Autonomy

Would Legal Assisted Suicide be the Final Triumph of Market Capitalism?

Tomorrow  in the House of Lords Lord Falconer’s bill on assisted dying will be debated. The bill would allow those who are terminally ill and likely to die within six months to request life-ending drugs from their doctor for the patients to use as and when they see fit.

As might have been expected, there has been huge discussion over the bill, but most of the arguments presented so far are not new, and the same will probably be true tomorrow. But there is one I haven’t seen before, put forward recently by Giles Fraser: that assisted suicide is the ‘final triumph of market capitalism’. Continue reading

Female genital mutilation (FGM) and male circumcision: should there be a separate ethical discourse?

Female genital mutilation (FGM) and male circumcision: should there be a separate ethical discourse?

This month, the Guardian launched a campaign in conjunction with Change.org (the petition is here) to end “female genital mutilation” (FGM) in the UK—see Dominic Wilkinson’s recent analysis on this blog. I support this campaign and I believe that FGM is impermissible. Indeed, I think that all children, whether female, intersex, or male, should be protected from having parts of their genitals removed unless there is a pressing medical indication; I think this is so regardless of the cultural or religious affiliations of the child’s parents; and I have given some arguments for this view herehereherehere, and here. But note that some commentators are loath to accept so broadly applied an ethical principle: to discuss FGM in the same breath as male circumcision (and perhaps intersex surgeries), they think, is to “trivialize” the former and to cause all manner of moral confusion.

Consider these recent tweets by Michael Shermer, the prominent American “skeptic” and promoter of science and rationalism:

 

 

This sort of view appears to be common. One frequent claim is that FGM is analogous to “castration” or a “total penectomy,” such that any sort of comparison between it and male circumcision is entirely inappropriate (see this paper for further discussion). Some other common arguments are these:


Female genital mutilation and male circumcision are totally different. FGM is necessarily barbaric and crippling (“always torture,” according to Tanya Gold), whereas male circumcision is no big deal. Male circumcision is a “minor” intervention that might even confer health benefits, whereas FGM is a drastic intervention with no health benefits, and only causes harm. The “prime motive” for FGM is to control women’s sexuality (cf. Shermer in the tweets above); it is inherently sexist and discriminatory and is an expression of male power and domination. Male circumcision, by contrast, has nothing to do with controlling male sexuality – it’s “just a snip” and in any case “men don’t complain.” FGM eliminates the enjoyment of sex, whereas male circumcision has no meaningful effects on sexual sensation or satisfaction. It is perfectly reasonable to oppose all forms of female genital cutting while at the same time accepting or even endorsing infant male circumcision.


Yet almost every one of these claims is untrue, or is severely misleading at best. Such views derive from a superficial understanding of both FGM and male circumcision; and they are inconsistent with the latest critical scholarship concerning these and related practices. Their constant repetition in popular discourse, therefore—including by those like Shermer with a large and loyal audience base—is unhelpful to advancing moral debate.

What is going on here?

To see the source of the problem, we need to begin by defining our terms—“FGM” and “male circumcision.” For FGM, The World Health Organization (WHO) gives us four major types, with multiple subdivisions:

  • Type I — Partial or total removal of the clitoris and/or the prepuce (clitoridectomy). Type Ia, removal of the clitoral hood or prepuce only; Type Ib, removal of the clitoris with the prepuce.
  • Type II — Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision). Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora.
  • Type III — Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation). Type IIIa, removal and apposition of the labia minora; Type IIIb, removal and apposition of the labia majora.
  • Type IV — All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

The first thing to notice about this list is that “FGM” is not just one thing. Disturbingly, there are many different ways to nick, scratch, or cut off parts of a girl’s vulva, ranging from, at the lowest end of the “harm” spectrum, pricking the clitoral hood (under anesthesia, and with sterile surgical equipment, as was proposed in the “Seattle Compromise” — note that this would qualify under FGM Type IV), up through various types of ‘piercing’ that do not necessarily remove tissue (of course, such piercing is common in ‘Western’ countries as a form of perceived “cosmetic enhancement”*), to interventions that alter the labia, but not the clitoris (the clinical term is labiaplasty – note that this is also popular in ‘Western’ countries), to, at the highest end, excising the (external) clitoris with a shard of glass and stitching together the labia with thorns. It is important to point out that the most severe types of FGM (such as the form just mentioned) are comparatively rare, whereas it is the more minor and intermediate forms that are more common.

