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.

Background

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…

I’m running a bit late with this, but the BMJ reported last week that Mohammed Al-Byati had been suspended from the medical register for 12 months for complicity in torture.  So far, the decision hasn’t been uploaded to the list of Fitness to Practise decisions, but the outline of the case is available here, on the “upcoming hearings” calendar:

The Panel will inquire into the allegation that between December 1992 and March 1994, Dr Al-Byati visited camps and prisons in his capacity as a doctor in Iraq.  It is alleged that during these visits and whilst administering treatment, Dr Al-Byati knew that some prisoners he treated had sustained injuries as a result of torture, and it was likely that the prisoners would be tortured again.  It is also alleged that as a consequence of Dr Al-Byati’s engagement in these events, he was complicit in acts of torture.

The BMJ report relates that

the panel decided not to end his career by erasing him from the medical register, after accepting that he played no part in the torture and had effectively no choice but to carry out orders.  He told the panel that he had been “terrified” of what would happen to him and his family if he did not do as he was told.   The panel’s chairman, Michael Whitehouse, said, “He was a junior doctor whose behaviour was being controlled by a dictatorial, totalitarian regime which used systematic, widespread, and extremely grave violations of human rights to control the population.  Dissent from orders was not tolerated.

There’s a couple of things that’re perplexing about this.

The first is that it’s not clear how close to the torture process Al-Byati actually was.  The FtP outline simply alleges that he knew the people he was treating had been tortured, and that they probably would be again.  The BMJ repeats this.  Al-Byati appears to have denied knowing it, but it’s not clear to me that it’d've mattered if he had known: treating someone in those circumstances doesn’t amount to endorsement of the torture.

I mean: imagine that you’re working in A&E and someone is admitted whom you suspect strongly (strongly enough for it to count as knowledge in the common-or-garden sense) to have been injured as a result of domestic violence.  You patch up the patient, who then goes home – to face, you suspect almost as strongly, more violence.  It’d be nuts to suppose that you could be criticised as complicit in or even supportive of that violence, though, or that there might be something problematic about treating the patient in the knowledge of what had happened and may happen again.  At most, you might be criticised for not contacting the police or social servives; but that’s a question of confidentiality, and of a totally different stripe – and, anyway, to whom would Al-Byati have reported his concerns?

The other thing that’s perplexing is that noone claims that Al-Byati had any real choice in the matter.  It doesn’t seem unreasonable for a twentysomething medic to agree to provide medical treatment to those who need it, especially when it’s at the request of the state and that state is Ba’athist Iraq.  Maybe he could have refused in principle – but in practice, that kind of refusal may well have been heroic, and it’s odd to criticise someone for not being sufficiently heroic.

In both cases, consider the alternative.  The alternative for the patient is not being treated.  The alternative for the doctor is… well, who can say?  I doubt that there was much scope for conscientious objection.  And remember that the complaint is not that he assisted in the torture, but that he knew about it.

So why apply sanction?  Here’s Michael Whitehouse, the panel chairman, quoted in the BMJ:

He said that the suspension, for the maximum period allowed, was necessary “to demonstrate clearly to him, the profession, and the public that even though his involvement as an accessory to torture was outside his control, such conduct is unacceptable.”

Ummm… Really?  The emphasis is mine, because this is a very, very odd thing to say.  Treating people for the effects of torture is not to be an accessory in any meaningful sense – especially if you didn’t have a realistic choice.  And the pour encourager les autres claim in this context stinks.  I mean, as a principle of justice, my inclination is to think that it’s iffy at best in any circumstance.  But it’s not really as if anyone needs to have it demonstrated that state-sponsored torture is a bad thing to begin with.  And if, mirabile dictu, someone does need to be reminded of that, it’s not clear that they’re going to be swayed by demonstrations of foot-stamping like this.

