Battin et al’s article1 suggests vulnerable groups are no more likely
to receive physician-assisted dying than other less vulnerable groups.
This claim needs challenging based both on the figures presented and from
experience in palliative medicine.
Palliative medicine frequently encounters patients wishing their
lives were over. They may not explicitly request to have physician-
assisted dying but clearly expres...
Battin et al’s article1 suggests vulnerable groups are no more likely
to receive physician-assisted dying than other less vulnerable groups.
This claim needs challenging based both on the figures presented and from
experience in palliative medicine.
Palliative medicine frequently encounters patients wishing their
lives were over. They may not explicitly request to have physician-
assisted dying but clearly express that, at that moment, they feel they
would be better off dead. The reasons for this include poor information
and communication skills, lack of effective symptom control,
misperceptions of what the last stages of life will be like, fear of being
a burden and the impact on families. In Oregon it is necessary for the
diagnosis of a terminal illness before a patient can be considered for
physician-assisted suicide, while the Netherlands require that the patient
be facing unbearable and hopeless suffering to be eligible for physician-
assisted dying. We would consider that all people facing such serious
concerns and conditions are vulnerable, and not just those who fall into
pre-identified social groups.
According to the 2005 study2 used as the basis for much of the
evidence in this paper, the reporting rate for physician-assisted dying in
the Netherlands has improved, but 19.8% of cases (477 deaths) remain
unreported. This study provides quantitative data on reasons for non-
reporting in only 28 cases. We remain concerned that “vulnerable” groups
may be receiving assisted dying in the Netherlands.
As a committee we are concerned that the early release of such
information to the press, and the widespread reporting that followed, left
professionals in a difficult position as without access to the article no
clear response could be made to patients and colleagues. Data such as this
may well be used to strengthen the argument to legalise assisted dying in
this country. As a body representing palliative medicine physicians (who a
recent survey demonstrated were against such legalisation) we would have
welcomed this paper being made available to professionals for academic
scrutiny before being released to the media.
References
1. Battin MP, van der Heide A, Ganzini L, et al. Legal physician-assisted
dying in Oregon and the Netherlands: evidence concerning the impact on
patients in “vulnerable” groups. J Med Ethics 2007; 33: 591 – 597
2. van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, et al. End-of-Life
Practices in the Netherlands under the Euthanasia Act. NEJM 2007; 356 (9):
1957
This critical response to Professor K M Boyd's paper [1] argues that
hermeneutics as a perspectives based approach is not an effective method
in moral discourse; it brings nothing distinctive to the arguments. The
construction of a new vocabulary which relies on the old way of speaking
for its sense does not clarify anything. Further, that Boyd's undefined
contrast between controversy and conversation does not point to any...
This critical response to Professor K M Boyd's paper [1] argues that
hermeneutics as a perspectives based approach is not an effective method
in moral discourse; it brings nothing distinctive to the arguments. The
construction of a new vocabulary which relies on the old way of speaking
for its sense does not clarify anything. Further, that Boyd's undefined
contrast between controversy and conversation does not point to any
improvement in communication: disputation occurs in conversation and
controversy may be conducted in gentle tones. We find too that his
discussion of the use of human embryos in stem cell therapy research does
not provide a model for ethical advance.
The broader context for Boyd's discussion is the common source of
human understanding and how different cultures and belief systems grow on
such understanding. In a recent television programme on God the question
was raised whether it was justified to regard God as moral if He were
responsible for the pain of an anguished death of one infant. An official
response talked of mystery and human ignorance and having trust in God;
there did not seem to be what Boyd is advocating as an alternative to
controversy, ie a 'sustained public conversation between many diverse
perspectives, each prepared to learn from others, and committed to seeking
a common mind on the question in hand' (p 486). He regards traditional
moral argument as failing and offers a method of inclusive conversation
intended to bring participants together; but we find his conversations are
equally controversies.
To get to the heart of moral discourse, Boyd advocates a
'perspectives based approach ... (which focuses) attention not on the act or
the agent, but the case', (p 483) which one may understand as the whole
situation confronted. Expressed in ordinary language, the view is that
the different perspectives on a situation would each contain personal
interpretations which through friendly conversations would be cleansed of
prejudices and would thus form a basis for moral agreement. Rather deeper
in his text and producing some confusion, Boyd relies on G H Gadamer's
general epistemological theory that different cultures produce different
frameworks of prejudice which provide isolated havens for knowledge. On
this view, then, individual clashes of culture give, according to Gadamer,
'fusions of horizons', (p 484) ie a meeting of foreign prejudices which
brings individual perspectives into relief and allows better understanding
for all. A conceptual difficulty here which Boyd does not address is that
in his context, doctor and patient share the same culture.
However, the first stage for Boyd is to set out, what we can see as
his interpretation, that 'A perspectives based approach recognises that a
moral problem is not something "out there" or given, like a natural
object. A moral problem is an interpretation of events seen from a
perspective shaped by history and tradition' (p 483). It may be helpful
from the start to recognise that when one applies a theory to human
experience it is important not to undervalue the human experience. If one
takes a non-moral example first, like a theory of gravity, whether the
experience of gravity is explained by an inverse square law or that
gravity is in some way indicative of the shape of space itself, the
explained is not to be explained away: moral conduct is real.
Hume taught us that one cannot deduce an 'ought' from an 'is', but
this does not show that what 'ought' refers to is not real. One cannot
deduce democracy from existence but this does not undermine the reality of
that system. A moral problem, like a political system, is a relation
between facts and human action: we see the killing of the vulnerable
individual; we say that ought not to happen. In this moral context, one
may even accept the view that there is no meaning in nature; but at least,
humans bless or adorn nature with meaning. When one says that a moral
problem is an interpretation it is important to see that it is a shared
interpretation, shaped over time and in communities. Cultures develop,
and Boyd tells us that he is guided by the 18th century physician John
Gregory who taught that the physician 'had a positive moral duty to be
"ready to acknowledge and rectify his mistakes"' (p 481). Gregory held
that this would be helped if the general public were admitted to medical
studies so as to be better able to judge their physician's merit. We can
see that this is a source of Boyd's idea of conversation but it contains
too the weakness of unequal contributors to the inquiry. In this
connection, 'a conversation between friends seeking to come to a common
mind' (p 483) has its own reality and does not need any 'hermeneutic
model' (p 483) to justify it; similarly, the aristocratic Aristotle is
hardly a model here for he believed that only equals can be friends: he
would have no friend in the hoi-polloi.
We have already alluded to the idea that Boyd's 'case' is the
empirical reality in which people dispute what it is. He sees principle-
based ethics and person-based ethics as only part of the story in
understanding what the moral elements are in any particular 'case'; though
part of the justification for this conclusion is that a perspective-based
approach contains all the 'interpretations' of the case, including the
principle- and person-based analyses of moral conduct. In other words,
there is an element of tautology underpinning Boyd's conclusion that
'Approaches based on principles or persons are among the relevant
perspectives' (p 483). His conclusion does not show that an approach
through 'perspectives' is a superior or effective method to analyse moral
discourse. One might just as well say that because authors and poets are
among the members of society that society produces such works of art.
It may well be that 'Cultures differ in what they perceive to be
moral problems, and about the right way to resolve those that they do
perceive' (p 483), but does this justify Boyd in following Gadamer with
'All of us, if you want to put this at its strongest, are prejudiced, one
way or another'? (p 483). He appeals to Gadamer, 'Without it, he says, we
would never understand anything at all', (p 483) but does this mean that
the newborn baby is prejudiced when his name is called? For Gadamer, the
baby is being introduced to its culture and way of working, eg doctors
diagnose; but this does not support Boyd's discussion. We have to conclude
that his idea of social prejudice is not really clarified or advanced by
Gadamer's epistemology. It is important here to see that human prejudice
is social property in one culture or another; prejudices float in
communities: the difficulty is not in finding them in the deep recesses of
the human mind, but rather of using social ideas to deal with them.
Prejudice is not defined by Boyd, although one sees that my
perspective may be different to your perspective, and that this gives rise
to the possibility that I do not understand your perspective or in some
way that I cannot understand it. One's culture may limit one's
understanding of something or make the required understanding impossible;
consider the concept of 'counting up to forty' for different primitive
groups. The point here is to give an account of communication, but we
have to be aware that theories may mislead. With Gadamer's phrase 'fusion
of horizons' (p 484) we see the tautologous character of his theory, ie
empirically, the horizons limit understanding; but when they 'fuse' we
have the tautologous 'we learn what we are taught'. Additionally, Gadamer
relies on 'the tyranny of hidden prejudices' (p 483) indicating that
communication may be impossible. Though, a lack of culture may be
sufficient for this, rather than a presence of hidden prejudices.
Gadamer's prejudice in favour of his theory may be misleading him, but
what is missing in Boyd's account is a clear definition of 'prejudice'.
