We thank Dr. Post for his response to our brief report, "Conflict of
interest in online point-of-care clinical support websites" (J Med Ethics
doi:10.1136/medethics-2013- 101625). We additionally commend UpToDate for
many of its policies that protect the integrity of the educational
material presented. In light of Dr. Post's comments, we recommend further
clarification in the UpToDate conflict of interest policy, particu...
We thank Dr. Post for his response to our brief report, "Conflict of
interest in online point-of-care clinical support websites" (J Med Ethics
doi:10.1136/medethics-2013- 101625). We additionally commend UpToDate for
many of its policies that protect the integrity of the educational
material presented. In light of Dr. Post's comments, we recommend further
clarification in the UpToDate conflict of interest policy, particularly in
regards to the role of the deputy editor versus the section editor.
As per the UpToDate conflict of interest policy "Deputy Editors may
not accept funds from "educational" arms of health industry organizations
(such as speaker's bureaus)." We commend this policy and believe as
mentioned in our article, that a supervising editor with no conflicts of
interest is necessary. In his response, Dr. Post describes the role of the
Deputy Editor as one that prevents "inappropriate material from being
published in UpToDate topic reviews." This is not, however, mentioned in
the UpToDate conflict of interest policy. We believe that this should be
added to the conflict of interest disclosure statement. Additionally, the
role of the section editor should be discussed. Otherwise, the shared
potential conflicts of the author and section editor may remain a concern
to the reader. Likewise, the review process described in Dr. Post's final
point should additionally be disclosed in the conflict of interest section
to improve transparency.
Even if such an accountable review process with multiple named
reviewers takes place, it is imperative that readers have such information
to support a critical evaluation of the material. This is a flaw in the
conflict of interest policy in Dynamed that both our report and Dr. Post's
response describe, preventing verification of potential documented and
undocumented conflicts. While minimizing the number of conflicts of
interest remains essential for unbiased scientific writing, this goal
depends on the clear disclosure of conflict-of-interest policies.
It does us all well to recognize that despite only a minority of
scientists engaging in dishonest means to achieve academic gains, their
disrepute will unfortunately taint the hard work of the honest majority.
The greater harm will be loss of faith in publicly funded research and the
waste of resources on non-credible work. Provided one evades detection,
contemporary academia's unbridled publish or perish imperative breed...
It does us all well to recognize that despite only a minority of
scientists engaging in dishonest means to achieve academic gains, their
disrepute will unfortunately taint the hard work of the honest majority.
The greater harm will be loss of faith in publicly funded research and the
waste of resources on non-credible work. Provided one evades detection,
contemporary academia's unbridled publish or perish imperative breeds and
rewards ethical lapses, leading to an irreparable breach of trust.
Deliberately misleading research could be unwittingly adopted into
daily life and even be incorporated as detrimental advances in medical
treatment, putting all of us at risk. The issue should be deemed to go
beyond research misconduct to the material risk of harming people. This
occurs by giving false hope, patients receiving non-beneficial treatment
and forgoing therapies that do work, and incurring unnecessary side-
effects. When standards are not adhered to, we depend on personal ethics
and morals to avoid research misconduct. It is high time that all
researchers were trained in ethical approaches to career advancement,
preferably in their formative years.
Science fetishes the published paper as the gold medal of prestige
and achievement, more so if it is headline grabbing, hosted in a top
journal and concentrates on a hot topic such as sex and race. The perverse
academic promotion and incentive system that view high-profile journals as
the pinnacle of success corrupt us by rewarding those who cut corners, or
worse, cheat for a shot at glory. The pressure to publish or perish has
become the sole currency of tenure, grants, prestige and promotion. The
scientific endeavour is dysfunctional with cheating in scientific papers
growing ever deeper roots. Recent headlines of misdemeanours suggest
exaggeration, fraud and manipulation to enhance academic standing and
competitive funding have only has gotten worse, or that we are better at
detecting problems that would have gone unnoticed in the past.
Falsified or erroneous results have forced authors and editors to
retract papers from journals whose peer reviewers have failed to detect
conclusion-altering biases and misrepresentations. In the same week that
gay marriage was legalised by popular vote in Ireland, Science retracted a
paper that purportedly showed gay political canvassers to be better at
influencing conservative voters' views on same-sex marriage. Diederik
Stapel's sensational findings that garbage-strewn train platforms made
racial prejudice worse made for great press. The hope that cleaning up our
environment could set free the better angel of our natures was dashed when
a whistle blower revealed the social psychology experiments to have never
taken place. Tilburg University defended him to the last, and Stapel
continues to defend his actions as being driven by "a quest for
aesthetics, for beauty-instead of the truth." Yoshiki Sasai, a senior
author of a 2014 Nature paper that claimed to have developed an easy
method to create multipurpose stem cells, was found hanging in his office
stairwell. Vaccination rates tumbled and a rash of measles cases followed
Andrew Wakefield's published contentions that thiomerisal vaccines could
lead to autism. Wakefield is now in jail and deregistered as a medical
practitioner. Authors submit fake peer reviews under assumed false
identities, often ones they themselves have written in praise of their own
work.