Note that this case seems to raise questions similar to those raised in respect of medical involvement in capital or corporal punishment.  However, it’s also significantly different from what I can tell.  For one thing, in regimes in which capital or corporal punishment is used and the presence of a medic is mandated as an integral part of that process (for example, if the law demands that a lethal injection be administered by a medical professional), it seems to me that it’d be conceivable that minimally decent doctors would refuse participation, thereby bringing the whole process to a halt.  One might even imagine doctors refusing to be involved as a means of bringing the process to a halt – though you could, alternatively, make a rule-of-law case to insist that medics ought not to aim to undermine valid laws from valid sources, and draw a distinction between conscientious objection that makes the execution of a sentence (and a prisoner) impossible as a side-effect, and more activistic attempts to exert moral pressure on a notionally unjust law.

Whatever.  There’s a debate to be had there, but it doesn’t really speak to this case, because Ba’athist Iraq was not a rule-of-law regime, and (perhaps more importantly) non-participation wouldn’t – on the face of it – have made any real difference, because from the way the story is reported, the presence of a medic like Al-Byati wasn’t a part of the process.  That is: even if Iraq had been a rule-of-law regime, there’s a difference between treating someone who has been tortured and may be tortured again, and treating that person as a part of the torture framework.  There’s no reason to believe that the law required that the torture be overseen by a medic: only that he happened to be the guy closest to hand when the prisoners needed patching up.  Had he not been there, it’s all-too-easy to believe that the torture would’ve happened anyway.

Maybe I’ve missed something about the case.  But from the way it’s reported, it seems possible that the decision has been at least partially determined by the idea that Al-Byati is contaminated by association with bad people.  Either that, or because of PR concerns about the public perception of the matter should the “news”paper to which I do not link get wind of it.

I think that there’s more to be said.  There must be, mustn’t there?

via Isra Black:

The convenors of the 7^th annual Postgraduate Bioethics Conference invite doctoral students working in any area of bioethics to submit abstracts for this year’s conference, which will take place on 22-24 May 2013 at King’s College London.

In accordance with the theme of this year’s conference, we would particularly welcome papers that explore the law and/or policy dimensions of bioethics scholarship. We hope that the papers presented at PGBC 2013 will relate not only to the ethical implications of a particular issue, but also to the additional problems raised by the responses to ethical issues fashioned by laws and policies.

Please submit your abstracts to postgrad.bioethics [at] outlook.com. Abstracts should be in English, no more than 300 words, and in Word or preferably .pdf format.  Please note that you must be a registered PhD student, and we will only accept abstracts sent from a valid institutional email address.

The deadline for abstract submissions is 31 March 2013. Successful applicants will be notified by email by 10 April 2013. There will be an opportunity for unsuccessful applicants and those not wishing to give a paper to register as attendees (for free!) from 22 April 2013. The link to registration is: pgbc2013.eventbrite.co.uk.

Confirmed speakers include: Jonathan Glover (KCL), Rosamund Scott (KCL), Stephen Wilkinson (Lancaster), John Coggon (Southampton), James Wilson (UCL), Mark Sheehan (Oxford), and Tom Douglas (Oxford).

More information on PGBC 2013 is available at postgradbioethics.org. We are also on twitter (twitter.com/pgbc2013) and facebook (facebook.com/postgradbioethics). Please contact us via social media or email (postgrad.bioethics [at] outlook.com) with any questions.

 We look forward to meeting you in May!

I thought our readers might be interested in this story which is happening in New Zealand as it has echoes of the Post-Birth abortion “debate” that occurred on this blog last year.

Then as now academics have argued in an academic journal (in this case the New Zealand Medical Journal) for a position that some find controversial – although the position seems considerably more innocuous than post-birth abortion since they are arguing that the introduction of earlier less invasive diagnosis of genetic disorders such as downs syndrome is morally acceptable and indeed preferable. You can see the paper here since it is open access at the moment.

In reaction to this disability activists have claimed that the authors are promoting discrimination against those with Downs syndrome and are calling for the resignation of the Head of the Otago Bioethics Centre.

