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Journal of Medical Ethics – Special Issue on Circumcision

19 Mar, 13 | by BMJ

Guest Post by Brian Earp

The Journal of Medical Ethics is pleased to announce the forthcoming release of a special issue – “The Ethics of Male Circumcision”  - to be published in full in the coming days.  Selected papers have already been posted Online First and can be seen by clicking here. Contributions cover a wide range of perspectives, and were invited from leading legal scholars, bioethicists, political theorists, pediatricians, and medical historians with expertise in this area. All essays were subjected to rigorous peer review. A list of main contributors and highlights from the arguments showcased in this Special Issue can be found below.


Recent events have re-ignited controversy around the oft-debated issue of the moral and legal permissibility of infant male circumcision.

According to a recent German court ruling, circumcising minors on religious grounds amounts to grievous bodily harm.  The court held that children have fundamental rights to bodily integrity and self-determination that cannot be outweighed by the right of parents to practice their religion and raise their children as they see fit. German chancellor Angela Merkel suggested that the ruling was an affront to religious liberty, while anti-circumcision groups as well as a number of ethicists hailed it as a victory for child rights.  In December of 2012, the German parliament passed a law to protect religious circumcision from future legal threats.

Meanwhile, in New York City, health officials recently succeeded in enacting a consent form requirement for circumcision after it was revealed that dozens of infants have contracted herpes in the last decade from a form of the surgery practiced by some Orthodox Jews. This form, called  , involves the sucking of blood directly off of the infant’s penis. Disagreements about the relative importance of religious tradition versus health concerns have shaped the ensuing controversy there.

Finally, in late summer of 2012, the American Academy of Pediatrics (AAP) issued a new circumcision policy statement and technical report, in which the child health organization suggested that the possible health benefits of circumcision outweigh the risks and complications.  This pronouncement was cited favourably by some commentators, while other groups, such as Doctors Opposing Circumcision, issued harsh criticisms.  The Journal of Medical Ethics announces today that it is hosting a continuation of this debate in the pages of its Special Issue, publishing a further critique of the AAP report and policy statement, alongside a formal reply by the AAP. more…

Is Medical Equipment Halal? Kosher?

23 Nov, 12 | by Iain Brassington

A recent intercalating student of mine got in touch with this query the other day:

Total parenteral nutrition is given as a replacement for nutrition where the patient cannot or should not be digesting food: it is given intravenously so bypasses digestion.  Two patients have asked my current educational supervisor if the TPN solution is halal, and no-one, including the manufacturers, seems to know. There are various parts that are derived from animals but the manufacturers can’t say where from, even which animal seemingly.

The two relevant patients have been told the ‘don’t know’ answer and have agreed to continue taking the TPN but the team is now left wondering whether to tell all patients before they commence TPN that they do not know the origin of the products used and therefore the TPN cannot be guaranteed as halal, or indeed kosher either.

A pharmacist has also pointed out that beef gelatine is also used in many tablet coatings and this is generally never discussed with patients.

There is a suggestion in this paper that we should routinely be telling all patients about gelatine in tablets and IV infusions, which is definitely what my instinctual reaction agrees with.  The authors suggest that continuing not to do so would mean modern medicine “might be thought to be following the sort of self certain, paternalistic line that doctors were accused of decades ago in relation to Jehovah’s Witnesses”. I think that sums it up quite nicely!

Another interesting question comes from a legal point of view – of the regulations surrounding labelling of food products, which I think are increasingly strict, and the information provided by manufacturers about origins of medical products and then how much of that is communicated to patients.  (I think Margot Brazier might have mentioned this issue in our regulations seminar.)

Having chatted with the student in the pub since, we agree that, ethically at least, it’s a bit of a no-brainer: since it isn’t an imposition on anyone to warn that we can’t be sure of the origin of the treatment, there’s no harm in doing so – and, for the sake of preserving patients’ control over what goes into their bodies, we ought.