The dog-eat-dog competition to be published in prestigious journals,
weak oversight by supervisors or study monitors, the rush by journals to
publish ground-breaking press-worthy studies, cursory appraisal by
reviewers juggling the demands of their own wor, the secrecy and
unavailability of original data for inspection all lead to sloppy or even
unethical research. However, most researchers are honest to their calling,
despite the career and competitive gains that become their due from
disseminating their work in high profile journals. Of 2 million papers
published each year, only a single paper a day is withdrawn from journals
because of misconduct, ranging from plagiarism to fabrication of results.
If we accept that only 2% of researchers commit deliberate or false
misrepresentation, then 98% of the scientific research remains above
board. However, the rare occurrence of fraud taints the whole scientific
community, incurs loss of public trust on whom most funding depends,
embeds erroneous findings in health care (resulting in patient harm),
incurs the adoption of ineffective social policy and undermines future
research underpinned by false premises.
There are ways to minimise fraud, but it will require changing the
process, from how scientists share their data to how their peers review it
and who is allowed to enforce academic standards. Surveillance and
regulatory oversight, such as that provided by Retraction Watch and Office
of Research Integrity in the United States, police for fraud after it has
occurred. Although sanctions, official reprimand and even jail serve as
deterrents for potential offenders, could the problem be weeded out at an
earlier stage, when a study manuscript is appraised by peer reviewers for
suitability to be published? A journal's peer reviewers are supposed to
detect errors, but they often do not have the critical data needed to
check the findings, nor the time to do so, particularly since they are
seldom paid.
The scientific community clearly needs to build a better safety net,
more so in biomedical research involving human subjects. Institutional
review boards are only delegated to assess and approve a clinical trial
protocol for participant safety and methodological validity, with no remit
to monitor a researcher's adherence to safety standards during the conduct
of the study. Although misrepresentation of findings leading to biased,
exaggerated and fraudulent claims can be discerned by independent re-
evaluation of full outcome data that are made available after publication
of a clinical trial, this process does not protect a patient from harm and
coercion for the duration they are enrolled in a clinical trial.
I have previously advocated for the important role of data monitoring
and safety committees in conferring protection to participants and detect
fraud whilst the trial is in progress. With their in depth understanding
of the study objectives and protocol, as well as access to fully disclosed
results as they accumulate, these committees are well placed to gauge
breaches in safety mechanisms, coercive recruitment and fraudulent
behaviour from the start of a trial to its completion. Data monitoring
committees are independent and widely perceived to be extremely competent.
Using these committees to review and approve the completeness of outcomes
reported before publication would also enhance the trustworthiness and
credibility of clinical studies. The DAMOCLES Study Group recommends that
data monitoring committees "ensure that trial results are published in an
unbiased, correct and timely manner" and that the committee discusses
final data and their interpretation with study investigators. The ability
to monitor for errors, whether deliberate or not, while the study is being
conducted improves the validity and credibility of submitted manuscripts,
eliminates the need for resource intensive post-publication re-evaluation,
and averts disseminating erroneous studies to journal audiences in the
first place.
Given what we know and don't know about the processes from which the
'safe limits' for alcohol consumption in general are derived, would the
author not agree that his criticism applies more generally in this area?
On a somewhat pedantic note it's not establishing a negative correlation
that's difficult, it's establishing a lack of correlation. Absence of
evidence is not evidence of absence.
To the Editor:
The threat posed by human "population explosion" goes beyond that capable
of being supported by the earth's diminishing food and natural resources.
The long standing but recently dormant debate on the sustainability of
population growth is an integral topic that complements recent media focus
on global warming and catastrophic weather events. There needs to be
balanced discussion on the societal and health...
To the Editor:
The threat posed by human "population explosion" goes beyond that capable
of being supported by the earth's diminishing food and natural resources.