Now there are several problems here. Firstly and most obviously the authors of the piece and in particular Gareth Jones who they have focused on is not in fact the Head of the Otago Bioethics Centre (that would be John McMillan) so it is hard for Gareth Jones to resign that position. Worse still as Udo Schuklenk points out in this thoughtful piece – Gareth Jones is in fact an emeritus professor – it is slightly difficult to resign from being retired… It’s also argued that some of the statements they are attributing to Gareth Jones (not that they seem that controversial) were actually made by a different Gareth Jones.

Still factual issues aside what seems illegitimate here is the personal attack involved. I must admit this looks to me like activists shamelessly latching on to an opportunity to kick up a fuss about an issue which they care deeply about, without any consideration of the potential impact on the individuals involved. While discussions like this one must be written with consideration and due care as John McMillan points out the paper is both careful and considerate, so why attack the authors?

While they of course have a right to their opinion and to express them vocally – given that what they are arguing against is the status quo there doesn’t seem to be any reason to demonise academics, why not engage with the arguments – play the ball not the player. After all if their position is strong then the truth should out right? Resorting to smear tactics like this makes the position they are defending seem weaker than it actually is, I share the concern that selective abortion of the disabled may constitute discrimination – although like abortion itself I’m inclined to view this as regrettable rather than morally objectionable.

Sadly, the list entitled “Great Moments in Italian Pop” is short; but the entry that must surely be at the top is probably very near the top of the list entitled “Great Moments in All Pop”.  It’s a 1972 song by Adriano Celentano.

Prisencolinensinainciusol.

It’s pure gibberish – a parody of what anglophone pop sounds like to people who don’t speak English.

I mention it here for a couple of reasons.  The first is that it’s great.  The second is that it’s a nice way of talking about people who appear to be going through the motions of thinking about ethical matters, but who just get it wrong, and are actually talking gibberish.

Via Dominic Wilkinson, this gem from BioEdge is a lovely example of bioethical prisencolinensinainciusol.  On the face of it, it’s a plea for consistency when it comes to policymaking.

[I]n the Australian state of Queensland [...], the police union has argued that pregnant women who abuse alcohol should be forced to live in safe houses. “Those [unborn] children also deserve a right to full life and health and should not be disadvantaged simply because of the actions or inaction of their birth mother,” said Union president Ian Leavers.

Obviously this is a controversial issue, but I can’t understand how one can both defend access to legal abortion and lock up women who might harm their children.

The link provided is to The Australian, which is behind a paywall, so not something I can access.  However, News.com.au carries the story, too, reporting Union president Levers to have said that the state should be able to intervene in cases where children are at risk of foetal alcohol syndrome and drug addictions.

“Those children also deserve the right to a full life and health and should not be disadvantaged simply because of the actions or inaction of their birth mother.  The state must have the ability to intervene and protect the unborn child when its mother refuses, or is incapable or unwilling to do so.”

Mr Leavers said tougher laws would complement the criminal code, which provides for a charge of killing an unborn child or grievous bodily harm for any person who violently kills or harms an unborn child.

This is a bit odd, all told.  I mean: it might be easy enough to agree that pregnant women probably ought to reduce, or even eliminate, certain behaviours.  But the idea that that might be a matter for the law is very strange indeed.  What would the sanction be?  Is the idea that it’d be better for pregnant women to be in prison?  Fined?  And what about the plausible claim that alcohol or drug abuse is itself a health problem?  Or the distinct possibility that women who do drink or use drugs are much less likely to seek any medical advice at all during their pregnancy if they think that the state might punish them for their behaviour, thereby making a suboptimal situation even worse?  Legal intervention of the sort indicated would be both cack-handed and unjust.

But what about BioEdge‘s plea for consistency?  From what I can see, there’s a fairly obvious set of rejoinders.  First, the police union can say what it likes about what the law should be, but the role of the police is to enforce the law as it stands.  So not interfering with a woman’s legal right to abortion is not the same as defending it.  Likewise, mooting the idea that women might be sanctioned for risking the health of the foetus is not the same as locking women up.  BioEdge seems to have got the difference between voicing an idea, and enforcing a policy, utterly the wrong way around.  BioEdge‘s writer makes it sound like a moral argument is being made; but, really, it isn’t.  Second, that it’s odd to defend abortion but advocate sanctions against risky behaviour in pregnant women may be true – I mean, it’s not a crazy suggestion – but it doesn’t follow from that that one ought to change one’s mind about abortion (which is, I think, given BioEdge‘s commitments generally, what the implication is): all else being equal, and given a whole truckload of secondary arguments about the moral status of the foetus and the moral status of the mother, it’s at least prima facie more likely that it’s the risky behaviour claim that’s off.  Third, that the representative of a policing union has made a statement about what the law should be is in no way an indication that that statement should be taken seriously.

