Male Circumcision and the Enhancement Debate: Harm Reduction, Not Prohibition
This blog is a brief response to ‘Out of Step: Fatal Flaws in the Latest AAP Policy Report on Neonatal Circumcision’ by Steven Svoboda and Robert Van Howe, and the AAP Task Force on Circumcision’s Response. This is part of a special issue summarised by Brian Earp.
Around one third of men worldwide are circumcised. It is probably the most commonly performed surgical procedure. Circumcision is also one of the oldest forms of attempted human enhancement. It is and has been done for religious, social, aesthetic and health reasons.
Circumcision has a variety of benefits and risks, many of which are discussed in this issue. There is some dispute about the magnitude and likelihood of these benefits and risks. Some argue that the risks outweigh the benefits and circumcision should not be performed on children who are not competent to make their own decisions.
If it were true that the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure. Around one third of men have been harmed. This is an extraordinary public health injury. Presumably, some would be entitled to compensation.
The fact that few people think that there is not such a bad situation affecting millions of men indicates that most people implicitly believe that circumcision is not a significant harm, if a harm at all. (This is an example of the kind of argument called modus tollens. If p, then q. Not-q, therefore not-p.)
It is reasonable to conclude either that:
1) It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.
Or
2) If circumcision is against the interests of an infant, it is only mildly so.
In general, people should make their own decisions about body modification and human enhancement when this is possible. Such an approach speaks in favour of waiting until a child is adult to make his or her own decision about circumcision. And procedures which are not clearly in a child’s interests should not be performed on that child. However, religious and other social exclusion may make delay in circumcision psychologically harmful.
It would be a mistake to ban circumcision, given its importance to many people. A dangerous “black market” would be created. As with other forms of potentially risky human enhancement, the best policy is one of harm reduction, not prohibition. Non-medical circumcision should be discouraged, but not prohibited(for further discussion see ‘Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgements of What Is Best for Their Patients’and ‘Liberal Rationalism and Medical Decision-Making’).
If The Jury System Is The Best Option, Can We Make it Better?
By Julian Savulescu and Anders Sandberg
Vicky Pryce, wife of disgraced ex-MP Chris Huhne, is back in court this week after the jury trying her case was discharged last week having failed to reach a verdict on her charges of perverting the course of justice. In 2003, Pryce accepted Huhne’s speeding points, but is claiming a defence of marital coercion. In 10 questions to the judge, the first jury showed an alarming and deep lack of understanding. Questions included:
“Can a juror come to a verdict based on a reason that was not presented in court and has no facts or evidence to support it?”
They also showed the jury had apparently forgotten key concepts which were explained during the trial:
“Does this defence require violence or physical threats?”
“Can you define what is reasonable doubt?”
Following the jury’s discharge, the judge said the jury showed “absolutely fundamental deficits in understanding”, adding that he had never seen this in 30 years of presiding over criminal trials. In Pryce’s trial, the questions the jury asked after several days of deliberations raised alarm bells, but in another trial where a verdict was reached, we would never know what the standard of jury understanding or deliberation had been. Yet juries are asked to decide (in some countries) on matters of life or death.
The Pryce case may have been unusual, but in any trial, and particularly in complex fraud cases, juries are asked to juggle and compute vast amounts of information, and to retain it throughout the trial in order to make an informed decision at the end. We have argued in “The Memory of Jurors: Enhancing Trial Performance” and “Cognitive Enhancement in Courts” with Walter Sinnott-Armstrong, that cognitive enhancement, particularly memory enhancers should be made available to jurors. If this had been available in the Pryce case, would the jury have spent more time discussing the decision at hand, and less on (mis-)remembering the judge’s instructions on reasonable doubt or the definition of coercion? If we ask people to take on a civic duty we should offer them all the tools we have available to assist them in its completion.
“The Best Interests of the Family”: Parents v Baby?
There is much that is good to be said about Dominic Wilkinson’s new book Death or Disability? The ‘Carmentis Machine’ and decision-making for critically ill children.
My favourite part of the book is how Dominic confronts head on the issue of the best interests of the family in relation to care, and withdrawal of medical treatment, in newborns.
This is one of the most neglected areas of bioethics.
On the one hand, there is a rhetoric that goes we are all social beings, we are socially connected, not atomistic individuals, the community matters, etc etc The usual communitarian mantra.
Then there is the alleged overriding legal and medical ethical principle of the best interests of the patient, which is the newborn infant in the case of neonatal medicine. The sole basis of the provision of medical treatment is meant to be to promote the best interests of the patient, and medicine should never be used to harm the patient, etc etc. The usual medical ethics and law mantra.