Gadamer's essentially solipsistic view of the intellect starts with
prejudice and may not be able to escape from it. His view is reminiscent
of a Freudian perspective where hidden forces guide men and women. Boyd
suggests not letting 'our prejudices run too far ahead and overwhelm what
the other person is actually saying ...', (p 483) but this picture does not
offer a method of dissolving prejudice. One may be inclined to ask what
prejudice Gadamer is under when he says 'if we think we are not
prejudiced, while remaining "under the tyranny of hidden prejudices"' (p
483). We can see a similar difficulty where the traditional solipsist's
lack of confidence in his perceptions is simultaneously replaced by hidden
mechanisms in his mind which produce perceptions. One conceptual
confusion is exchanged for a ghostly machine in the mind. Gadamer's
hidden prejudices are similarly hidden from the thinker: we have a
metaphysical theory without proof. If we accept this theory we would
never be in the position of knowing when all the relevant prejudices in an
individual's mind had been exposed: the better approach is to deal with
assumptions or prejudices as they are recognised. This need not be
entirely arbitrary for social prejudice occurs in a context of particular
rules, eg prejudice against a man is a judgement or action in which his
rights are disregarded. Of course, many prejudices are not relevant in
particular circumstances; and the logic of the situation exposes others.
The lack of clarity in what a prejudice is taken to be, is seen in
Boyd's 'a doctor is professionally prejudiced in favour of a diagnosis:
but for the doctor to think of that, then, as a prejudice is not very
helpful' (p 483). We see here a misunderstanding of Gadamer's idea of
necessary prejudice as a mental framework clashing with Boyd's idea of an
accidental social prejudice. To correct Boyd we need simply to replace
'prejudiced' with 'trained' to see its sense but the conceptual confusion
remains. Boyd admires Gadamer's idea that builds on 'two friends seeking
to come to a common mind about something ... (as) an appropriate model for
medical ethics', (p 484) which 'does not entail moral relativism', (p 484)
though he does not explain why this is not a case of relativism, for as he
has said 'Cultures differ in what they perceive to be moral problems' (p
483). Certainly one can see that one does not need the theoretical
underpinning Boyd has borrowed from Gadamer, in order to accept in the
medical situation the need for sensitivity to expressed opinions: one
needs to listen carefully, and without unjustified assumptions.
There is an idea offered by Boyd that multiculturalism reduces
prejudice, when 'many people's prejudices are formed not by one, but by
several traditions', (p 484) but one sees that some traditions dominate
and the religious or political traditions may form the familial,
educational or professional perspectives. Of course, in a culture
enveloping a variety of different traditions there may be more
possibilities for individuals to change from one to another, but this may
be more a changing of prejudices than an evaporating of them. Boyd moves
from such an idea of dynamic in society to 'a tradition may have to
express itself differently if it is to remain true to itself' (p 484).
Paternalistic medicine may then change to '"patient choice" and
"concordance" .... (such change) is explored more readily through questions
and conversations than in the thrust and counterthrust of controversy' (p
484). One can see that such exploration may involve intellectual argument
or persuasion but each of these may be conducted in a variety of styles,
ie this example may not be a good model to decide that conversation is
better that controversy. Friendliness is a virtue, of course, but one
does need here to separate the 'bedside manner of the doctor' from the
intellectual approach to intellectual problems where it is not the person
which is confronted but the ideas or arguments.
Boyd in his acceptance of hermeneutics, here understood as 'the
interpretation of behaviour, speech, and institutions,' (p 483) believes
that in the appropriate situation 'we hold in check our own prejudices' (p
484). But clearly this is not easy, he has not done it in his reliance on
Gadamer; and his 'conversation' is quite prejudiced in seeking to
undermine moral resistance to the use of human embryos in stem cell
research by impressing his 'hermeneutic' interpretation on the ideas of
respect for life and the sanctity of life. With some flexibility Boyd
accepts that sometimes 'controversy is needed to puncture a complacent
consensus', (p 484) but on the controversy 'whether the use of embryos is
really necessary for stem cell therapy research', (p 484) he resists
controversy: he reminds us that 'the dominant scientific view is that it
is' (p 484). This is a technically difficult question which is compounded
by a possible scientific ideology or paradigm which may be reflected in
Boyd's perspective. Certainly, the assumptions underlying perspectives on
this research are better exposed, but contrary assumptions in different
camps may not be easily abandoned. We see that Boyd has avoided a
discussion of such difficulty around a 'dominant scientific view' (p 484)
by closing it with 'If that is correct ...' (p 484).
Rather oddly based on his personal experience of the German word
'Achtung', Boyd sees 'respect' as meaning 'wariness and wonder' (p 485)
which does not really capture what Kant was after with the principle of
respect for persons as ends in themselves. 'What about "sanctity"?' (p
485). Quoting Gabriel Marcel, Boyd seems to agree with him that the
sanctity of life means '"I really love life", or "I don't love life
anymore"' (p 485) so that it '" implies a basic and as it were
inarticulated reference to my life ...' (p 485). His conclusion is that
sanctity refers 'rather to the wondering way in which one living being may
recognise and respond to another' (p 485). He does qualify his view by
'If this interpretation is correct ... ' (p 485) though he doesn't say
whether it is his interpretation or Marcel's he is referring to. What
Kant was saying with 'respect for persons as ends in themselves' is that
one ought not to use people for ends they do not share, ie one ought not
to treat them as means only. And, the sanctity of life is an idea that is
at the centre of a number of religions, ie the idea that human life is
sacred and inviolable. The context of learning from conversations about
diverse perspectives on stem cell research should have encouraged Boyd to
bring these views into focus.
Boyd believes that respect for the human embryo occurs if it 'is in
some sense a "you" rather than an "it"', (p 485) it would then be for him
"an end in itself"' (p 485). His criterion or test for this 'would be to
actually greet each embryo in vitro as a potential person' (p 485). But,
he thinks, this would be problematic, for 'the majority of pre-
implantation embryos, in the wisdom of nature, are not potential persons'
(p 485). We can see that Boyd holds that some embryos would be persons
and some not; but his test to distinguish them is not usable. The
criterion of person, actually greeting that embryo in vitro which would
become a person, would, of course, actually apply to those that were in
fact potential persons but not to the others; and one may not know in
advance which were which. Thus, the criterion of actually greeting each
potential person from an embryo in vitro seems vacuous: it offers a
distinction without a difference.
Contrary to Boyd's view, it is worthwhile to notice that the
injunctions, 'respect for life' and 'the sanctity of life' are not applied
only to the researchers, they apply too to persons who donate spare eggs
and embryos for research. Boyd's conclusion that this donation
'specifically precludes their being potential persons' (p 485) does not
follow for some of the embryos may have been potential persons. But
perhaps more important in this context the idea of 'the sanctity of life'
raises more general questions which are not so easily overlooked. Boyd
considers that it may be 'the scientific manipulation of human life itself
that offends against "sanctity"' (p 485) where sanctity is taken to mean
'reference to my life' (p 485). Though on this definition of 'sanctity',
it would seem that if Boyd accepts such scientific manipulation as
acceptable then it does not offend against the sanctity of life. He then
extends his interpretation of sanctity to refer to the majority view which
accepts taking the lives of animals. But the idea of sanctity of life had
not excluded them, and to refer to the European parliament's acceptance of
safety testing on animals is an appeal to authority rather than argument.
Some prejudices are difficult to grow out of.
After his attempts to undermine opposition to the use of human
embryos in stem cell therapy research Boyd says 'the ethical problems they
raise are not helped by being debated within the win or lose constraints
of controversy' (p 485). Although he does not explain what it is about
controversy which he sees as unsuitable. In debating the use of embryos,
Boyd favours the 'nuanced but necessary terms such as Marcel's '"basic ...
reference to my life ... (rather than) whether or not they are biologically
human' (p 485). But he does not give an account of why he thinks Marcel's
use of terms is nuanced or necessary and why the question of whether
embryos are biologically human is inappropriate. However, he sees 'the
most morally challenging issue - that of the inevitably tragic character
of many choices necessarily involved in biomedical progress' (p 485). If
he had talked of the inevitably tragic character of many choices
necessarily involved in human life, this would have struck a more powerful
note for we see his contrast is a prejudice in favour of a particular
method to gain biomedical progress. It is useful to consider here that
one does not have to travel on a particular route to a particular place;
it would be most unusual if in the world there were only one method of
achieving something. Perhaps a conversation could lead Boyd to consider
other perspectives on biomedical progress in this field.
In delving into the human experience and puzzling over certain moral
problems Boyd says 'To invent appropriate answers therefore is a task that
practical wisdom can accomplish only through sustained public conversation
between many diverse perspectives, each prepared to learn from the others,
and committed to seeking a common mind on the question in hand' (p 486).