Nota bene, such “cosmetic enhancement” surgeries in ‘Western’ countries are typically carried out under conditions of informed consent (a point to which I will return, as I think the moral analysis turns on this factor), although there is an alarming trend among some teenage girls in these countries — some as young as 13 or 14 — of having their labia reduced (or undergoing other forms of “designer vagina” surgery), apparently with the permission of their parents. Global health agencies such as the WHO, however, have been strangely silent on this issue, preferring instead to focus their FGM-eradication efforts almost entirely on the continent of Africa.

In this African context, genital cutting (of whatever degree of severity) is most commonly performed around puberty, and is done to boys and girls alike. In most cases, the major social function of the cutting is to mark the transition from childhood to adulthood, and it is typically performed in the context an elaborate ceremony. Increasingly, however, African, Middle Eastern, Indonesian, and Malaysian genital alterations (again, of both boys and girls) are being carried out in hospital settings by trained medical professionals—and on infants as opposed to teenagers–on the model of male circumcision in the United States.

Understanding the harm

It should be clear that the different forms of cutting listed above are likely to result in different degrees of harm, with different effects on sexual function and satisfaction, and different chances of developing an infection, and so on. But as Obermeyer notes in her systematic analysis of health consequences for FGM:

It is rarely pointed out that the frequency and severity of complications are a function of the extent and circumstances of the operation, and it is not usually recognized that much of [our] information comes from studies of the Sudan, where most women are infibulated. The ill-health and death that these practices are thought to cause are difficult to reconcile with the reality of their persistence in so many societies, and raises the question of a possible discrepancy between our “knowledge” of their harmful effects and the behavior of millions of women and their families.

Notwithstanding these gradient differences for types FGM, as well as the gradient consequences that vary along with them, all forms of FGM—no matter how sterilized or minor—are deemed to be mutilations. All are prohibited in Western democracies. Again: I am in support of the motives behind such legislation. I do not think that a sharp object should be taken to any girl’s vulva unless it is to save her life or health, or unless she has given her fully-informed consent to undergo the procedure. In the latter case, of course, she wouldn’t be a “girl” anymore, but rather an adult woman, who can make a decision about her own body.

What about male circumcision?

The story is very different when it comes to male circumcision. In no jurisdiction is the practice prohibited, and in many it is not even restricted: in some countries, including in the United States, anyone, with any instrument, and any degree of medical training (including none) can attempt to perform a circumcision on a non-consenting child—sometimes with disastrous consequences. As Davis notes, “States currently regulate the hygienic practices of those who cut our hair and our fingernails … so why not a baby’s genitals?”

But just like FGM, circumcision is not a monolith; it isn’t just one kind of thing. The original Jewish form of circumcision (until about 150 AD) was comparatively minor: it involved cutting off the overhanging tip of the foreskin—whatever stretched over the end of the glans—thus preserving (most of) the foreskin’s protective and mechanical functions, as well as reducing the amount of erogenous tissue removed. The “modern” form is substantially more invasive: it removes one-third to one-half of the motile skin system of the penis (about 50 square centimeters of sensitive tissue in the adult organ), eliminates the gliding function of the foreskin (see here for a video demonstration), and exposes the head of the penis to environmental irritation.