The legal question is potentially quite interesting here.  Going off on one a bit, could there be a negligence issue here – on the grounds that it’s reasonable to suppose that at least some patients might want to know the information, even if they don’t expressly say they would (because it never crosses their mind)?  Not to warn could be a serious omission here – and I’m wondering whether it might make a difference to consent.  I genuinely don’t know: were someone to make a case that they should have been warned and would not have consented had they known, would there be legal mileage in it?

Any thoughts, anyone?

Kelly Hills, Data Miner

7 Nov, 12 | by Iain Brassington

Kelly Hills has been data-mining – collecting and collating information about the frequency with which certain terms appear in paper titles in three journals: the JME, Bioethics, and the AJoB.

I was going to say that the charts are not much use, but that they are pretty and quite cool; and I was going to add that their lack of utility doesn’t matter at all because prettiness and coolness is sufficient to make them worth looking at.  Not everything worthwhile is worthwhile because it’s useful, after all.  Being a philosopher, I have to believe that.

But then it occurred to me that there probably is some utility to them.  Taken with some care, they help us to see what is held to be important by people publishing work – and, I suppose, they might also help decide which journals are more receptive to certain topics (or, conversely, which journals are saturated with them).

Here’s what the JME‘s chart looks like:

The image isn’t perfect, of course: because size is a mark of brute numbers and the algorithm that generates the image isn’t sensitive to context, “ethics”, and “ethical” get separated, when the reality might not indicate that they merit separate consideration.  “Euthanasia” gets only a small amount of attention – which tells us something about the heat-to-light ratios in debates on the topic.  It also gives some support to John Coggon’s idea that it’s getting hard to find anything new worth saying in that particular field – though I’d’ve thought the same, and more, would apply in respect of consent, and that seems to generate a heck of a lot of attention.


23 Oct, 12 | by Iain Brassington

Seriously!  Theoretical Medicine and Bioethics has published a paper with a hundred and ninety-eight listed authors!

I’ve always been slightly puzzled by multi-authored papers – by just how many people get to add their names to a piece of work.  A friend of mine who is a proper scientist once tried to explain how it works in the sciences to me – about how you need to give credit to the people who ran the experiment, but also to those who did the titration and general donkey-work.  That seems fair enough.  Having said that, I suspect that there’s often a bunch of people who get credits that shouldn’t be there.  (I remember once seeing a CV from a guy that had 45 pages’ worth of publications listed.  Granted, it was double-spaced… but, still: there must have been the thick end of a thousand papers listed; there’s no way on God’s good Earth that he could have played a significant role in all of them.  So why was he entitled to claim them?  Why did he take the credit?  Apparently, it was because, although not all of the papers referred to work he’d done, they did all refer to work done by other people in a lab he ran.)  Anyway… the Steinhauser et al ad infinitum paper, with its 198 authors, isn’t lab-based, so the credit-where-it’s-due argument wouldn’t work.

(Jozsef Kovacs, writing in a paper currently available as a pre-pub in the JME, is also concerned about authorial inflation, and who should get the credit for a given paper, and how to improve things.  It’s definitely worth a look.)

The author list for the Steinhauser paper seems to have been generated at least in part via the membership of a Facebook group (and one that no longer exists, or at least one that is so private that it doesn’t show up on a search).  That’s just silly, and there’s no way that anyone can successfully marshall so many contributors.  That turns a paper into an open letter.  Indeed: the “authors” seem to think that their paper could be treated as such without loss: more…

Modesty, Conscience, and What it Takes to be a Doctor (with a bit of Comedy)

19 Oct, 12 | by Iain Brassington

Two apparently unrelated new and new-ish papers in the JME have caught my eye over the last few days.  One of them is this one: Salilah Saidun’s “Photographing Human Subjects in Biomedical Disciplines: An Islamic Perspective”.  We’ll come to the other in a little while.

There’s a couple of puzzling things about the paper.  One is that I’m not sure what the tone is supposed to be.