Apart from the conceptual difficulty that the abstract concept 'practical
wisdom' has been anthropomorphized into the agent for progress, it is
important to notice here that the common mind may not be the right mind;
democracy may not be a perfect substitute for practical wisdom.
But equally important, if one is going to put any weight on
theoretical considerations, is that they are at least plausible. Boyd has
a tendency to place exaggerated faith in individuals who do not deserve
the honour. Relying on Ricoeur, he says 'When a good ethical intention is
blocked by a right moral rule ... we need to know how far the particular
moral rule is applicable, not only to the case in hand, but also under the
universal Golden Rule - do not do to others what you would not have them
do to you' (p 486). It is clear that the Golden Rule is expressed as a
form of individual desire, rather than a moral standard, and as such would
not apply when a stronger desire opposes it. What we find is that this so
-called Golden Rule is based on an assumption that one is comparing only
virtuous actions; an outcome of this is that the 'rule' cannot distinguish
virtuous from vicious actions. We can see that the 'rule' fails when
applied to the tough robber who is prepared to take the risk of being
robbed by weaklings, or when applied to the sadistic boxer who is more
proficient than his neighbours. We may even remember the old example used
to undermine the Golden Rule, that of the homosexual individual in a
heterosexual society. The Golden Rule assumes equal individual powers in
contrary actions: it allows equal exchanges, but it has nothing to say
about what ought to be done. Interestingly, in the context of stem cell
research, the 'rule' may be seen as an appeal by an embryo to survive, ie
the Golden Rule does not provide a basis for a decision mechanism in moral
conflict.
We are coming nearer an idea of what the point of moral discourse is.
Boyd mentions practical wisdom and inventing or discovering 'appropriate
answers ... (and) seeking a common mind on the question in hand', (p 486)
and we remember we are dealing with very complex questions here. One might
even in the course of one's cogitations appeal to moral ideas in
developing an 'appropriate' answer to the question in hand. An important
point here is that when one has that 'answer', the time for relevance of
moral ideas regarding a particular question is not over: it is not the
'common mind' that settles the matter, even if it is the result of 'a slow
boring of hard planks': (p 486) the shepherd does not leave the flock.
Author's affiliations:
C Parker; Leeds (East) Research Ethics Committee, Lay Member.
Clinical Sciences Building, Room 5.2, St James's University Hospital,
Beckett Street, Leeds LS9 7TF.
Competing interests: none
References:
1 Boyd K M. Medical Ethics: principles, persons, and perspectives:
from controversy to conversation. J Med Ethics 2005; 31: 481-486. doi:
10.1136 / jme. 2003.005710.
This is a surprising scientific example of not seeing the forest
because of the trees which are carefully numbered and described. The
error is taking one example from tissue retention and building a theory on
it; the researchers take their own good research and simple information
and conclude patients do not need 'more complex information'. But the
contrast between simple and complex information is too simple.
This is a surprising scientific example of not seeing the forest
because of the trees which are carefully numbered and described. The
error is taking one example from tissue retention and building a theory on
it; the researchers take their own good research and simple information
and conclude patients do not need 'more complex information'. But the
contrast between simple and complex information is too simple.
Of course, information always needs to be appropriate, ie as simple
as possible and as comprehensive as necessary, but sometimes this does not
occur. We need to bring other examples into the equation. Consider the
information the patients or carers received at Alder Hey: it was not
sufficient, whether it was simple or complex or nonexistent. We are not
concerned simply with risks to the patient, but also with valuing them.
More pointedly, the researchers conclude with 'an important finding'
that for the patient, giving informed consent is secondary to feeling
valued and respected. Though interestingly they had found that their
framework analysis suggested that consent was important as it showed that
their opinions were valued and treated with respect. This is the
traditional view that the necessity of giving informed consent generates
the subjects' being valued and respected. To attempt to separate consent
and feeling valued undermines the value of consent. Additionally, the
researchers considered only those subjects who gave consent and
generalised their findings to include others who were not in the study and
who did not consent.
Regardless of all that, the patients valued being listened to, but
that is not enough as a method to balance the rights and duties of the
researcher with those of the potential participants. It is clear that one
cannot generalise from the Leeds example of good and trustworthy research
projects, simply because there are some medical research studies which are
not good and do not deserve participants' trust. One of the purposes of
research ethics committees is to improve or reject such deficient
projects.
It is quite well known that the personal justification for giving
consent is often inadequate; and it is a problem to know how to improve
understanding in this area. One of the reasons why a bureaucratic system
of evaluation of medical research studies is constructed in the UK is that
a system is needed to deal with many research applications, ie one cannot
assume that any particular research project is worthwhile or fair to
patients or subjects.
We can see that in some studies the subject's agreement to
participate may not be justifiable: so when we evaluate consent we cannot
equate a personal acceptance by the subject with an intellectual
acceptance, ie giving consent after one feels valued is no substitute for
relevant knowledge. The aim of the researcher in describing the protocol
in the participant information sheets should be to present sufficient
intellectual material about the risks and benefits of the research for the
potential participants to judge whether to consent. This is a moving
target and it is difficult to provide the right information for the
potential subject; but regarding the research ethics committee which in
this context represents an ideal of sufficient knowledge and ethical
concern to judge the research protocol, their work will however
inadequately reflect an idea of ideal social consent.
Rennie, Muula and Westreich are right to draw attention to ethical
questions surrounding circumcision. This is particularly important,
especially now, when circumcision is being promoted as a way of
reducing the chances of contracting HIV. I want to draw attention to
something that is clearly unethical: forced circumcision.
When Muslim extremists forcibly circumcised Christian men,
women and...
Rennie, Muula and Westreich are right to draw attention to ethical
questions surrounding circumcision. This is particularly important,
especially now, when circumcision is being promoted as a way of
reducing the chances of contracting HIV. I want to draw attention to
something that is clearly unethical: forced circumcision.
When Muslim extremists forcibly circumcised Christian men,
women and children in Ambon, Indonesia, the Sydney Morning
Herald, reported:
' Victims have told the Herald of multiple cuttings with the same
knives and razors that caused many to suffer infections.
' In the biggest city in the islands, Ambon, church and other groups
have gathered evidence that 3,928 villagers on at least six islands
have been forced to convert to Islam under the threat of death,
torture or destruction of their homes.
' They believe that local Muslim clerics, possibly under duress from
extremists, circumcised almost all the converts.
' Moderate Muslim leaders have condemned the forced
conversions and circumcisions, saying they are contrary to Islamic
teachings.
' The Muslim Governor of Maluku, Saleh Latuconsina, this week
led an investigation team to the island of Kesui, 420 kilometres
south-east of Ambon City, after receiving an official report in late
December confirming villagers there converted to Islam against
their will and were circumcised.' [1]
Muslim authorities were right to condemn this human rights abuse.
One man described what happened to him thus:
' "I could not escape," he said. "One of them held up my foreskin
between pieces of wood while another cut me with a razor ... the
third man held my head back, ready to pour water down my throat
if I screamed. "But I couldn't help but scream and he poured the
water. I kept screaming aloud and vomited. I couldn't stand the
pain." '
Idi said one of the clerics urinated on his wound, saying it would
stop infection.
' "All of the men at the house were cut using the same razor," he
said. "That night they circumcised about 60 men. I was bleeding all
over and had nothing to cover my wound. I was told to take a bath
but it kept bleeding until the next day. I could not imagine any
greater pain. One of my friends got infected and was taken to
hospital when we arrived in Ambon." ' [2]
A woman described what happened to her:
' At first the woman soaked her fingers in the water and then
inserted them into my vagina as she looked for the clitoris. After
she found it, she pulled it out, took out the kitchen knife and cut it.
That hurt very much. I shed tears. They left just like that without
giving me any medication.
' I was lucky, I had some money and went to the store immediately
to get antibiotics. I know the men suffered more than us women.
The circumcision hurt them more that it did to us because their
scars could not heal fast. Several of the men I knew got serious
infections after suffering from severe bleeding.
' My scar healed quite fast, but the sad, humiliated feeling stayed
until today.' [3]
While the reporter revealed the suffering of both sexes, the Sydney
Morning Herald gave far more prominence to the woman’s story.
Letters that followed [4] denounced female genital
mutilation but were silent about the forced circumcision of the men.
However, Christina testified that the men suffered even more than
the women from infections and bleeding and took longer to
recover.
The Koran states, “There shall be no compulsion in religion,”[5] but
for centuries, accounts of forced circumcisions have
followed Muslim attacks on others. In Iran with the coming of the
Muslims, Zoroastrians converted to Islam to avoid being enslaved
and were forcibly circumcised [6] . Forced
circumcisions followed the capture of British soldiers in India by
Tipu Sultan of Mysore after the Battle of Pollilur in 1780 [7] and
there are other reports in the Indian media of forced
conversions and circumcisions during Muslim rule in India [8] .