Circumcision—and other forms of male genital cutting—are performed at different ages, in different environments, with different tools, by different groups, for different reasons. Traditional Muslim circumcisions are done while the boy is fully conscious, between ages 5 and 8, or possibly later; American (non-religious) circumcisions are done in a hospital, in the first few days of life, with or without an anesthetic (usually without), and using a range of different clamps and cutting devices; metzitzah b’peh, done by some ultra-Orthodox Jews, involves the sucking of blood from the circumcision wound, and carries the risk of herpes infection and permanent brain damage; subincision, carried out in aboriginal Australia and elsewhere, involves slicing open the urethral passage on the underside of the penis from the scrotum to the glans, often affecting urination as well as sexual function; testicular crushing is an initiation rite in some parts of Africa and Micronesia; circumcision among the Xhosa in South Africa is done as a rite of passage, in the bush, with spearheads, dirty knives, and other non-sterile equipment, and frequently causes hemorrhage, infection, mangling, and loss of the penis—see here for some disturbing pictures—as well as a very high rate of death. But even “hospitalized” or “minor” circumcisions are not without their risks and complications: in 2011, nearly a dozen boys were treated for “life threatening haemorrhage, shock or sepsis” as a result of their non-therapeutic circumcisions at a single children’s hospital in Birmingham in England.

Here is the important point. When people speak of “FGM” they are (apparently) thinking of the most severe forms of female genital cutting, done in the least sterile environments, with the most drastic consequences likeliest to follow. This is so, notwithstanding the fact that such forms are the exception rather than the rule. When people speak of “male circumcision” (by contrast) they are (apparently) thinking of the least severe forms of male genital cutting, done in the most sterile environments, with the least drastic consequences likeliest to follow–because this is the form with which they are culturally familiar. This then leads to the impression that “FGM” and “male circumcision” are “totally different” with the first being barbaric and crippling, and the latter being benign or even health-conferring (on which more in just a moment). Yet as the anthropologist Zachary Androus has written:

The attitude that male circumcision is harmless [happens to be] consistent with Western cultural values and practices, while any such procedures performed on girls is totally alien to Western cultural values. [However] the fact of the matter is that what’s done to some girls [in some cultures] is worse than what’s done to some boys, and what’s done to some boys [in some cultures] is worse than what’s done to some girls. By collapsing all of the many different types of procedures performed into a single set for each sex, categories are created that do not accurately describe any situation that actually occurs anywhere in the world.

So it depends on what you’re talking about. Do those who oppose FGM (and that includes me) think (as I do) that even certain “minor” or “medicalized” forms of such cutting—done without consent, and without a medical indication—are inconsistent with medical ethics, deeply-rooted moral and legal ideals about bodily integrity, the principle of personal autonomy, and a child’s interest in an open future? Or is it only the wholesale removal of the clitoris – with a broken piece of glass – that inspires such condemnation? If the former is the case, then consistency would seem to require that one be opposed to the non-therapeutic, non-consensual circumcision of boys as well: not only is it much more invasive than several “minor” (yet prohibited) forms of FGM, but it is numerically a much greater problem, occurring several millions of times per year.

Cutting comes in degrees. Consequences vary. This is true for boys and for girls alike, and at some point the harms overlap. As a result of this realization, many scholars of ritual cutting are choosing to abandon the terms “FGM” and “male circumcision” (which presume a strict moral difference between them), and are using instead such terms as FGC, MGC, and IGC. These stand for female, male, and intersex genital cutting respectively; and they make no moral claims per se. Instead, the moral character of the genital cutting—regardless the person’s gender—can be assessed separately in terms of actual physical harms, as well with respect to such considerations as whether the cutting is therapeutic, consensual, or otherwise.

So let’s not be misled. There are many kinds of “FGM” as well as many kinds of “male circumcision” and the consequences vary for each one. But perhaps there are some other important differences between male and female forms of genital cutting – apart the sex or gender of the person being cut – that could serve to justify their strict separation in terms of ethical discussion. Let’s look at some further possibilities, from the set of common arguments I listed above.

Male circumcision … might … confer health benefits, whereas FGM [has] no health benefits, and only causes harm.

Both parts of this claim are misleading. First, how do we know that “FGM” (or FGC, as I’ll say from now on) does not confer health benefits? Certainly the most extreme types of FGC will not contribute to good health on balance, but neither will the spearheads-and-dirty-knives versions of genital cutting on boys. What about other forms of FGC? Defenders of FGC—including some medical professionals in countries where FGC is culturally normative—regularly cite such “health benefits” as improved genital hygiene as a reason to continue the practice, and at least one study has shown a link between FGC and reduced transmission of HIV! Indeed, the vulva has all sorts of warm, moist places where bacteria or viruses could get trapped, such as underneath the clitoral hood, or among the folds of the labia; so who is to say that removing some of that tissue (with a sterile surgical tool) might not reduce the risk of various diseases?