The long standing but recently dormant debate on the sustainability of
population growth is an integral topic that complements recent media focus
on global warming and catastrophic weather events. There needs to be
balanced discussion on the societal and health impact of overcrowding,
water and food depletion as well as heightened risk of conflict fueled by
competition for limited resources. Beyond mass starvation, environment
degradation, critical destruction of animal habitat and accelerated loss
of biodiversity needs to be foregrounded. When all living beings are
interdependent and inextricably linked, this omission is remiss.
Proponents of human population growth contend the declining impetus
to have children jeopardizes human prosperity and societal well-being. The
dilemma lies in matching the subsidized needs of a burgeoning number of
retirees and the long living elderly (the demand) with children raised to
tax-paying independence (the supply). However, this co-dependency holds
potential to generate an accelerating demand-supply loop. Today's children
will grow old and in turn seek their due from generations raised to adult
productivity that come after them. The cost of raising a child to
independence, an increasingly deferred milestone, is not just met by the
parents and families but also the rest of society.
Exponential human population growth is not just constrained by the
depletion of food stocks and rapid environmental degradation. Although
food production has kept pace with recent population growth through better
yield crops, improved farming practices and more efficient food
distribution, shortage of safe drinking water in many parts of the
inhabited world remains a threat to all life. The successful cultivation
of crops and animals for human consumption are contingent upon adequate
supplies of water. Water is the font of life on earth; no life (including
sources of human food) can take root without it. Indeed we search for it
in outer space as a harbinger of life.
Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.
Clinical senior lecturer, Division of Anaesthesiology and Critical
Care, University of Queensland Medical School, Brisbane.
Acute Care Programme, Mater Research Institute, The University of
Queensland, and Division of Critical Care and Anaesthesiology, Mater
Health Services, South Brisbane, QLD 4101.
The article entitled “Attorney General Forces Infectious Disease
Society of America to redo Lyme guidelines due to flawed development
process” that appeared in the Journal of Medical Ethics purporting to
explain the agreement between the Connecticut Attorney General and the
Infectious Diseases Society of America (IDSA) regarding its Lyme disease
guideline was extremely disturbing. This article is riddled with
inaccurac...
The article entitled “Attorney General Forces Infectious Disease
Society of America to redo Lyme guidelines due to flawed development
process” that appeared in the Journal of Medical Ethics purporting to
explain the agreement between the Connecticut Attorney General and the
Infectious Diseases Society of America (IDSA) regarding its Lyme disease
guideline was extremely disturbing. This article is riddled with
inaccuracies and misleading information. The article is the latest salvo
from a small but vocal group of physicians and patients who attribute a
wide range of vague symptoms to what they call “chronic” Lyme disease. To
treat “chronic” Lyme infection, this self-described “Lyme-literate” group
promotes the use of long-term antibiotics – often delivered intravenously
for months or even years. The cost of this treatment must be borne by
patients themselves, leading a discerning person to question the authors’
interest in the real reason why they want the treatment guidelines
changed.
Blinded, randomized controlled trials show that long-term antibiotic
treatment is not effective for any condition described as “chronic Lyme”
– a condition that currently has no consistent diagnostic markers. Far
worse, this treatment has been shown to be extremely risky, potentially
leading to fatal infections, serious drug reactions and fostering
development of life-threatening drug-resistant superbugs. That this group
continues to use its assaults on the IDSA and its Lyme disease guidelines
as a platform to promote a not only unproven but expensive and potentially
dangerous therapy is, we believe, clearly unethical.
Among the many inaccuracies in this article, the most egregious
charge is that the IDSA’s Lyme disease guidelines “excluded most Lyme
patients and denied them treatment for their illness.” It is difficult to
find an accurate sentiment in that statement. To start with, the
guidelines are simply that, guidelines, and by their very nature do not
“exclude” patients, nor “deny” them treatment. Further, the authors seem
intentionally to confuse Lyme disease – a proven and highly treatable
illness – with “chronic” Lyme infection, an unproven condition that a
small group of doctors may provide as a “diagnosis” for patients with
vague but often serious symptoms. There is no solid evidence of the
existence of “chronic” Lyme infection. Although we do not doubt that there
are patients who initially were treated for Lyme disease infection and
subsequently have ongoing, vague symptoms, we are concerned these patients
likely are suffering from a different or new illness and are receiving
potentially dangerous “treatment” rather than being evaluated, properly
diagnosed, and treated appropriately.
Although a comprehensive response to the remaining charges would
require an entire article, following are our comments regarding several of
the most salient.
• Regarding the agreement (not “settlement”) between the IDSA and the
Connecticut Attorney General, the IDSA was not forced to “redo” the Lyme
guidelines and no “antitrust laws” were broken. The Lyme disease
guidelines remain in effect. IDSA voluntarily agreed to a special one-time
review of the Lyme disease guidelines. IDSA paid no fines or penalties and
is not restricted from promulgating guidelines of Lyme disease or other
conditions.