There are accounts of forced conversions and
circumcisions of Armenians in the Armenian Genocide [9] ,
The1955 pogrom against Greeks and Armenians in Turkey, again
resulted in accounts of forced circumcisions [10] . There are also
claims of the forcible circumcision of Serbian soldiers in former
Yugoslavia [11] . From the Sudan in 2003 came a report of both
boys and girls being forcibly circumcised and raped [12] .
But these aren’t the only ones forcing circumcision on others. In
April 2005, a Nepalese boy escaped from a male brothel in
Mumbai, India, and revealed details of the trafficking of underage
boys in India.
' “I spent seven years in hell,” says Raju, now 21, trying hard not
to
cry. Thapa Magar took him to Rani Haveli, a brothel in Mumbai that
specialised in male sex workers and sold him for Nepali Rs
85,000.
' A Muslim man ran the flesh trade there in young boys and girls,
most of them lured from Nepal.
' For two years, Raju was kept locked up, taught to dress as a girl
and circumcised. Many of the other boys there were castrated.
Beatings and starvation became a part of his life.' [13]
Forced circumcisions can even happen in Australia. Late in 1996,
Irwin Brookdale was drinking with a group of Aborigines on the
banks of a river in far north Queensland. After he passed out, a
woman in the group felt down his pants, found out that he was not
circumcised and called on her companions to ‘make a man out of
him.’ They attempted to circumcise him with broken beer bottle and
Brookdale ended up in hospital. One man was convicted of
unlawful wounding and Brookdale was awarded $10,000
compensation for nervous shock [14] .
In August 2002 a Kenyan man was stripped naked, frog-marched
to a nearby river and forcibly circumcised by traditional surgeons
as an excited crowd watched. The police stood by helplessly.[15]
In November 2005, the Kenyan Human Rights Commission
announced that it would seek prosecutions against politicians for
inciting violence against others. One cabinet minister responded
“Those who are not circumcised should be taken for a circumcision
ceremony.” The Kenyan Human Rights Commission accused the
Minister of inciting people to violence.[16] When two elderly men
were forcibly circumcised in Busia, Kenya in August, 2006, several
arrests were made and the local police chief announced that no-
one would be allowed to harass uncircumcised men [17].
Kenyan circumcision customs put such pressure on young people
that the idea of free agreement to be circumcised must be
questioned. One 18 year old Kenyan boy turned on the man who
circumcised him immediately after his circumcision, forcing the
circumciser to flee for his life.[18]
In neighbouring Uganda, local uncircumcised men were fleeing
into hiding. Mr Dan Wakayaba, 45, the father of seven children,
was seized and forcibly circumcised after his wife reported him to
the tribal authorities because he wasn’t circumcised. A local official
said the authorities could not intervene [19] .
South Africa has a particular problem with forced circumcisions. In
1999 there was a grisly report of young people being kidnapped,
forcibly circumcised and then held for ransom. Those who
threatened to expose the people involved were threatened with
death. The bodies some of the kidnapped victims were found in
shallow graves. The decomposed body of one victim was found –
with the genitals cut off. [20]
In July 2004, when Litha Ntshoza, was seized by relatives,
dragged to a field, stripped naked and forcibly circumcised there
was an outcry. But not from everyone. Litha’s father said the forced
circumcision was for his own good.. When Litha fled the ceremony,
bleeding and naked, two policemen took him back to the
ceremony. Tribal authorities fined the father because his son ran
away from the ceremony [21] South African anti-
circumcision campaigner, Dean Ferris, said that circumcision
without consent, was "unacceptable and illegal,". However, Rabbi
Ruben Suiza, registrar of the Jewish Ecclesiastical Court,
responded that "to stop circumcision would be to prevent Jews
from practicing their religion."[22]
In November 2002 Chief Mwelo Nonkonyana, the provincial
chairman of the Congress of National Traditional Leaders of South
Africa, said traditional leaders would never tolerate hooligans
demeaning the custom of circumcision. He called for the traditional
surgeon to be prosecuted along with the 30 men who abducted
and forcibly circumcised a 48-year-old Port Elizabeth man to be
charged,[23] [24] .
However, early in 2005, when relatives seized a man and forcibly
circumcised him, and the police rescued him and arrested and
charged the man’s wife and other family members with assault
[25] , traditional chiefs were contesting the ‘Westernised’ law that
banned forcible circumcisions [26] . In July 2005, when a 35 year
old man who was forcibly circumcised died, the police treated the
death as a murder [27]. In the Transkei region, when three
initiation candidates died after being circumcised, the traditional
healer who ran the circumcision school where one of the victims
was circumcised was charged under the Eastern Cape’s
circumcision law and denied bail.[28]
These cases show that forced circumcision is a significant issue in
itself and a sign of other human rights abuses. A firm stand
against forced circumcisions would go a long way towards
alleviating this problem. However, there is a reluctance to accept
the evidence. Despite the clear evidence in the Sydney Morning
Herald of forced circumcisions in Ambon, Indonesia, a spokesman
for Lascar Jihad claimed that though circumcisions took place, no-
one was forced to do anything. The BBC report was headed,
‘Maluku refugees allege forced circumcision’ Thus the BBC
reduced the outrage to a mere allegation. Also, the defensive
reaction of Rabbi Suiza to Dean Ferris’s contention that forcible
circumcision was illegal, while understandable as a reaction to an
anti-circumcision campaigner, shows that action against the
obvious abuse of forcible circumcision could face opposition if it is
perceived as an attack on circumcision itself.
Forced circumcisions are clearly wrong. There is no religious or
other justification for them. They are totally unacceptable. Nor is it
acceptable to dismiss these outrages as isolated instances of
abuse, where little or nothing can be done. In fact, firm action can
stop these abuses.
When 18 children in Kirani High School in Meru, Eastern Kenya
were bullied and threatened by older boys because they were not
circumcised, the Principal sent the younger boys home to be
circumcised.[29] However, the Education Minister
George Saitoti said the action was uncalled for and against
ministry regulations. "We abhor such a practice and we shall not
give any chance to this kind of primitive action in our schools," said
Mr Saitoti.[30] This action was controversial for many,
but it did make a forceful stand for the rights of students, regardless
of circumcision status [31] . Similarly, all who support
human rights must support a firm and public stand against forced
circumcisions. This is vital, especially in a climate when mass
circumcision is being so vigorously promoted.
Michael Glass
References:
[1] Lindsay Murdoch, ‘Terror attacks in the name of
religion’The Sydney Morning Herald, Sydney, NSW, Australia,,
Saturday January 27, 2001. http://www.cirp.org/news/
morningherald01-27-01/
[2] Ibid.
[3] ‘Christina’s story’, Sydney Morning Herald, 27
January 2001 http://old.smh.com.au/news/0101/27/review/
review9.html (accessed 12 January 2003)
[4] , Michael Glass, ‘The double standard for male and female
suffering’, Journal of Medical Ethics, letters 22 November 2005,
http://jme.bmjjournals.com/cgi/eletters/31/8/463
(accessed 12 October 2006)
[5] The Koran: 2:256
[6] Iran Chamber Society, Religions of Iran
“Thousands of Iranians were enslaved by Arabs one way to get out
of slavery was to become Muslims since Muslims could not be
enslaved and as a result many converted. All these pressures,
humiliation at the time of paying jizya, deliberate destruction of
temples and forced conversions resulted in massive conversions.
There are accounts of Muslim rulers forcing mass circumcision on
the newly converted males to make sure they had truly become
Muslims.”http://www.iranchamber.com/religions/articles/
zoroaster_zoroastrians_in_iran.php
[7] Robert Darby, ‘A Surgical Temptation: The
Demonization of the Foreskin and the Rise of Circumcision in
Britain’, The University of Chicago Press, Chicago & London,
2005, ISBN 0-226-13645-0, page 33
[8] K.N. Pandita, On the Sidelines of Kashmir History Kashmir
Herald, May 15 2007, http://www.kashmirherald.com/main.php?t=
OP&st=D&no=263 accessed 16 May 2007
[9] The History Place, Genocide in the 20th Century,
Armenians in Turkey, 1915-1918 1,500,000 deaths http://
www.historyplace.com/worldhistory/genocide/armenians.htm
[10] Kathimerini, Greece’s International English
Language newspaper, Tuesday June 28, 2005 – Archive,
(accessed 5 August 2006) http://www.ekathimerini.com/4dcgi/
_w_articles_ell_6506581_28/06/2005_57964
A former slave writes of "the rape of girls and boys alike, the
forced
circumcision of boys and girls, often with them fully conscious and
screaming and having to be held down by many people. Sodomy
and sadistic torture are common. Living hell."