And then there is real life. The interests of the parents, siblings, other relatives, friends, society etc can all diverge from the interests of the patient, even a newborn infant. How are these to be weighed? The hard edged reality is that the interests of families and especially parents do play a role in clinical decision making, and even in cases to withdraw life-prolonging medical treatment. (For example, in one survey 90% of American intensivists believed that family interests should be included in decisions for incompetent patients. )
In ‘Death or Disability?’, Dominic reaches several striking conclusions. We should certainly give some weight to the interests of the family for decisions about children. This is most likely to sway our decisions in relatively borderline cases, where the net benefit or harm to the child is small. But he also argues that the amount of weight will vary depending on the age of the child, and on the availability of resources. We should give greater weight to the wishes of parents for newborn infants than for an older child. And we should give greater weight again in societies with few resources, where the burden of caregiving is going to fall heavily on families, and where health resources are seriously limited.
It is time for an honest, open and rational approach to these kinds of dilemmas. Dominic does just that.
Yet Another Reason to Legalise Doping in Sport: Organised Crime
Unsurprisingly, the Australian Crime Commission has found widespread use of performance enhancing drugs in sport in Australia and the involvement of organized crime in its distribution.
I have given many arguments for why it would be better for athletes, spectators and sport to liberalise laws currently banning performance enhancing drugs. I have also argued that they are likely to be involved in all sports – football, baseball, rugby, soccer, and so on, and not merely in athletics and cycling.
The Australian Crime Commission report suggests another reason to legalise drugs in sport – that would be the most effective way of reducing the involvement of organized crime in the doping market. As experience with recreational drugs has shown, bans inevitably fail, harm the user and invite crime. The way to put drug lords out of business is to legalise the substance.
When prostitution, alcohol, abortion or recreational drugs are banned, organized crime moves in to deliver the desired product or service. The best to deal with these issues is not through some fanatical moralistic war but through legalization, oversight, regulation, monitoring and harm reduction.
When will we learn?
Whom Should We Refuse to Treat? Pregnant Rape Victims? Surrogates?
By Lachlan de Crespigny and Julian Savulescu
An emergency centre doctor working in Germany has claimed 2 nearby catholic hospitals refused to accept a rape victim who needed treatment, in case she was pregnant . This was allegedly in line with their ethics committee’s policy to refuse to examine sexual assault victims in an effort to avoid future treatments such as the morning after pill coming into conflict with the hospital’s catholic ethos. The hospitals claim this was a misunderstanding and await an internal inquiry.
The Catholic Church does not support abortion and includes the morning after pill as an abortifacient. It is in violation of Catholic (ethical) standards. The doctor making the claims says that Cologne’s Cardinal Meisner had been consulted.
The Catholic Church insists life must be protected with the utmost care from the moment of conception. From the first moment of his or her existence, a human being must be recognized as having the rights of a person. But in this case, they did not only deny the rape victim access to legal contraceptives, they refused to treat or examine her in any way for any of the resulting injuries of the rape. They did not treat her in her hour of need as a person who deserved the utmost care.
Back to the Future: The Ethics of Cloning Neanderthals and Creating Genetically Modified Animals
“George Church, a genetics professor of Harvard School of Medicine, said that the process was possible and that far from being brutal and primitive, Neanderthals were intelligent beings.
They are believed to be one of the ancestors of modern man and became extinct 33,000 years ago. He added that altering the human genome could also provide the answers to curing diseases such as cancer and HIV, and hold the key to living to 120.
He told Der Spiegel, the German magazine: “I have already managed to attract enough DNA from fossil bones to reconstruct the DNA of the human species largely extinct. Now I need an adventurous female human.”
The professor claims that he could introduce parts of the Neanderthal genome to human stem cells and clone them to create a foetus that could then be implanted in a woman.”
From The Telegraph
This would be illegal in the UK and many other parts of the world. But is it morally wrong?
Persistent Vegetative State and Futility: Should Communication by fMRI Change the Law?
Earlier this month, I discussed Adrian Owen’s research using fMRI scanners to communicate with patients who appeared to be in a Persistent Vegetative State (PVS) . By interpreting brain activity in Canadian PVS and minimally conscious patients, the researchers claim that patients can not only answer questions, but even lay down new memories.