Come on, BioEdge.  Fair play to you: you look like you’re doing the job… but… Prisencolinensinainciusol.

Maybe there’ll be richer pickings from the other story behind the link.  In Tasmania,

the premier and deputy premier have released a long report on legalised euthanasia. They insist that there is no “sound evidence” of potential elder abuse. However, rates of child abuse are nearly 60% higher there than in other Australian states. Isn’t that a bit inconsistent? The kind of people who abuse children probably won’t mind abusing grannies.

Ummm… wait a sec: What?

Spoiler alert: Almost certainly not.  But hear me out for a bit.

The Christian Medical Fellowship blog had an article posted yesterday about what it praised as a balanced documentary concerning “sexual orientation change efforts” – gay conversion therapy to you and me – on Radio 4 on Sunday.  Actually, it wasn’t a documentary – it was a short article on Sunday, the station’s religious-affairs-quota-filling hour (go to about 30:50 here), and it’s no more a documentary than is the sports bulletin - and the balance is “BBC balance”, which means giving equal airtime to the fireman and the fire.  But anyway, that’s not what struck me.

Neither am I particularly bothered for the sake of this post about whether or not psychotherapy can make any difference to sexual orientation.  I’ll simply allow, for the sake of the argument, that it can at the very least make a difference to sexual behaviour, and maybe to orientation tout court.

What struck me was a couple of things that Peter Saunders says on his CMF blog post about the use of such “therapies”.  One of the striking things was this: more…

Details here; bioethics PhDs are available in the conventional form, or as a structured PhD in Bioethics and Medical Jurisprudence.

NB: the first deadlines are next week, so get your skates on.

Today’s blast of righteous indignation is directed towards New Mexico.  House Bill 206 says, in essence, that… well, it’s short, so here it is in full:

HOUSE BILL 206

51ST LEGISLATURE - STATE OF NEW MEXICO - FIRST SESSION, 2013

INTRODUCED BY

Cathrynn N. Brown

AN ACT

RELATING TO CRIMINAL LAW; SPECIFYING PROCURING OF AN ABORTION AS TAMPERING WITH EVIDENCE IN CASES OF CRIMINAL SEXUAL PENETRATION OR INCEST.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

SECTION 1.  Section 30-22-5 NMSA 1978 (being Laws 1963, Chapter 303, Section 22-5, as amended) is amended to read:

“30-22-5.  TAMPERING WITH EVIDENCE.–

A.  Tampering with evidence consists of destroying, changing, hiding, placing or fabricating any physical evidence with intent to prevent the apprehension, prosecution or conviction of any person or to throw suspicion of the commission of a crime upon another.

B.  Tampering with evidence shall include procuring or facilitating an abortion, or compelling or coercing another to obtain an abortion, of a fetus that is the result of criminal sexual penetration or incest with the intent to destroy evidence of the crime.

C.  Whoever commits tampering with evidence shall be punished as follows:

(1)  if the highest crime for which tampering with evidence is committed is a capital or first degree felony or a second degree felony, the person committing tampering with evidence is guilty of a third degree felony;

(2)  if the highest crime for which tampering with evidence is committed is a third degree felony or a fourth degree felony, the person committing tampering with evidence is guilty of a fourth degree felony;

(3)  if the highest crime for which tampering with evidence is committed is a misdemeanor or a petty misdemeanor, the person committing tampering with evidence is guilty of a petty misdemeanor; and

(4)  if the highest crime for which tampering with evidence is committed is indeterminate, the person committing tampering with evidence is guilty of a fourth degree felony.”