[13] Former sex worker’s tale spurs rescue mission,
Gulf Times, Doha, Qatar,
10 April, 2005, http://www.gulf-times.com/site/topics/
article.asp?cu_no=2&item_no=32822&version=1&template_id=
44&parent_id=24 <http://www.gulf-times.com/site/topics/
article.asp?cu_no=2&item_no=32822&version=1&
amp;template_id=44&parent_id=24> , accessed, 25 May
2007.
[14] ‘Court awards man $10 000 for beer bottle
circumcision’ http://www.cirp.org/news/1997.10.08_Australia/
[15] Man forcibly Circumcised as Crowd Watches,
The Nation, Nairobi, Kenya, 23 August 2002 http://www.cirp.org/
news/thenation08-23-02/
[16] Ayub Savula ,“Six ministers on violence List of
Shame” The East African Standard, Nairobi, Kenya, Saturday
November 12, 2005
[17] Ouma Wanzala “Man held over circumcision
incident,” Kenya Times, 2006. http://www.timesnews.co.ke/
18aug06/nwsstory/news5.html
[18] ‘Drama As 'Cut' Youth Hits Back’. The East
African Standard, Nairobi, Kenya, 15 August 2002. http://
www.cirp.org/news/eastafricanstandard08-15-02/
[19] ‘Bagisu flee circumcision’, The Monitor,
Kampala, 25 August 2004 http://allafrica.com/stories/
200408250493.html
[20] Sibusiso Bubesi, ‘Children kidnapped and
mutilated Boy threatened with death after investigation into
circumcision Sunday Times, South Africa, 14 March 1999
The article by Stuart Rennie, Adamson Muula and Daniel Westreich
[JME, 33:357], which focuses on the promotion of male circumcision for
public health purposes, raises many practical issues, economic issues and
ethical issues. The ethics of male circumcision have been already widely
discussed, especially from a physician perspective [1]. Here we focus on
the arguments developed by Rennie and colleagues...
The article by Stuart Rennie, Adamson Muula and Daniel Westreich
[JME, 33:357], which focuses on the promotion of male circumcision for
public health purposes, raises many practical issues, economic issues and
ethical issues. The ethics of male circumcision have been already widely
discussed, especially from a physician perspective [1]. Here we focus on
the arguments developed by Rennie and colleagues with emphasis on the
population perspective.
Firstly, to recommend systematic male circumcision, a genital
mutilation, as a public health policy raises in itself many ethical
concerns. Even with solid epidemiological evidence, male circumcision
would not be considered acceptable in most European, Latin-American or Far
-East Asian countries, for a variety of reasons ranging from low efficacy
to lack of cultural acceptance.
Secondly, male circumcision violates basic principles of ethics:
1) Autonomy: To achieve full efficiency such a policy would have to focus
on neonatal circumcision. In this case however, it would violate basic
children’s rights, and would be illegal in a variety of countries. As the
authors rightly point out, if recommended in adolescence or adulthood it
would have a much lower acceptance rate. The argument of “child’s best
interest” is highly controversial, since it all depends on who defines it.
A European, Latin-American or Far-East Asian family will usually consider
their child’s best interest to remain uncircumcised. Comparison with
recommended vaccines (authors quote DPT) is misleading since these
vaccines have a very high efficacy, a very low rate of complications, no
stigma associated with them, and provide huge population benefits at low
cost. As a result, most parents all over the world consider vaccination to
be in their child’s best interest.
2) Non-malevolence (first do no harm): Male circumcision does harm the
person who endures it: numerous risks associated with the surgical
procedure have been described, including death, and in addition male
circumcision reduces the sensitivity of the glans, and induces
stigmatisation. Furthermore, mass circumcision in countries with poor
hygiene could lead to transmission of infectious diseases, ranging from
Hepatitis B and C to HIV.
3) Benevolence: The assumed “benevolence” is also highly questionable, and
this has been a recurrent issue over the past 150 years. Male circumcision
has been presented as a prevention against a wide array of infectious
diseases, cancers, non-communicable diseases, mental disorders, without
any serious epidemiological proof. Countries practicing widely male
circumcision have basically the same morbidity rates for these conditions
as others, and in particular for sexually transmitted infections [2, 3].
At the individual level, male circumcision offers no protection per
se, and most agree that, circumcised or not, when exposed during an
intercourse with an infected partner the only protection is to use a
condom. When exposed repeatedly, the reduced risk of transmission
associated with circumcision will simply delay the date of infection.
The potential population impact is worth considering, since a
reduction in the risk of contamination by males could have some kind of a
population impact. However, empirical evidence from Africa tells a
different story: a meta-analysis of the 11 DHS/AIS surveys conducted in
Africa with data on both male circumcision and HIV seroprevalence indicate
the same level of infection for circumcised and uncircumcised men (Odds
ratio= 0.97, P= 0.264). These data are collected independently, on large
representative samples of the general population, totalling 47976 men, and
constitute probably the most convincing piece of evidence of the
population impact of male circumcision. Hiding this fact also raises some
important ethical issues.
Alternative strategies:
Other strategies do exist to control the spread of HIV/AIDS. A mix of
changing sexual behaviour (in particular reducing number of partners for
young adults) and systematic condom use for risky intercourse were shown
to be effective in changing the course of HIV epidemics in various
settings, including in Africa [4]. Is it ethical to recommend a strategy
for which no population impact has ever been shown, when alternative
efficient strategies do exist? In the field of fertility control,
contraceptive methods with low efficacy in clinical trials (such as the
rhythm method) are not recommended because alternative strategies exist
and are more effective. Similarly, in the field of vaccination, vaccines
with low efficacy (such as the cholera vaccine) are not recommended,
because again alternative strategies exist.
Lastly, a large program focused on male circumcision might reduce the
public efforts already made in the prevention of HIV, and might give false
hope to persons who will consider themselves as somehow protected. Both
are likely to have negative consequences.
References:
[1] Doctors opposing male circumcision. Medical ethics and the
circumcision of children. Report, 2006. [available on web site:
http://www.doctorsopposingcircumcision.org/pdf/A4-MedicalEthicsReport.pdf
[2] Darby R. A surgical temptation. Chicago: University of Chicago Press,
2005.
[3] Aggleton P. Just a snip? A social history of male circumcision.
Reproductive Health Matters, 2007;15(29):15-21.
[4] Low-Beer D, Stoneburner RL. Behaviour and communication change in
reducing HIV: is Uganda unique? African Journal of AIDS Research, 2003;
1(2):9-21.
Michael Potts emphasized that the social acceptance of BD since the Harvard Report was induced by the longing to find organ for transplants. We agree that the final success of transplants was improved by refining the BD concept. Nonetheless, when in 1959 the first accounts of BD were published, organ transplant surgery was in its first steps.(1)
Potts also argued about accepting BD. Some scholars who wer...
Michael Potts emphasized that the social acceptance of BD since the Harvard Report was induced by the longing to find organ for transplants. We agree that the final success of transplants was improved by refining the BD concept. Nonetheless, when in 1959 the first accounts of BD were published, organ transplant surgery was in its first steps.(1)
Potts also argued about accepting BD. Some scholars who were strong defenders of BD are now favoring a circulatory-respiratory view.(2, 3, 3) Shewmon remarked that clinical findings in BD are more attributable to multisystem damage and spinal shock than to brain destruction per se.(3)
However, this author accepted that the brain plays a role in integrating functions, using as an example the psychoneuroimmunology. He emphasized that "the brain role is one of modulating, fine-tuning, and enhancing an already established and well functioning immune system". If we accept Shewmon's view, then a specific emotional state could influence the immune system, either diminishing or enhancing the immune response. We can ask ourselves: Can we consider this brain's effect over other systems, of "modulating" or “fine-tuning", the highest level of integration within the organism?(4)
Korein and Machado proposed that the critical system of the human being is the brain, which is irreplaceable by an artifice, be it biological, chemical, or electromechanical. This critical system of the brain (CSB) is the minimal irreplaceable anatomical substrate of those functions that are utilized by the organism as a whole towards behavior that will result in decreased entropy production.(5)
The classical definition of cardio-respiratory death, as used in medicine, is incomplete and cannot be applied in many situations. Hence, we defend the concept of BD as death of the individual.(4, 5)
Epstein remarked that we defended that the concept of (brain death) BD evolved independently of social interests. There is a relationship between organ transplants and BD. Nonetheless, during the fist half of the XX century both the development of BD concept and transplantation evolved completely independent.(6)
We also agree that BD was canonized by the Harvard Committee,(7) although Dr. Machado demonstrated that the first organ transplant using a brain-dead donor was performed by Alexandre, in 1963. Moreover, at late ‘50s and early ‘60s, surgeons brought a donor into the operating room with the recipient for the removal, stopping the respirator until the donor’s heart ceased to beat. Hence, donors had been declared dead by cardio- respiratory criteria, and technically, those donors were not brain-dead.(8)
Wijdicks recently commented about a widespread apprehension that in the Committee transplant physicians played a main role to delineate BD, to impel organ transplants. Wijdicks remarked: “I am uncertain after reading the documents whether an alleged agenda of facilitating transplantation through a new construct of death existed.” He concluded that neurologists played a major role in the Committee.(7)
Epstein also commented that a cardio-respiratory view of death seems to come back. This is an extremely dangerous precedent. (8) If surgeons declare death within minutes after heart stops, without fulfilling BD criteria, for us these subjects are not dead. What would happen with those cases suffering accidental hypothermia combined with circulatory arrest, who were rewarmed to normothermia by use of extracorporeal circulation, with good outcome in several cases. The neuroprotective effect of hypothermia demonstrates that the brain is the target organ after cardiac arrest. Hence, death occurs after cardiac arrest when ischemia and ischemia is sufficiently prolonged to destroy the brain.(6, 9) .
