down to your last dollar, it's not
worth $0.10 or some other amount; it's still worth a dollar. The
subjective value of that dollar to its owner may be greater (it becomes
more precious to its owner because the owner does not have the other
$999), but the objective worth of it is still one. If anything, as life
shortens, it becomes more precious (particularly for the atheist, who
believes that this is all we get!), so it may be more wrong kill people
with less time left to live.
In discussing violations of the dead donor rule, the authors miss the
mark in clearly establishing what death is. Brain death is merely a
surrogate marker for determining death proper. What we actually care about
is whether the organism itself, the person, is dead. We use brain death as
a marker for the organism's inability to maintain cohesion of its various
systems to the benefit of itself. According to Maureen Condic, a
neurobiologist at the Universty of Utah, when an organism can no longer
"act in a coordinated manner for the continued health and maintenance of
the body as a whole," it's considered dead (Condic, M. Life: Defining the
Beginning by the End. First Things. 2003). This appears to be the most
intuitive, holistic definition of death. The reason why we look for brain
death is because we care whether we're using machines to artificially
prolong the survival of an organism that can no longer perform this
fundamental function; it is not strictly to determine whether higher-order
brain function is lost. Thus Condic explains:
"It is often asserted that the relevant feature of brain death is not
the loss of integrated bodily function, but rather the loss of higher-
order brain activities, including consciousness. However, this view does
not reflect the current legal understanding of death. The inadequacy of
equating death with the loss of cognitive function can be seen by
considering the difference between brain death and "persistent vegetative
state" or irreversible coma. Individuals who have entered a persistent
vegetative state due to injury or disease have lost all higher brain
functions and are incapable of consciousness. Nonetheless, integrated
bodily function is maintained in these patients due to the continued
activity of lower-order brain centers. Although such patients are clearly
in a lamentable medical state, they are also clearly alive; converting
such patients into corpses requires some form of euthanasia."
Therefore if one is brain dead, one is properly dead because brain
death is a marker for the organism's permanent inability to coordinate the
maintenance of all its various sub-systems into a cohesive whole. The
authors' ignore the implication that brain death is being used as a
surrogate marker for the death of the organism in light of the fact that
we can use machines to keep the cellular processes of the organism going
without the organism ever being able to recover its coordinated manner by
which it sustains its life. To procure organs from these individuals is
not a violation of the dead donor rule; they're dead.
They raise a second example in which they believe the dead donor rule
is violated, yet they fail to point out that the decision has been made to
not resuscitate these individuals, just like anyone else with a "do not
attempt resuscitation" order in their chart. Obviously it's
philosophically inconsistent if a patient goes through vital organ
donation but has an advanced directive still in place to attempt
resuscitation. Irreversibility isn't included in the legal definition of
death because plenty of people who die could be resuscitated but are not
because of their advanced directive, yet we still declare them dead when
they enter into that state because we will not prevent them from naturally
progressing to the point at which their body loses the capacity to
maintain cohesion amongst its sub-systems.
Interestingly, Dr. Miller co-authored a paper in the New England
Journal of Medicine on the topic of the dead donor rule, and a point was
made that seems to stand contrary to the central argument of the article
in question (Truog and Miller. The Dead Donor Rule and Organ
Transplantation. 2008. NEJM):
"At the dawn of organ transplantation, the dead donor rule was
accepted as an ethical premise that did not require reflection or
justification, presumably because it appeared to be necessary as a
safeguard against the unethical removal of vital organs from vulnerable
patients. In retrospect, however, it appears that reliance on the dead
donor rule has greater potential to undermine trust in the transplantation
enterprise than to preserve it. At worst, this ongoing reliance suggests
that the medical profession has been gerrymandering the definition of
death to carefully conform with conditions that are most favorable for
transplantation. At best, the rule has provided misleading ethical cover
that cannot withstand careful scrutiny. A better approach to procuring
vital organs while protecting vulnerable patients against abuse would be
to emphasize the importance of obtaining valid informed consent for organ
donation from patients or surrogates before the withdrawal of life-
sustaining treatment in situations of devastating and irreversible
neurologic injury."