It could be a descriptive piece, along the lines of “Look, here’s what Muslims might think about medical photography, and if you’re going to take or use medical photographs, you might want to keep it in mind.”  Of course, it’s by no means certain that all Muslims think alike, or that if (mirabile dictu) they do, it has anything much to do with Islam – but we’ll put that to one side.  Similarly, the fact that some people do think this won’t tell us much about what practical implications there ought to be, beyond keeping it in mind.  It won’t tell us that we ought to adhere to those opinions.  Islamic rules might provide a reason to behave in a certain way; but there might be other reasons to behave in a certain other way - and they might sometimes be more compelling.  I’ll put that to one side, too, though.  As a descriptive paper, it might very well be the sort of thing that’s useful on the wards.

But a descriptive reading won’t explain the passages that appear to have a more normative dimension: more…

Jon Cogburn’s Plea to Grad Students (and Others)

24 Sep, 12 | by Iain Brassington

[IB: I'm taking the liberty of copying in its entirety Jon Cogburn's post on NewAPPS about submitting papers to journals, because it's worth reading.  He directs it to graduate students - but I think that the same point applies to anyone, especially if they're new to the field in which they're writing.  Since a lot of people writing for journals like the JME - especially on topics in clinical ethics - are medics before they're ethicists, or are coming at ethics from a non-standard direction, I think that the advice is particularly pertinent.]

A Plea to Graduate Students Submitting Papers

Three times this year a bad thing has happened after I’ve encouraged editors to give a paper “revise and resubmit.”

Note that whenever I review a paper and don’t recommend immediate acceptance I work really hard trying to help the writer so that their rewrite will to be up to the quality of the journal.  Even when I counsel “rejection” I still try to give detailed constructive advice about how the paper could be recast, even suggesting places the author should send the rewritten paper.

So three times this year instead of making the changes I recommended the author resubmitted substantially the same paper and argued with some vehemence that they should not have to change their paper in the ways I suggested.  In all three cases the journal editor had given the paper “revise and resubmit,” but then rejected the insufficiently rewritten paper.  In two of these cases I googled the paper title after this was over and found out that the submitters were graduate students.  This is so bad on so many levels.

First, it’s clear to me that some graduate students have no idea that “revise and resubmit” is a very, very good thing, that if you just rewrite the paper up to the reviewer and editor’s standards that at most journals it is almost certain to get accepted.  All three of the people viewed “revise and resubmit” as if it were a kind of rejection, and not a kind of conditional acceptance, as it usually amounts to (de facto if not de jure).  Second, it’s clear to me that some graduate students have no idea what “idiot-proofing” a paper amounts to.  Let me explain.  Suppose that your reviewer is an uncharitable idiot.  Suppose I was when reviewing the papers.  It doesn’t matter!  My comments are still invaluable because you still need to rewrite the thing so that the next uncharitable idiot reviewing it doesn’t make the same mistakes.  Third, it’s clear to me that some graduate students have no idea how high the burden of proof is if you want to convince an editor that the reviewer who has published extensively in the topic in question is making elementary mistakes about the paper.So please communicate this to all and sundry: (1) Revise and resubmit is something to be celebrated, (2) always take into account criticism and suggestions, even if only to idiot-proof for the next reviewer, (3) have some humility.I”m not trying to be censorious here.  If I was I wouldn’t spend so much time giving detailed advice about how to get papers up to publishable standards.  In addition, I know first-hand how stressful this process is for writers and first-hand how stress can produce weird and suboptimal behavior.  I’m trying to help.

I’d very be interested to hear if other reviewers have faced this kind of self-destructive behavior, and if so if there’s anything more we should be doing to stop it.  But if I’m being a jerk here, I trust that someone will point that out too.

Stacey Swimme reports that: Ethicist Reports: Prostitution is Not Harmful

4 Sep, 12 | by David Hunter

Stacey Swimme a political advocate for sex workers in the US has written a rather nice response piece to a paper recently published in the JME: Is prostitution harmful?