David W. Evans agreed with us that the concept of BD was certainly built up in separation from organ transplant practice. We also agree with Evans that Barnard’s first successful cardiac transplantation prompted to settle BD diagnostic.(10) Although we have previously remarked on Alexandre’s contribution performing the first even known organ transplant using a brain-dead donor in 1963.(11)
Long before modern technology, everyone agreed that death occurred when heartbeat and breathing ceased. Nonetheless, the concept of death evolved as technology progressed, forcing medicine and society to redefine the ancient cardiorespiratory diagnosis to a neurocentric view of death.(12,6) Historically, It is important to remember, the papal allocution of Pope Pius XII in 1957 to a group of Italian anesthesiologists regarding the limitation of resuscitation.(7)
There are still worldwide controversies regarding the concept of death and the putative neurological grounds for diagnosing it. Moreover, a group of scholars who were strong defenders of a brain-based standard of death are now favoring a circulatory-respiratory view. Hence, the debates on human death are far from concluded.(13-15)
This has stimulated us to hold Coma and Death Symposia in Cuba since 1992, every 4 years.(16) The 5th International Symposium of the Definition of Death Network will be held in Varadero Beach, Cuba, on May 20-23, 2008.
Calixto Machado
President of the National Cuban Commission for the Determination of Death
Institute of Neurology and Neurosurgery
Julius Korein, Yazmina Ferrer, Liana Portela, Maria de la C. Garcia, Jose M. Manero
References:
1. Barnard CN. The operation. A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town. S Afr Med J 1967;41:1271-1274.
2. Machado C. The first organ transplant from a brain-dead donor. Neurology 2005;64:1938-1942.
3. Fischgold H and Mathis P. Obnubilations, comas et stupeurs. Electroenceph.clin.Neurophysiol 1959;Suppl No 11 (Masson et Cie, Paris):126.
4. Korein J. The problem of brain death: development and history. Ann N Y Acad Sci 1978;315:19-38.
5. Pius XII. The prolongation of life (an address of Pope Pius XII to an International Congress of Anesthesiologists. November 24, 1957). The Pope speaks 1958:393-398.
6. Machado C. Consciousness as a definition of death: its appeal and complexity. Clin Electroencephalogr 1999;30: 156-164.
7. Korein J, Machado C. Brain death: updating a valid concept for 2004. Adv Exp Med Biol 2004;550:1-14.
8. Korein J. Ontogenesis of the fetal nervous system: the onset of brain life. Transplant Proc 1990;22: 982-983.
9. Machado C. Havana and the coma and death symposia. N Engl J Med 2004;351(11):1150-1151.
10. Machado C, Korein J, Ferrer Y, Portela L, De la C García M, and Manero JM. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197-200.
11. Potts M. A requiem for whole brain death: a response to D. Alan Shewmon's 'the brain and somatic integration'. J Med Philos 2001;26: 479- 491.
12. Shewmon DA. Spinal shock and brain death': somatic pathophysiological equivalence and implications for the integrative-unity rationale. Spinal Cord 1999;37: 313-324.
13. Machado C, Korein J, Ferrer Y, Portela L, De la C Garcia M, and Manero JM. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197-200.
14. Wijdicks EF. The neurologist and Harvard criteria for brain death. Neurology 2003;61: 970-976.
15. Korein J. Brain states: Death, Vegetation, and life. In: Cotrrell JE, Turndorf H (eds). Anaesthesia and Neurosurgery, 2nd edn. New York: C.V. Mosby Co, 1986: 293-351.
16. Landau WM, Schneider S, Machado C, Longstreth Jr WT, Fahrenbruch CE, Olsufka M, Walsh TR, Copass MK, and Cobb LA. Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac arrest. Neurology 2003;60:1868-1869.
The author offers his personal interpretation on a number of themes
that have been at the centre of a heated debate in Italy in the past few
years. Scientists, ethicists, and politicians have expressed their views
on these themes, moreover the mass media and the public opinion have
pinned a great attention to them. The author refers to a number of topics,
including, for instance, genetically modified fo...
The author offers his personal interpretation on a number of themes
that have been at the centre of a heated debate in Italy in the past few
years. Scientists, ethicists, and politicians have expressed their views
on these themes, moreover the mass media and the public opinion have
pinned a great attention to them. The author refers to a number of topics,
including, for instance, genetically modified food, the so-called “Di
Bella case”, the referendum on assisted reproduction and others.
However, the abstract of the article only mentions the referendum on
assisted reproduction and particularly the fact that, according to him
“The Italian political e [sic] bioethical debate on assisted reproduction
was manipulated by the Catholic Church, which distorted scientific data
and issues at stake with the help of Catholic politicians and
bioethicists”. The author brings a serious and hard charge against the
Catholic Church, that shall certainly stimulate the interest of every
reader. Nevertheless, the text presents a series of personal
reconstructions and interpretations on several topics, but the Catholic
Church is not mentioned any more in the text. A simple rule of the
cultural and scientific debate consists in explaining one’s declarations.
Therefore, the author is required to mention the bibliographical
references stating that the “Catholic Church” reportedly had “distorted
scientific data and issues”, so as to allow the alleged “falsifiers” to
reply.
While trying to make out what the hits expressed in the abstract and left
undeveloped in the text refer to, it is easy to believe that the author
shared an opinion widely supported by some Italian political parties,
whereby the pre-referendum debate saw an undue interference of the Italian
Church that revealing its opinion supposedly imposed choices that pertain
to every individual’s free conscience. This is an old story: leaving
freedom of conscience. How could anyone oppose to this? The referendum
required a choice on the sanctity of human life. Before such a far-
reaching theme and in the name of pluralism, every social individual in
Italy expressed their point of view. Denying such right to the Church is a
serious mistake, also because it will be up to the citizens anyway to
accept or not the evaluations expressed by the Church according to their
conscience and spiritual and cultural background.
Calixto Machado and his colleagues (1) claim that because the
development of organ transplantation and brain death originally developed
independently, that “the concept of brain death did not evolve to benefit
organ transplantation.” This is a classic non sequitur, since it remains
possible that the contemporary development of brain death criteria from
the Harvard Report (2) on was influenced by the de...
Calixto Machado and his colleagues (1) claim that because the
development of organ transplantation and brain death originally developed
independently, that “the concept of brain death did not evolve to benefit
organ transplantation.” This is a classic non sequitur, since it remains
possible that the contemporary development of brain death criteria from
the Harvard Report (2) on was influenced by the desire to find
transplantable organs. The Harvard Ad Hoc Committee Report explicitly
states that “Obsolete criteria for the definition of death can lead to
controversy in obtaining organs for transplantation” (2), with the obvious
implication that such controversy should be avoided. Three years after the
publication of the Harvard Committee Report, Beecher and Dorr (3) state
that one of the reasons for the Harvard Criteria “was to increase the flow
of organs for transplantation,” and they continue, “there is indeed a life
-saving potential in the new definition, for, when accepted, it will lead
to greater availability than formerly of essential organs in viable
condition, for transplantation, and thus countless lives inevitably will
be saved.”
Even if Machado et al. were correct in their claim about the
development of the brain death concept, brain death criteria themselves
have come under increasing criticism (4, 5). The conceptual basis for the
U.S. “whole brain” criteria, the belief that whole brain death means the
loss of integrated organic unity in a human being, has been subjected to a
powerful critique by neurologist Alan Shewmon (6). Some physicians are
questioning whether we can be sure the entire brain is really dead in
patients declared dead by whole brain (US) or brainstem (UK) criteria (7).
This suggests that physicians who support removing organs from “brain
dead” individuals should take a second look at the evidence in favor of
brain death criteria if they wish to avoid removing organs from patients
who may well still be alive.
References:
1. Machado et al. The concept of brain death did not evolve to
benefit organ transplants. J Med Ethics 2007;33:197-200
2. Ad Hoc Committee of the Harvard Medical School to Examine the
Definition of Brain Death. A definition of irreversible coma. JAMA
1968;205:85-88.