• The statement “at least 21 studies documenting death in patients
with this potentially devastating tick-borne illness” is patently wrong.
Lyme disease is not a life-threatening disease. This statement is
reminiscent of a tabloid headline – the patients may have had Lyme
disease, and may have died, but not of Lyme disease.
• The IDSA Lyme disease guideline panel spent months scouring all of
the Lyme disease research. Specific studies were not “selectively
ignored,” but in fact stringently reviewed along with all of the other
research. Based on widely accepted principles of evidence-based medicine,
some studies were determined to lack scientific rigor, and were therefore
not used as a basis for treatment guidelines.
• The comment that the guidelines are “treated as mandatory” and end
up “denying” treatment to patients is inaccurate. The purpose of the
guidelines is to attempt to guide physicians in providing the highest-
quality treatment that is not harmful to patients. However, they are
guidelines, not mandates.
• IDSA does not have nor seek monopoly power. We do not work with
insurers on any guidelines, nor do we develop our guidelines for the sake
of insurers. We develop guidelines to provide guidance to our members,
with the ultimate goal of ensuring the best quality in patient care and to
protect the public’s health.
• Regarding the makeup of the guidelines panel, the IDSA chose the
panel of experts that we believe is the most knowledgeable for the job.
Further, the panel was not limited to “researchers known to have a bias
against the diagnosis and treatment of Lyme disease.” In fact, the point
of the panel was to guide physicians in treating Lyme disease, a known and
highly treatable disease.
• The remark that some of the panel members were working on the
development of vaccines is irrelevant. There are no Lyme disease vaccines
approved for use in humans and the IDSA has made no recommendations in
that regard. The vaccine mentioned in the article was previously in
development, but the decision not to manufacture it was made before the
guidelines were published.
• Regarding conflicts of interest among panel members, physicians
with expertise in a specialty of medicine are often called upon to serve
as expert witnesses, just as lawyers are often asked to do. This is a
professional activity, and compensation is relatively modest. The same is
true of consultation fees with commercial organizations, as long as
specific guidelines are followed. The physicians on our panel followed
those guidelines. The implication that physicians on the guidelines panel
stand to monetarily gain from their recommendations seems particularly
hypocritical coming from a group of practitioners who stand to gain
financially from treating vulnerable patients with an unproven condition
using an unproven, expensive, invasive and risky long-term therapy.
The IDSA is widely recognized as the pre-eminent authority on the
treatment of infectious disease. We are in good company in our lack of
support of the therapy advocated by the authors of this article, including
the American Academy of Pediatrics, the American College of Physicians,
the Medical Letter, the Centers for Disease Control and Prevention (CDC),
the National Institutes of Health (NIH), and even review articles in major
medical journals such as the New England Journal of Medicine. We take our
responsibility as protectors of the public health seriously, and as
physicians who stand by our Hippocratic Oath to “above all, do no harm,”
we wish there were more evidence that these authors and the groups they
represent did the same.
Non-therapeutic circumcision is a contentious issue on which most readers will drift toward the position that reflects their backgrounds or affirms their cultural affinities. Unfortunately, the efforts of various self-appointed "experts" have done little to clarify the issues, and some are notorious for cherry-picking a vast and inconclusive medical literature in order to advance their prior agenda.
Non-therapeutic circumcision is a contentious issue on which most readers will drift toward the position that reflects their backgrounds or affirms their cultural affinities. Unfortunately, the efforts of various self-appointed "experts" have done little to clarify the issues, and some are notorious for cherry-picking a vast and inconclusive medical literature in order to advance their prior agenda.
We invite readers to take the time to read the 29 self-citations that Brian Morris provided in the latest e-letter[1], check out the veracity of the claims contained therein, read the studies attacked by the letters to editor and the responses to these, perform their own literature searches, and reach their own independent, fully-informed judgments. Such a review will show that Morris is simply out of line with most other authorities.
For example, Morris and a colleague have recently disclaimed the Hippocratic Oath,[2] thereby rejecting a venerable medical principle.[3] Even the American Academy of Pediatrics is unwilling[4, 5] to support Morris' assertions that circumcision is a "biomedical imperative"[6] that "should be made compulsory"[7]. Finally, apart from a legally questionable[8] German law protecting religious circumcision,[9] Europe has begun to see circumcision as a violation of an infant's human rights[10-11], medical ethics,[12] and even criminal law.[13-14]
1 Morris BJ, Tobian AAR, Hankins CA, et al. Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. J Med Ethics 2013; epub ahead of print.