SECTION 2.  EFFECTIVE DATE.–The effective date of the provisions of this act is July 1, 2013.

The new bit is section B.

In a statement, the congresswoman who introduced the Bill, one Cathrynn Brown, said that her intention was to punish the person who commits incest or rape and then procures or facilitates an abortion to destroy the evidence of the crime.

Hmmm.  Except that that’s not what it says, is it?  Maybe she should read the text of her own Bill.  It talks about procuring an abortion, as well as compelling or coercing another person to have one.

I think that the second bit is actually fairly unobjectionable.  To compel someone to have a medical procedure, whomever that someone is, and whatever the procedure, is to wrong them; and if you compel them to have the procedure in order to remove evidence of another wrong, then the wrongness is multiplied.  But, y’know… that first bit… um… more…

A bit more on the cochlear implant thing that I’ve been mentioning off and on for the past couple of months.  William Mager posted a link to something a little while ago on why some members of the deaf community are against CIs.  This attitude had always puzzled me.  Anyway, this, by Christina Hartmann, is the thing to which he linked.

Not wanting one yourself, I can understand easily enough.  Not wanting one for your children based on uncertainty about their benefit, I can understand.  But being against them in principle?  Couldn’t get my head around that.  It always seemed a bit wilfully isolationist – a bit identity-politics.  Hartmann’s contribution, I think, makes things a bit clearer.

Without ASL, there is no Deaf community. We band together not because of our “hearing loss” but because of a common language.  Like English, Bengali, French, American Sign Language (ASL) informs the cultural underpinnings of the Deaf community. Deaf history shows the importance of ASL to Deaf people. It’s not something we’ll give up easily and gladly.

In the 1800s and early 1900s, many educators tried to eradicate ASL in favor of oralism. They wanted to assimilate deaf people into the “mainstream” community. Many deaf people suffered because of this. They received marginal education because they couldn’t understand the spoken language. One of the older deaf men that I knew in my childhood couldn’t get a job better than a janitor because he received no valuable education from his oral school.  They just tried to teach him how to talk, to no avail.

Amidst all of this, a vibrant community emerged. People would converge at Deaf schools and churches just for a chance to use their own language with someone else. A feeling of kinship grew in face of oppression. (Yes, trying to abolish a language and forcibly integrate people is oppression.)  Many Deaf people throughout history fought very hard for the right to sign and live on their own terms.  One example is the Gallaudet protests of the 1980s. The thought that this hard-earned culture will disappear because parents don’t want to learn ASL sparks abject fear and anger in many Deaf people.

And why not?  Wouldn’t you be angry if someone told you that your culture is outdated and irrelevant now?

This last sentence or two seems to me to be important.  CIs reduce the need for ASL (or BSL); SL sustains a culture; therefore CIs erode that culture. more…

People who listen to Today may have heard an article in the prime 8:10 slot on the 9th about the correlation between a drop in the use of leaded petrol, and a drop in violent crime rates.  (Mother Jones actually beat the BBC, having published a piece on the same research last week: I meant to post something then, but was buried by other stuff.)

The nub of the story is this: that violent crime has been falling in the past few years, and though this pattern seems to lag about 20 years behind a fall in the use of lead in petrol, the fit is pretty good: a decline in leaded petrol predicts a decline in violent crime by about two decades – which is just about the time that we might expect would elapse between the formation of the brain and the highest likelihood of violent behaviour in humans.  Neat.  The Mother Jones piece provides lots of links to the relevant research – links to this (from 1999), and this (from 2007), and this (from 2012).

If the lead hypothesis is sound, it seems to be ethically interesting in a couple of ways. For one thing, it opens the way to at least some antisocial behaviour to be seen as being symptomatic of a deeper public health problem.  That’s interesting enough as it is, but – admittedly – it might be little more than interesting, on the grounds that leaded petrol is pretty much a thing of the past anyway (Wikipedia says that, as of 2011, leaded petrol was widely available only in 7 countries).

But the other way in which it’s interesting has to do with arguments about so-called “moral enhancement”. more…