3. Beecher HK, Dorr HI. The new definition of death: some opposing
views. Int. J. Clin. Pharmacol. 1971;5:120-124.
4. Potts M, Byrne PA, Nilges RG (eds.). Beyond Brain Death: The Case
Against Brain Based Criteria for Human Death. Dordrecht, The Netherlands:
Kluwer Academic Publishers, 2000.
5. de Mattei R (ed). Finis vitae - is brain death still life?
National Research Council of Italy, Rubbettino Editore, 88049 Soveria
Mannelli (Catanzaro), 2006.
6. Shewmon DA. Chronic ‘brain death’: meta-analysis and conceptual
consequences. Neurology 1998;51:1538-1545.
7. Evans DW. What is brain death: a British physician’s view. In de
Mattei R (ed). Finis vitae - is brain death still life? pp. 99-105.
National Research Council of Italy, Rubbettino Editore, 88049 Soveria
Mannelli (Catanzaro), 2006.
We have a clinical case of a woman 77 y.o. with gastric cancer that
was sent home to die and to get morphine as an ultimate resource to
control pain or reduce pain.
We started to treat her with an extract of Calendula officinalis
(hydroalcoholic: 6%Ethanol, 2% Calendula flores, a spoonfull 3 times a
day, and her reaction is incredible. After 6 months of treatment she has
no pain, has a normal life...
We have a clinical case of a woman 77 y.o. with gastric cancer that
was sent home to die and to get morphine as an ultimate resource to
control pain or reduce pain.
We started to treat her with an extract of Calendula officinalis
(hydroalcoholic: 6%Ethanol, 2% Calendula flores, a spoonfull 3 times a
day, and her reaction is incredible. After 6 months of treatment she has
no pain, has a normal life for her age and her hemoglobin that was 4.0 g/dL is
now 12.5 g/dL
If this should be called palliative medicine, then I am not a scientist
with 40 years of experience.
Thanks for your attention.
P.D.
We will keep you up to date with the follow up of this patient.
--Part of a traditional nursery rhyme, quoted in Lewis Carroll,
Alice’s Adventures in Wonderland, Chapter 11.
Alice watched the White Rabbit as he fumbled over the list, feeling
very curious to see what the next witness would be like, `--for they
haven't got much evidence YET,' she said to herself.
--Lewis Carroll, Alice’s Adventure’s in Wonderland, Chapter 11.
In the complete version of the traditional nursery rhyme part of
which is quoted above the Knave of Hearts is found guilty of wrongdoing,
and beaten for this by the King of Hearts. In quoting the full version of
this rhyme as the epigraph to the letter that she wrote in response to my
article “A Queen of Hearts trial of organ markets: why Scheper-Hughes’s
objections to markets in human organs fail,” Professor Scheper-Hughes
seems to be implying that I, as the Knave, am guilty of wrongdoing—in
particular, of mischaracterizing her position. In what follows, however, I
will show that, just like the charges leveled against the Knave in Alice’s
Adventure’s in Wonderland, there is no evidence for the charges that
Professor Scheper-Hughes levels against me.
1. Mischaracterization
Professor Scheper-Hughes is right to note that I claim that she
mischaracterizes the pro-market position, but she is wrong to claim in
response that “the reverse is the case”. Although, for reasons that I will
outline below, it is difficult to know whether we should take Professor
Scheper-Hughes’s claims at face value, if we do so here we should
understand Professor Scheper-Hughes as claiming both that she does not
mischaracterize the views of persons who favour markets in human organs,
and that I have mischaracterized her views. Let me address these claims in
turn.
In my article I note that her claim that those who defend markets in
human organs presuppose that persons have a right to purchase life in the
form of human organs is mistaken, for “not all who advocate such a market
believe that people have a right to buy” (2007, p. 201). In response to my
charge Professor Scheper-Hughes notes that “a great many pro-market
scholars and bioethicists, including Janet Radcliffe -Richards , Abdullah
Daar , and Arthur Matas have defend a 'right to buy and to sell organs'
based on principle of individual liberty and autonomy”. But noting this
does nothing to undermine my claim that she was mistaken to claim that all
proponents of markets in human organs defend such a right. That some
persons who support such markets do does not show that all do. Professor
Scheper-Hughes also holds that a “right to buy” might function implicitly
in the arguments that Mark J. Cherry and I offer in favour of markets in
human kidneys. While I cannot speak for Cherry, I can reiterate a point
from my “Queen of Hearts” article; that “we can hold that it is morally
permissible for a person to offer to buy an organ from another to save his
or her own life, without thereby holding that people have the right to
make such offers to buy, for we can hold that such offers are permissible
while denying the existence of rights” (2007, p. 202). Since I made it
clear in that article that my arguments in my book Stakes and Kidneys: Why
markets in human organs are morally imperative had a broadly utilitarian
basis it should also be clear that rights play no role in them. As such,
then, my charge that Professor Scheper-Hughes has mischaracterized the
views of the proponents of markets in human organs stands.
What, then, of her charge that I have mischaracterized her position?
Professor Scheper-Hughes claims that her arguments “are not with moral
philosophers and academic bio-ethicists,” but “with the organs brokers,
kidney buyers, medical insurance companies and rogue surgeons involved in
illegal transplants with organs procured through unregulated black
markets,” and “with Ministries of Health, medical credentialing boards,
international transplant societies and policing institutions that have
generally failed to interrupt, correct, disbar, and/or prosecute those
involved in breaking existing laws as well as international regulations”.
There are three points to be made with respect to this response. First,
Professor Scheper-Hughes seems to concede my point that she sentences
markets in human organs “to moral condemnation before considering the
arguments for them” (2007, p.201). Rather than supporting her claim that I
have mischaracterized her position, then, her response seems instead to
undermine it. Second, Professor Scheper-Hughes’s claim that her arguments
are not typically with academic bioethicists is unfounded. To be sure, as
I note above, she does not often engage with their arguments. But even in
her articles that are not written as ethical debates or as reviews of
books on bioethics she does write as though her work is critical of
theirs. Of the eight anthropological articles written by Professor Scheper
-Hughes that I cite in my article, seven include explicit criticisms of
academic bioethicists as being unable “to break ranks with powerful
biomedical and pharmaceutical interests,” (2004, p.59) and of adhering to
a discipline “which has been finely calibrated to meet the needs of
advanced biomedicine/ biotechnologies and the desires of postmodern
medical consumers” (2003g, p.204). Indeed, Professor Scheper-Hughes
approvingly quotes Francis Fukuyama’s claim that the “community of
bioethicists” has “grown up in tandem with the biotech industry” and is at
times “nothing more than sophisticated (and sophistic) justifiers of
whatever it is the scientific community wants to do”. (2004d, p.204). To
claim that her arguments are “not with or about” academic bioethics is
thus disingenuous. Third, even if we grant to Professor Scheper-Hughes
that her arguments are typically addressed only to those persons who are
engaged in, or who enable, black markets in human organs, this does not
salvage any part of her anti-market stance. Almost no one, whether pro-or
anti-market, would defend the fraudulent and coercive practices that her
research has exposed. As such, if her arguments are only leveled against
such practices unless she explicitly notes otherwise, then they are simply
orthogonal to the mainstream debate concerning whether or not markets in
human organs should be legalized.
2. The Language of Deconstruction
In Alice’s Adventures Through the Looking Glass Humpty Dumpty said
that when he used a word “it means just what I choose it to mean --
neither more nor less.” Professor Scheper-Hughes seems to have adopted the
same policy towards words in her earlier work concerning the shortage of
available transplant organs. The most natural reading of Professor Scheper
-Hughes’s claims that the current scarcity of transplant organs is
“invented” and “artificial” is that she believes that it is not real—and
hence that there is less of a medical need for transplant organs than is
generally believed. This is the claim that I criticized in my article. I
am pleased to see that Professor Scheper-Hughes has now clarified her
position here, using the language of English rather than “the language of
deconstruction” to do so, and acknowledges the very real and pressing
shortage of organs available for transplantation.
Although it is not a response to my claims, it is worth noting that
Professor Scheper-Hughes’s concerns about the “futility” of transplanting
organs into people over 70 years old are misplaced. In a recent article in
Transplantation Rao et al. showed that such transplant recipients had a
41% lower overall risk of death than did wait-listed candidates—figures
that show that their organ transplants were hardly futile.