You can read her response here: ethicist-reports-prostitution-is-not-harmful

Hat Tip to Christian Munthe for picking up on this.

Religious Preferences and the Best Interests of the Child

16 Aug, 12 | by Iain Brassington

So the JME has – finally – published the paper by Brierley et al concerning withholding and withdrawal of futile treatment from children in the face of doctrinally-informed objections by the parents.  It’s taken a while, but it’s there now.

The essence of the paper’s claim is pretty simply put: if parental preferences run contrary to the medical best interests of the child, then we shouldn’t be too hesitant when it comes to discounting those preferences.  Or, as the paper’s conclusion has it:

Traditional mechanisms for resolution of end-of life disagreements based upon local cultural, secular or religious values [are] not infrequently unsuccessful.  Protracted dialogue [is] often unable to resolve these differences, while the child [is] subject to pain and discomfort from invasive ventilation, suctioning and multiple injections.  We suggest it is time to reconsider current ethical and legal structures and facilitate rapid default access to courts in such situations when the best interests of the child are compromised in expectation of the miraculous. [Emphasis mine - IB]

And this, it seems to me, seems fairly straightforward – albeit quite a limited claim about legal process.

Granted, there is a couple of niggles that one might have with the paper.  For example, the authors concede that those parents most likely to object to decisions to end treatment are those from African Evangelical churches.  But since members of those churches are more likely to be immigrants, or from other less privileged parts of the community, I wonder whether it’s religion that’s the main signifier here: it might equally well be class.  Or it might be other things.  (Mark Sheehan makes a similar point – that religion may be a red herring – in his commentary on the paper.)  Either way, what counts is a fairly straightforward question about what we should do when it comes to deciding best interests in life-and-death situations.  (Steve Clarke offers suggestions about what to do in his commentary.)

I wonder whether the appeal to torture and the Human Rights Act might be a bit of overkill in at least some cases, too.

But a bigger worry might have to with a paradox of publicity.  more…

Matters of Principlism

23 Mar, 12 | by Iain Brassington

There’s a short paper in the latest JME about which I’ve been meaning to write something for a while – ever since I noticed it as a pre-pub: William Muirhead’s “When Four Principles are Too Many”.  (Raa Gillon provides a commentary here.)

Anyone who’s ever heard me talk professionally for longer than about 35 seconds at once will know that I have little time for “Principlism”.  This is not quite the same as a claim that I have little time for the principles themselves – but this itself is arguably because what those principles demand is vague, or trivial, or some combination of the two.  (It’s one thing to say that actions should be just, for example, but that just leaves open the question of what justice demands; and who in their right mind would demur from the idea that actions ought to be just, especially when no substantive account of justice is entailed?  Or what about respect for autonomy?  That’s often taken to mean that autonomy is king – but giving something its proper respect doesn’t tell us that a great deal of respect is warranted…)  But, anyway: a critique of Principlism is all groovy in my view.

Except… well, this one doesn’t quite seem to work for me; and it’s problematic for a few of reasons. more…

Some Responses to Giubilini and Minerva

5 Mar, 12 | by Iain Brassington

I did mention last week that I’d post links to sites that mentioned Giubilini and Minerva’s paper as they crossed my radar; but it turned out very quickly that there’d be no way to keep up.  And, to be frank, a lot of the blogosphere’s response has been fairly scattergun outrage rather than dispassionate engagement with the paper, and directed at Giubilini and Minerva themselves rather than at the argument they put forward.  There’s been much more heat than light.

This is perhaps unsurprising, as considered responses are almost certainly going to take a while to materialise.  However, they have begun to appear.  Here’s the first that I’ve spotted; I’ll post links to more in this thread as and when.  And if any readers have responses on or SSRN that they’d like mentioning, or if anyone spots anything of interest, do let me know. more…

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