Fortunately, it’s impossible to perform this type of research in the West, because any scientist who tried to do so would be arrested under anti-FGM laws (and would never get approval from an ethics review board). So we simply do not know. As a consequence of this, every time you see the claim that “FGM has no health benefits”–a claim that has become something of a mantra for the WHO–you should read this as saying, “we actually don’t know if certain minor, sterilized forms of FGM have health benefits, because it is unethical, and would be illegal, to find out.”

Indeed, Western societies don’t seem to think that “health benefits” are particularly relevant to the question of whether we should be cutting off parts of the external genitalia of healthy girls. Without the girl’s consent, or a medical diagnosis, it’s seen as impermissible no matter what. By contrast, a small and insistent group of (mostly American) scientists have taken it upon themselves to promote infant male circumcision, by conducting study after well-funded study to determine just what kinds of “health benefits” might follow from cutting off parts of the penis. Why is there a double standard here? (Actually, there is an answer to this question; and it hinges on prejudicial cultural influences on what constitutes science and medicine—as well as on what sorts of research questions are deemed worthy of funding, among other problematic factors.)

Let’s look at one example of a “health benefit” that has been attributed to MGC: a lowered risk of acquiring a urinary tract infection. When it comes to girls, who get UTIs after the age of 1 fully 10 times more frequently than boys do, doctors prescribe antibiotics and try other conservative treatments; they also encourage girls to wash their genitals and practice decent hygiene. When it comes to boys, however, circumcision apologists tout the wisdom of performing non-therapeutic, non-consensual genital surgery, to the tune of 111 circumcisions to prevent a single case of UTI. Yet as Benatar and Benatar explain, “UTI does not occur in 99.85% of circumcised infant males and in 98.5% of un-circumcised infant boys.” And when it does occur, against those odds, it is both “easily diagnosed and treatable with low morbidity and [low] mortality.” So let’s review: washing the genitals for girls, foreskin amputation for boys?

With respect to reducing rates of HIV transmission in Africa—another health benefit that is frequently cited for MGC—remember that those studies were carried out on adult volunteers under conditions of informed consent, not on infants. I have no problem with a mature adult requesting surgery to remove a part of his own penis as a form of partial prophylaxis against HIV (in environments with very high base rates of such infection); that is certainly his right. Of course he would need to wear a condom either way to achieve any kind of reliable protection, but it’s his body, and it’s his decision to make. It’s quite a different matter, however, to circumcise an infant—who is not at risk of HIV or other STIs unless he is molested, who cannot consent to the procedure in the first place, and who might prefer to practice safe sex strategies when he does become sexually active, rather than forfeit a part of his penis. See herehereherehere, and here for further discussion of the “health benefits” arguments for MGC. The upshot is that they are not compelling, particularly in developed nations with functioning healthcare systems and access to soap and clean water.

So what other differences between FGC and MCG might justify their strict compartmentalization? Back to the arguments from above:

The “prime motive” of FGM is to control women’s sexualities – it is sexist and an expression of male power and domination. Male circumcision has nothing to do with controlling male sexuality.

There is a lot to say here. First, female genital cutting is performed for different reasons at different times in different cultures; likewise for male genital cutting. Contrary to common wisdom, however, it is not the case that FGC is uniformly “about” the control of female sexuality. For example, in Sierra Leone:

Among the Kono there is no cultural obsession with feminine chastity, virginity, or women’s sexual fidelity, perhaps because the role of the biological father is considered marginal and peripheral to the central ‘matricentric unit.’ … Kono culture promulgates a dual-sex ideology … [The] power of Bundu, the women’s secret sodality [i.e., initiation society that manages FGC ceremonies], suggest positive links between excision, women’s religious ideology, their power in domestic relations, and their high profile in the ‘public arena.’