2. Morris BJ, Tobian AAR. Reply to 'Circumcision is a Religious/Cultural Procedure, Not a Medical Procedure.' JAMA Pediatrics 2014;168(3):294.
3 Miles S. The Hippocratic Oath and the Ethics of Medicine. New York: Oxford University Press; 2005.
4 American Academy of Pediatrics Task Force on Circumcision. Technical report: male circumcision. Pediatrics;2012:130:e757-e785.
5 American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics;2012:130:585-586.
6 Morris BJ. Why circumcision is a biomedical imperative for the 21(st) century. Bioessays 2007;29:1147-58.
7 The kindest cut? Sunday Night program. Seven Television Network. May 24, 2009. YouTube. Available on: http://www.youtube.com/v/7yDvL4hNny4. Accessed March 23, 2014.
8 Merkel R and Putzke H. After Cologne: Male circumcision and the law. Journal of Medical Ethics 2013;39: 444-449.
9 German Civil Code (Burgerliches Gesetzbuch)1631d.
10 Council of Europe. Resolution: Children's right to physical integrity. Available on: http://www.assembly.coe.int/nw/xml/XRef/Xref-DocDetails-EN.asp?FileID=20174???=EN. Accessed March 23, 2014.
11 KNMG (Royal Dutch Medical Association). Non-therapeutic Circumcision of Male Minors (Utrecht, Netherlands: KNMP, 2010).
12 Suomen Laakariliitto. Poikien ymparileikkaus. Available on: http://www.laakariliitto.fi/uutiset/kannanotot/ymparileikkaus.html. Accessed March 23, 2014.
13 Landgericht Koln; 7 May 2012; Urteil Ns 169/11.
It is not surprising that Anne Gershon, the current president of the
Infectious Diseases Society of America (IDSA), would come to the defense
of her society's beleaguered Lyme guidelines. What is disturbing is that
Dr. Gershon relies on the same specious arguments that were debunked by
the Connecticut Attorney General's investigation of the IDSA Lyme
guidelines proc...
It is not surprising that Anne Gershon, the current president of the
Infectious Diseases Society of America (IDSA), would come to the defense
of her society's beleaguered Lyme guidelines. What is disturbing is that
Dr. Gershon relies on the same specious arguments that were debunked by
the Connecticut Attorney General's investigation of the IDSA Lyme
guidelines process
(<http://www.ct.gov/AG/cwp/view.asp?a=2795&q=414284>) and refuted in
our article. Here is a rebuttal to her views.
As stated in our article, the IDSA Lyme guidelines are not "simply
guidelines", as Dr. Gershon meekly maintains. They are a highly
restrictive set of directives published by the largest group of infectious
disease specialists in the world, and they allow a monopolistic medical
society to set a standard of care that forecloses treatment options for
patients. The IDSA guidelines trivialize Lyme disease, ignoring the
growing number of patients with persistent symptoms of tick-borne illness
leading to significant disability. The guidelines also discount the
importance of clinical judgment and fail to provide treatment options for
Lyme patients. As Dr. Gershon knows, the IDSA Lyme guidelines are treated
as the mandatory standard of care by insurers, government agencies and
medical boards, and they are used to deny patients access to the only
viable treatment option for chronic Lyme disease.
Readers can easily refer to the findings of the Attorney General to
dispel Dr. Gershon's protestations regarding suppression of evidence and
the use of a hand-picked panel with known biases and substantial conflicts
of interest, as the findings on these points are clear. Basically, IDSA
researchers selected their own papers based on their own research bias,
found no faults with their own studies, discounted the studies of others,
and excluded opposing viewpoints in reaching their conclusions. Even the
strongest proponents of evidence-based medicine would cringe at the amount
of bias the panel members brought to the table. As noted in our article,
their conclusions support the interests of vaccine patent holders who
favor a narrow disease definition that increases the efficacy and odds of
approval of a vaccine. Their conclusions also favor diagnostic test
patent holders by mandating a positive test for diagnosis. Their
conclusions put money in the pocket of consultants who help to deny
patient care and reduce costs for insurers. The Attorney General found
that IDSA panel members had conflicts of interest in each of these areas.
Did anyone on this panel represent the interests of patients to gain
access to the only medical option that might improve their quality of
life? The answer is no.