3. Concentration camps and invisible sacrifice
Professor Scheper-Hughes claims that I mischaracterized her views
concerning presumed consent, noting that she never equated “deviant or at
best semi-legal practices in public morgues with organized, normative and
transparent policies of presumed consent (opting out) as exist in central
Europe and as was attempted (in good faith) in Brazil in 1997”. However,
just as Professor Scheper-Hughes never equated deviant practices in public
morgues with transparent policies of presumed consent, I never claimed
that she did. Rather, I noted in my article that she compared “the use of
policies of presumed consent…with the atrocities that ‘highly deviant
authoritarian and police states’ have visited upon their citizens”. In
support of this claim I quoted the following passage from Professor
Scheper-Hughes’s article “The end of the body”: “Until very recently, only
highly deviant authoritarian and police states—Nazi Germany, Argentina in
the 1960s and 1970s, and South Africa under apartheid—had assumed this
capacity in the 20th century…” (2003, p.110). The “capacity” mentioned in
this passage was the capacity “to define and determine the hour of death
and to claim…the ‘first rights’… to the disposal of the body parts” (2003,
p.110)—a capacity, that is, of states to secure parts of the bodies of its
recently-deceased citizens, such as through policies of presumed consent.
Immediately following this quoted passage Professor Scheper-Hughes wrote
that “The ‘democratization’ of practices bearing at least some family
resemblance to these (i.e., the ‘living dead’ maintained in intensive care
units for the purposes of organ retrieval) in neo-liberal states has
generally occurred in the absence of public outrage or resistence, with
the possible exception of public unrest following democratic Brazils’
[sic] passage of its authoritarian law of ‘presumed consent’ to organ
donation in 1997…” (2003, p.110). Unless these passages too are written
“in the language of deconstruction” and thus do not mean what they mean in
the language of English, it clear that Professor Scheper-Hughes was
comparing the institution of polices of presumed consent in liberal
democracies to the actions of deviant police states. My claim that she did
so is thus an accurate one.
In fairness, however, it should be noted that Professor Scheper-
Hughes has now defended the institution of policies of presumed consent,
in at least one article (published, incidentally, after mine appeared).
This, though, seems to be reversal of her earlier position—just as she has
now altered her characterization of Brazil’s institution of a policy of
presumed consent.
4. The trade in living organs
Professor Scheper-Hughes claims that I “leap” from her “discussions
of tissues harvesting from the dead to living, voluntary sale of organs”.
But, as I make clear in my article, this move is hers, not mine. In her
article “The End of the Body”, from which the above quotations concerning
“deviant authoritarian and police states” come, Professor Scheper-Hughes
moves from this characterization of the types of society that try to
reduce their waiting lists using policies of presumed consent, to a
discussion of using markets to reduce organ waiting lists. As I note in my
article, it appears that she is trying to tar all such methods of organ
procurement with the same brush. The purpose of my discussion of her segue
here is simply to note that “there is a vast ethical gulf” between forcing
persons to perform certain actions, and the voluntary transactions of a
marketplace free from coercion and fraud.
Professor Scheper-Hughes challenges me to provide evidence for my
assertion that “voluntary trades in human organs that take place between
consenting adults, untainted by force or fraud, make all parties to them
better off,” noting that “[t]o date, however, all empirical studies of
living kidney donors indicate varying degrees of coercion, deception,
feelings of exploitation, shame, and resentment following arranged kidney
sales”. There are three responses to this. First, none of the empirical
studies she refers to concern markets “untainted by force or fraud”. As
such, they are irrelevant to my claim. Second, Professor Scheper-Hughes
need only look around her to find indirect evidence for my claim. It is
simply undeniable that voluntary market transactions typically make all
parties to them better off; this is precisely why the parties to them
transacted in the first place. To be sure, we might not have direct
evidence of this with respect to markets in human organs—but that is only
because persons such as Professor Scheper-Hughes have succeeded in
coercively prohibiting persons who wish to engage in a legal and properly
regulated market in them from doing so. Finally, it should be noted that
to advocate the continued prohibition of a properly regulated market in a
good, and then to justify one’s position on the grounds that there is no
empirical evidence to show that it could function ethically for no such
market currently exists, is more than a little Kafkaesque.
5. Scheper-Hughes’s anti-market arguments
Professor Scheper-Hughes is, of course, correct to note that she has
“never used the word 'repulsive' or any word resembling 'repulsive' with
respect to markets in kidneys”. I did not, however, claim that she had.
Instead, I argued that in the absence of any explicit arguments offered by
her to oppose markets in human kidneys, three could be developed from her
work: The Argument from Interpersonal Coercion, the Argument from the
Black Market, and the Argument from Repugnance. Noting that I have
addressed the first two of these arguments elsewhere, I briefly addressed
the final argument in my article. Given that Professor Scheper-Hughes
wishes to disavow this argument, however, it seems that she has no
principled reason to oppose properly regulated markets in human kidneys.
Professor Scheper-Hughes claims that she has “been able to see and
hear and document in the field and on the ground” that the markets in
human kidneys that she has observed are “exploitative, unfair, unjust, and
unsafe for buyers and sellers”. It is no doubt true that participation in
the illegal markets that she has observed is unsafe for both buyers and
sellers. However, it is deeply puzzling as to how Professor Scheper-Hughes
has seen and heard exploitation, unfairness, and injustice. These are
normative concepts, and, as such, simply cannot be observed in the way
that Professor Scheper-Hughes claims to have observed them—at least, not
with the human senses that sciences recognizes. One has to argue that a
practice is exploitative, unfair, or unjust after arguing for one’s view
of the conditions that must be met for these adjectives properly to
apply—and it is precisely Professor Scheper-Hughes’s lack of arguments in
these respects that I was decrying in my article.
Finally, Professor Scheper-Hughes is mistaken to attribute the
(mis)quotation “Nothing that is human disgusts me” to the Carthaginian
theologian (rather than “Greek philosopher”) Tertullian. The closest
classical quotation to this is from Publius Terentius Afer’s Heauton
Timoroumenus: “Homo sum: humani nil a me alienum puto” (roughly, “I am a
human being, so nothing human is strange to me”). This quotation from
Terentius, however, will not do the work that Professor Scheper-Hughes
wishes it to do, since something might still disgust one even if it is not
strange to one. Perhaps, though, she was thinking of the rather more
modern quotation “Nothing human disgusts me…” uttered by Hannah Jelkes in
Tennessee Williams’s The Night of the Iguana. But, if this is so, then had
Professor Scheper-Hughes concluded it (“…Mr. Shannon, unless it's unkind,
violent) she would have realized that it this quotation was inappropriate,
given that she considers markets in human kidneys to be both “unkind,
violent”. Alas, though, this is not the first time that Professor Scheper-
Hughes seems to have had problems with quotations. In her paper “Keeping
an eye on the global traffic of human organs,” she attributes the
quotation “They call us prostitutes. Actually, we are worse than
prostitutes because we have sold something we can never get back” to a 27-
year old kidney seller called Niculae Bardan from a village called Mingir,
Moldova (2003f, p.1647). However, in her later paper “Rotten trade:
millennial capitalism, human values and global justice in organs
trafficking,” she attributes almost the same quotation (“We [kidney
sellers] are worse than prostitutes because what we have sold we can never
get back…”) to another 27-year old kidney seller, Viorel, from Chisenau,
the capital of Moldova (2003g, p.200). Perhaps, though, it is just the
case that some of the persons that she interviewed have very similar
views—and very similar ways of expressing them.
References:
Scheper-Hughes, N. In Defense of the Body from the Queen of Hearts to
the Knave of Hearts. eLetter, J. Med. Ethics. (23 April 2007).
http://jme.bmj.com/cgi/eletters/33/4/201#1532
Taylor, J.S.. A "Queen of Hearts" trial of organ markets: why Scheper
-Hughes’s objections to markets in human organs fail. J Med Ethics 2007;
33: 201-204.
Cherry, M.J.. Kidney for sale by owner: human organs,
transplantation, and the market. Washington, DC: Georgetown University
Press, 2005.
Taylor, J.S.. Stakes and kidneys: why markets in human body parts are
morally imperative. Aldershot, UK: Ashgate Press, 2005.
Scheper-Hughes, N. Parts unknown: undercover ethnography of the
organs-trafficking underworld. Ethnography 2004; 5: 29-73.
Scheper-Hughes, N. Rotten Trade: millennial capitalism, human value
and global justice in organs trafficking. J. Hum Rights 2003g; 2: 197-226.
Rao, P.S., Merion, R.M., Ashby,V.B., Port, F.K., Wolfe, R.A., Kayler,
L.K., Renal Transplantation in Elderly Patients Older Than 70 Years of
Age: Results From the Scientific Registry of Transplant Recipients.
Transplantation; 83: 1069-1074.
Scheper-Hughes, N. The Tyranny of the Gift: Sacrificial Violence in
Living Donor Transplant. American Journal of Transplant 2007; 7:1-5.
Scheper-Hughes, N. The end of the body. In: Swatz, TR, Bonello, FJ,
eds., Taking sides: clashing views on controversial economic issues. New
York: McGraw-Hill. 2003.
Scheper-Hughes, N. Keeping an eye on the global traffic in human
organs. Lancet 2003; 361: 1645-1648.
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