The question, it seems, is irrelevant as long as strict adherence to
informed consent and the advanced directive of the patient (if present) is
upheld. Those are our guiding principles in choosing to withdraw
aggressive care, whether it be from the patient with multi-organ failure
in the intensive care unit or the patient with metastatic cancer in the
outpatient setting who just wants to live his last two weeks free from the
burden of chemotherapy and other aggressive interventions. The valid
concern is that organs would begin to be harvested from people who have
reasonable chances of survival or are not even in imminent danger of
death. Yet we seem to navigate this labyrinth fairly well when patients or
their families request a cessation of aggressive care apart from concerns
of organ transplantation; the additional piece that must be added to it in
matters of transplantation is the avoidance of euthanasia and physician-
assisted suicide, the ethics of which will not be discussed here, but for
the sake of this discussion I take for granted as wrong. I suspect it
would be very difficult to determine a general rule that could apply to
all cases, but that each patient must be approached individually.
Interestingly, Dr. Truog and Dr. Miller identify that, at worst,
"this ongoing reliance [on the dead donor rule] suggests that the medical
profession has been gerrymandering the definition of death to carefully
conform with conditions that are most favorable for transplantation." It
seems that is exactly what is being done in this paper Dr. Sinnott-
Armstrong and Dr. Miller have submitted to the Journal of Medical Ethics
and the applications reach beyond the field of transplantation. The
authors are trying to figure a way to broaden the population that would be
available to donate their organs. With the precedent set, each following
step becomes easier to take and before long we really are harvesting
organs from people who are in no imminent danger of death. Indeed, the
reductio ad absurdum would be the harvesting of organs from individuals
who are disabled in some capacity and do not even want their organs
harvested. The authors attempt to stave off this objection by stating, "We
can hold the line for vital organ donation by continuing to restrict it to
those in a state of total (universal and irreversible) disability. It is
only these donors who would not be harmed or wronged by vital organ
donation, since all other donors have abilities to lose." Yet they are not
holding the current line (i.e., the dead donor rule). So the line is moved
this time and, perhaps even after the authors themselves are dead, still
others will desire to move the line and will make arguments in favor of
it. And another argument will be made to move the line further. This is
the power of precedent setting. Why should we trust those who move the
line to hold the line?
"What makes killing wrong" is a transparent attempt to do what Dr.
Miller denounces in his paper in the New England Journal of Medicine:
"gerrymander the definition of death," or in this case, gerrymander those
circumstances about which one might be declared suitable for
transplantation. The scope of this argument extends beyond organ
transplantation, however, and into the broader world of medicine. If
adopted, this view would color for the worse how we perceive the weak, the
sick, the aged and the unborn.
Case against circumcision overstated.
In his eLetter George Hill asserts, of circumcision, that "The evidence of injury to the child's sexual function is now conclusive". However, this view is not supported by the literature he cites. He tells us that Podnar found that the penilo-cavernosus reflex is harder to elicit in circumcised men (or those with their foreskins retracted)1. So it is harder to elicit a co...
By Stephen Moreton Ph.D.
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...
Dear Editor:
The otherwise excellent paper by German law professors Merkel and Putze1 fails to sufficiently emphasize the prohibition against using Wisconsin v. Yoder (1972) to support physical injury to a child in the name of religion.
Then Chief Justice Burger wrote the majority opinion for the court and specifically exempted the case from application to physical harm. In his opinio...
Dear Editor:
Benetar argues:
The evidence of injury to the child's sexual func...
We read with great interest Daoust and Racine's contribution to the ongoing debate about brain death and its ethical and medical implications [1]. The authors argue that little is known about how the public understands the concept of death determined by neurological criteria (DNC). They set out to trace common sources of public confusion about DNC and seek to "better define the relationship between expert and lay views...
We would like to thank Professor Stewart Justman for his thoughtful paper "Placebo: the lie that comes true", in which he highlights the often neglected deception in research on placebos and points out the potential harms related to half-truths or exaggerated claims about the "power of the placebo" (1). We agree strongly with his conclusion that "it is necessary to root the placebo effect in the attentive practice of me...
As a layman, I read the paper with pleasure. The thoughts were clearl...
I am grateful for the response to my paper.
For clarity's sake, however, I would like to point out in reply that I do not cite Ahsan to 'legitimize' any claim. Rather I present it as legal authority for a claim about legal principle. The principle is clear, though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies to patients...
In a recent article by Walter Sinnott-Armstrong and Franklin G. Miller, the argument is made that ability should be the metric of value among human life and thus the determining factor on what constitutes moral harm when killing. Someone who has permanently lost all abilities no longer has value and killing them would not only fail to add more harm and it would also fail to take away any more value.
In the author...
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