Nor can IDSA shore up its guidelines by asserting that other medical
societies independently corroborate them. First, most of the groups
listed by Dr. Gershon do not endorse IDSA's 2006 guidelines. Second, as
pointed out by the Attorney General in his findings, corroboration of the
IDSA guidelines was anything but independent. Hence, the Attorney General
found that "The IDSA portrayed another medical association's [American
Academy of Neurology] Lyme disease guidelines as corroborating its own
when it knew that the two [guidelines] panels shared several authors,
including the chairmen of both groups, and were working on guidelines at
the same time". The New England Journal of Medicine article cited by Dr.
Gershon also shared authors with the IDSA panel. Both publications
appeared after the Attorney General's investigation was launched, and
there was no disclosure of the rather glaring conflict of interest of
panel members who authored these "independent" attempts to exonerate
themselves in the face of an ongoing investigation.
Dr. Gershon implies that "Lyme-literate" physicians prey upon
misinformed and misguided patients. Nothing could be further from the
truth. In reality, patients by the thousands seek care from "Lyme-
literate" physicians because the IDSA guidelines have failed them and the
IDSA physicians who rely on those guidelines have abandoned them. Dr.
Gershon also derides treating physicians for being paid fees for their
services. However, there is a big difference between being paid to care
for patients and profiting from third-party industry ties that should have
no place in determining patient care. If patients are unhappy with their
treatment, they have the power to leave a treating physician and seek
another, and they also have the ability to express their concerns and
ensure that those concerns are addressed. In short, their physicians are
accountable for their care. Patients have no similar recourse with the
guidelines panel of a dominant medical society that has the authority to
set the rules for patient care but is not accountable to those patients
when care fails.
It is all too easy to turn a blind eye on treatment failures and
patient suffering when one never sees or treats the patient, is not
responsible for the consequences of failure and neglect, and has no
obligation to the individual. IDSA's assertion that this medical
abandonment is necessary to honor its hypocratic oath to "first, do no
harm" could be used to justify the denial of any medical treatment, as all
treatments have the potential to do harm. While this may appeal to
insurers, Lyme patients who are suffering a disability equivalent to
congestive heart failure certainly deserve better.
Lorraine Johnson, JD, MBA,
Chief Executive Officer,
California Lyme Disease Association
<http://www.lymedisease.org>
Raphael B. Stricker, MD,
Past President,
International Lyme & Associated Diseases Society
<http://www.ilads.org>
Evidence-based policies[1-6] concur that medical male circumcision (MC), best performed early in life[7] under local anaesthesia by a trained provider, is a simple, safe procedure conferring lifetime protection against numerous adverse medical conditions that together affect half of all males[2,7]. Data from numerous clinical trials and hundreds of research studies show benefits greatly exceeding risks[2,7], particularly in resour...
Evidence-based policies[1-6] concur that medical male circumcision (MC), best performed early in life[7] under local anaesthesia by a trained provider, is a simple, safe procedure conferring lifetime protection against numerous adverse medical conditions that together affect half of all males[2,7]. Data from numerous clinical trials and hundreds of research studies show benefits greatly exceeding risks[2,7], particularly in resource-poor communities. Claims of adverse effects on sexual function, sensitivity, and satisfaction are not supported by scientific evidence[8]. Opponents often deny confirmed benefits and overstate or fabricate the harms[9].
While the AAP concluded that the benefits of neonatal MC exceed the risks, it nevertheless acknowledged that for some families other considerations might be more important[1]. This is also true for other neonatal interventions that physicians strongly recommend such as vaccinations and genetic screening that some families oppose. However, given the strong data on MC's substantive health benefits, we are concerned that widespread vocal unscientific opposition to neonatal MC may hamper the ability of health care workers to offer it, or may lead to the stigmatization of those who request it. Policies that are embraced by the medical, scientific, and bioethics communities in support of parent-approved elective newborn MC should be implemented just as any other safe, effective, approved public health measure.
REFERENCES
1. American Academy of Pediatrics. Circumcision policy statement. Task Force on Circumcision. Pediatrics 2012;130:e756-e785.
2. Morris BJ, Wodak AD, Mindel A, et al. Infant male circumcision: An evidence-based policy statement. Open J Prevent Med 2012;2:79-82.
3. American Urological Association. Circumcision. http://www.auanet.org/about/policy-statements/circumcision.cfm 2012. (accessed 10 Mar 2014)
4. Centers for Disease Control and Prevention. Male Circumcision. http://www.cdc.gov/hiv/prevention/research/malecircumcision/ 2013. (accessed 4 Mar 2014).
5. WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention. 2007. http://www.who.int/hiv/mediacentre/news68/en/index.html (accessed 10 Mar 2014)
6. Mayo Clinic. Circumcision (male): Why it's done. http://www.mayoclinic.com/health/circumcision/MY01023/DSECTION=why-its-done 2012. (accessed 10 Mar 2014)
7. Morris BJ, Waskett JH, Banerjee J, et al. A 'snip' in time: what is the best age to circumcise? BMC Pediatr 2012;12(article20):1-15.
8. Morris BJ, Krieger JN. Does male circumcision affect sexual function, sensitivity or satisfaction? - A systematic review J Sex Med 2013;10:2644-2657.
9. Morris BJ, Tobian AAR, Hankins CA, et al. Veracity and rhetoric in pediatric medicine: A critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. J Med Ethics Epub ahead of print 16 Aug 2013.
Obesity being designated a disease recognizes its adverse effects on
physical and psychological health. Pleas on behalf of the corpulent to not
being judged and regarded without compassion are timely. However,
obesity's classification as a disease could devolve the self-control
needed to assume personal responsibility for the unhealthy dietary and
sedentary choices we make. Dieting, weight consciousness, anxiety about
bo...
Obesity being designated a disease recognizes its adverse effects on
physical and psychological health. Pleas on behalf of the corpulent to not
being judged and regarded without compassion are timely. However,
obesity's classification as a disease could devolve the self-control
needed to assume personal responsibility for the unhealthy dietary and
sedentary choices we make. Dieting, weight consciousness, anxiety about
body weight/shape and widespread hostility to obesity are fundamental
themes in contemporary life. There is tension between trying to control
our body weight in the midst of unprecedented access to unhealthy foods.
The impulse to ridicule and publicly monitor the body shape has its basis
in the highly visible markers of overweight transgressing aesthetic
standards and signalling pathology and disease. Seeing fatness leads to
the negative reading of fat bodies. More than ever, judgements about our
own and others' worth is based on the morphological body as compared to
the ideal. Although there is psychological toil from discrimination meted
out to the obese, being insulated from the externally-imposed assessment
of our weightiness imposes the inertial foundation to stay as we are.
There is indeed a fine line between a stern reprimand that could avert a
burgeoning public health disaster and abuse and derision that debases the
esteem of others. Aside from being susceptible to more serious iterations
of a whole range of chronic medical problems, the obese sustain higher
risks of anaesthetic, pregnancy and post operative complications. They are
more difficult to resuscitate in trauma and critical illness. Life-
sustaining procedures such as intubation and central venous access pose an
anatomical challenge. Due to their thickset habitus, even the longest
chest drains could fail to reach large clots pressing on lungs in major
trauma. The treat of loss of life and limb with acute injury and serious
illness could be far more effective message than low grade hazard spread
over years to decades .
pleas on behalf of the corpulent to not being judged and regarded
without compassion by society. Dieting, weight consciousness, anxiety
about body weight/shape and widespread hostilty to obesity are fundamental
themes in contemporary life. There is tension between trying to control
our body weight in the midst of unprecedented access to unhealthy foods.
The impulse to ridicule and publicly monitor the body shape has its basis
in the highly visible markers of overweightedness transgressing aesthetic
standards and signalling pathology and disease. Seeing fatness leads to
the negative reading of fat bodies. More than ever, judgements about our
own and others' worth is based on the morphological body as compared to
the ideal. Shriver rightly protests the psychological toil from
discrimination suffered by the obese. On the other hand, being insulated
from the externally-imposed assessment of our weightiness imposes the
inertial foundation to stay as we are. There is a fine line between a
stern reprimand that could avert a burgeoning public health disaster and
abuse and derision that debases the esteem of others.
Joseph Ting, MBBS MSc (Lond) BMedSc PGDipEpi DipLSTHM FACEM.
Clinical senior lecturer, Division of Anaesthesiology and Critical
Care, University of Queensland Medical School, Brisbane.
Acute Care Programme, Mater Research Institute, The University of
Queensland, and Division of Critical Care and Anaesthesiology, Mater
Health Services, South Brisbane, QLD 4101.
This excellent paper should be taken in light of several reports,
conferences and papers that draw attention to guidelines and procedures to
be followed by research ethics committees (RECs).
I wish to suggest five simple prescriptive precepts or commandments that
ought to be institutionalized in RECs, and be part of the values or moral
code of members of such organizations. Most of these are self-explanatory
and are ther...
This excellent paper should be taken in light of several reports,
conferences and papers that draw attention to guidelines and procedures to
be followed by research ethics committees (RECs).