The question of how this new research will affect patients diagnosed with PVS or minimally conscious patients is already being tested in court. Yesterday, the Vancouver Sun reported on the case of Kenny Ng, a minimally conscious patient following a major car crash 7 years ago. Mr. Ng’s wife, Lora, wishes to withdraw hydration and nutrition. According to her lawyers, Doctors advised this course of action shortly after his car accident, but, hoping for an improvement, Mrs Ng had initially refused. After 7 years with no outward signs of improvement, Mrs Ng has asked for nutrition and hydration to be removed, ending his life. However, Mr. Ng’s parents and siblings argue that Owen’s research is “exactly what Kenny has been waiting for over the last seven years”, and that he should be kept alive so he can be assessed for inclusion in Owen’s trials.
If the decision is made in favour of the family, as Thaddeus Pope highlights, it will represent a major change to previous US and Canadian case law.
Owen has made a major scientific breakthrough. However, it is not clear that the discovery of consciousness means that the treatment should not be withdrawn. Paradoxically, the discovery of consciousness in very severely brain-damaged patients may provide more reason to let them die. Although functional neuroimaging is likely to play an increasing role in the assessment of patients in a vegetative state, caution is needed in the interpretation of neuroimaging findings.
The Fable of Speeding and Prance Legstrong
Imagine that the Teetotaler party came to power. They stood for family, safety and old fashioned values. Their first target was the car and the speeding culture. They wanted driving to be as safe as possible. Indeed, they would have preferred it if there were no driving cars at all and people returned to bicycles or horsedrawn carts. But they knew that was impossible. People were used to driving cars.
So they slashed the speed limits from 100km/hr to 50 on open roads, and 60km/hr to 20 in built up areas. This, it was proven, was a safer speed to drive at.
Nearly everyone, however, sped. It was just more convenient – you could do so much more. And it cut down travelling times for work, so people could get a competitive advantage by getting to work earlier and leaving later.
Some professions involved speeding. Couriers, truck drivers, and salesmen all sped. There were a few speed cameras but they picked up people only rarely and many had camera detectors installed in their cars. People continued to drive at 100km/hr, just as they always had. Those who were caught were punished heavily – banned for a couple of years.
However, the benefits of speeding, or going at what was the previous limit, vastly outweighed the punishments.
One particularly successful courier was Prance Legstrong. He used to speed and deliver packages quicker than any other service. He established DEEHL, a courier service that became more successful than US postal. Pretty soon, he was a multimillionaire.
The Ban on Doping, Not Armstrong, Is the Problem with Cycling: Armstrong Is a Scapegoat for Cycling’s Hypocrisy
The International Cycling Union has stripped Lance Armstrong of his 7 Tour de France wins . UCI president Pat McQuaid said: “Lance Armstrong has no place in cycling. He deserves to be forgotten.”
The UCI is acting in response to a “Reasoned Decision” by USADA , which claims Armstrong presided over “the most sophisticated, professionalised and successful doping programme that sport has ever seen”.
The decision includes the findings that:
“He was not just a part of the doping culture on his team, he enforced and re-enforced it.”
And the conclusion that, with their disposal of Armstrong:
“So ends one of the most sordid chapters in sporting history.”
Public condemnation has been swift, and harsh:
“Lance Armstrong has made it hard for anyone to trust cycling”
(British Cycling boss Dave Brailsford) .
“LANCE Armstrong is a creep. A liar, cheat and a bully. So awful is Armstrong, you are right to question whether all his work for cancer patients is not just calculated camouflage to protect his abuse of drugs, his competitors, teammates and supporters.
He is not just part of the drug regime that saturated cycling when he was at his peak, but he has been that culture’s bodyguard. Its enforcer. And he remains so today, arrogantly dismissing the US Anti-Doping Agency findings by telling the world through Twitter that he was “unaffected” by the release of the 1000-page investigation findings. No one in sport has lived a bigger lie.”
It is hard in the face of the evidence presented to imagine that Armstrong rode clean. Nevertheless, he has become a scapegoat for endemic problems in cycling and sport that go far beyond the purview of any one rider, however successful and charasmatic.
Conjoined Twins, Cloning and Artificial Intelligence
Rosie and Ruby Formasa at 12 weeks are two ‘normal, smiling bubbly babies’. But they have already survived major surgery, just one day after their birth.
Conjoined at the abdomen at the level of the umbilicus, the girls shared an intestine. Pregnancy scans in the second trimester had identified that the twins were conjoined, but could not show exactly where until the birth was induced at 34 weeks.
Angela Formasa, the twins’ mother, said “ What they have done for my two girls is amazing. When I was pregnant they were saying that the survival chances were quite low”
The surgery to separate them and replumb their intestines was apparently successfully performed and they have the expectation of a normal life.
Conjoined twins raise difficult ethical dilemmas . They can be joined by a thin sliver of skin, at the abdomen, chest or even brain. They arise because of anomaly of human development.
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