I wish to suggest five simple prescriptive precepts or commandments that
ought to be institutionalized in RECs, and be part of the values or moral
code of members of such organizations. Most of these are self-explanatory
and are therefore elaborated only briefly.
(1) Thou shalt not steal ideas of researchers who submit papers for ethics
reviews. This form of plagiarism is difficult to detect. In case a
reviewer or a member of the REC thinks of an idea based on a paper
submitted for review, the proper process should be to inform the REC,
contact the author and discuss further collaboration or development of the
idea.
(2) Thou shalt not destroy the spirit of the research proposal. Some
reviewers and members of REC take great pleasure in suggesting their ideas
for the proposal often distorting the initial research question. They must
be cognizant that their remit is to approve or disapprove or suggest
changes to proposals. The latter is mainly by improving methodology where
appropriate and helping to resolve ethical issues. Suggestions for
improvement of a study ought to remain suggestions. As for these
suggestions, the researcher should have the option to ignore, include and
re-submit or develop a fresh proposal.
(3) Thou shalt not delay the approval process. ERCs must have a fast-track
process at least for certain studies that do not contain major ethical
issues. Members of the ERC must be held accountable for unnecessary delays
in granting approval to studies and there should always be a fall-back
position (for e.g. in case a reviewer does not meet a time-line).
(4) Thou shalt not be influenced by the personalities who submit the
proposal. It is always possible that doyens in a particular field
(unwittingly)intimidate RECs, while smaller-fry researchers are critiqued
mercilessly on minutiae.
(5) Thou shalt not be influenced by the funds at stake. The refusal to
grant approval may have adverse implications to an institution but that
should not sway decisions of ERCs.
We thank Dr. Post for his response to our brief report, "Conflict of interest in online point-of-care clinical support websites" (J Med Ethics doi:10.1136/medethics-2013- 101625). We additionally commend UpToDate for many of its policies that protect the integrity of the educational material presented. In light of Dr. Post's comments, we recommend further clarification in the UpToDate conflict of interest policy, particu...
It does us all well to recognize that despite only a minority of scientists engaging in dishonest means to achieve academic gains, their disrepute will unfortunately taint the hard work of the honest majority. The greater harm will be loss of faith in publicly funded research and the waste of resources on non-credible work. Provided one evades detection, contemporary academia's unbridled publish or perish imperative breed...
Given what we know and don't know about the processes from which the 'safe limits' for alcohol consumption in general are derived, would the author not agree that his criticism applies more generally in this area? On a somewhat pedantic note it's not establishing a negative correlation that's difficult, it's establishing a lack of correlation. Absence of evidence is not evidence of absence.
To the Editor: The threat posed by human "population explosion" goes beyond that capable of being supported by the earth's diminishing food and natural resources. The long standing but recently dormant debate on the sustainability of population growth is an integral topic that complements recent media focus on global warming and catastrophic weather events. There needs to be balanced discussion on the societal and health...
The article entitled “Attorney General Forces Infectious Disease Society of America to redo Lyme guidelines due to flawed development process” that appeared in the Journal of Medical Ethics purporting to explain the agreement between the Connecticut Attorney General and the Infectious Diseases Society of America (IDSA) regarding its Lyme disease guideline was extremely disturbing. This article is riddled with inaccurac...
Non-therapeutic circumcision is a contentious issue on which most readers will drift toward the position that reflects their backgrounds or affirms their cultural affinities. Unfortunately, the efforts of various self-appointed "experts" have done little to clarify the issues, and some are notorious for cherry-picking a vast and inconclusive medical literature in order to advance their prior agenda.
We invite readers...
IDSA Lyme Guidelines: Response to Dr. Gershon
It is not surprising that Anne Gershon, the current president of the Infectious Diseases Society of America (IDSA), would come to the defense of her society's beleaguered Lyme guidelines. What is disturbing is that Dr. Gershon relies on the same specious arguments that were debunked by the Connecticut Attorney General's investigation of the IDSA Lyme guidelines proc...
Obesity being designated a disease recognizes its adverse effects on physical and psychological health. Pleas on behalf of the corpulent to not being judged and regarded without compassion are timely. However, obesity's classification as a disease could devolve the self-control needed to assume personal responsibility for the unhealthy dietary and sedentary choices we make. Dieting, weight consciousness, anxiety about bo...
This excellent paper should be taken in light of several reports, conferences and papers that draw attention to guidelines and procedures to be followed by research ethics committees (RECs). I wish to suggest five simple prescriptive precepts or commandments that ought to be institutionalized in RECs, and be part of the values or moral code of members of such organizations. Most of these are self-explanatory and are ther...
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