In nearly every place that FGC is performed, it is carried out by women (rather than by men) who do not typically view it as an expression of patriarchy, but who instead believe that it is hygienic (see above), as well as beautifying, even empowering, and as an important rite of passage with high cultural value. (The claim that such women are simply “brainwashed” is a gross oversimplification.) At the same time, the “rite of passage” ceremonies for boys in these societies are carried out by men; these are done in parallel, under similar conditions, and for similar reasons–and often with similar (or even worse) consequences for health and sexuality: see this discussion by Ayaan Hirsi Ali.

Nevertheless, anthropological research does suggest that FGC is, in some cultures–especially in Northeast Africa and parts of the Middle East–intimately tied up with sexist expressions of patriarchal values; in these settings, the emphasis on female sexual ‘purity’ can more readily be discerned. As I have argued elsewhere, such an asymmetrical focus on female virginity in Islam (as expressed through genital cutting as well as through other practices) is extremely problematic and morally unjustifiable. However, it is important to note that, speaking generally:

The empirical association between patriarchy and genital surgeries is not well established. The vast majority of the world’s societies can be described as patriarchal, and most either do not modify the genitals of either sex or modify the genitals of males only. There are almost no patriarchal societies with customary genital surgeries for females only. Across human societies there is a broad range of cultural attitudes concerning female sexuality—from societies that press for temperance, restraint, and the control of sexuality to those that are more permissive and encouraging of sexual adventures and experimentation—but these differences do not correlate strongly with the presence or absence of female genital surgeries.

Indeed, in cultures where forms of FGC (and MGC) are culturally normative, many women regard the cutting as part of their cultural heritage and vigorously defend against the efforts of Western agencies, and sometimes the men in their own societies (see also here), who seek to wipe it out. Such a realization has led to the emergence of a counter-discourse among some Western feminists, who regard anti-FGC campaigns as a form of cultural imperialism. On this sort of view, the fight against FGC is inextricably bound up with a broader colonial and neo-colonial project of “white people saving brown women from brown men” (as well as from themselves). Thus as Nancy Ehrenreich writes in the Harvard Civil Rights-Civil Liberties Law Review:

 … the mainstream anti-FGC position is premised upon an orientalizing construction of FGC societies as primitive, patriarchal, and barbaric, and of female circumcision as a harmful, unnecessary cultural practice based on patriarchal gender norms and ritualistic beliefs. … Lambasting African societies and practices (while failing to critique similar practices in the United States) … essentially implies that North American understandings of the body are “scientific” (i.e., rational, civilized, and based on universally acknowledged expertise), while African understandings are “cultural” (i.e., superstitious, un-civilized, and based on false, socially constructed beliefs). [Yet] neither of these depictions is accurate. North American medicine is not free of cultural influence, and FGC practices are not bound by culture—at least not in the uniform way imagined by opponents.

Dustin Wax makes a similar argument:

In the case of anti-FGC advocacy, the voice of  “brown women” is almost entirely absent, literally silenced by an insistence that the horrendousness of the practice precludes any possible positive evaluation, and therefore the only valid voices are those that condemn FGC. All contradictory testimony is dismissed as the result of  “brainwashing,” “false consciousness,” “fear of male reprisal,” “anti-Westernism”, “ignorance,” or other forms of willful or unwillful complicity.

What about the other side of things? The usual claim is that male circumcision has “nothing to do” with controlling male sexuality. While it is probably true that most contemporary, Western parents who choose circumcision for their children do not do so out of a desire to “control” their sexuality (just as is true of most African parents who choose “circumcision” for their daughters), male genital cutting has been historically steeped in just such a desire, and it is implicated in problematic expressions of power to this day. Contrary to common wisdom, male genital cutting has indeed been used as a form of sexual control, and even punishment, for a very long time; the Jewish philosopher Maimonides argued that diminished sexual sensitivity was part of the point of doing circumcisions (to reduce excessive “lust” as well as “concupiscence”); circumcision was adopted into Western medicine in the Victorian period largely as a means to combat masturbation (as well as other expressions of juvenile sexuality); and forced circumcision of enemies has been used as a means of humiliation since time immemorial: this practice continues among the Luo of Kenya among numerous other groups. To return to the specific question of patriarchy, in Judaism, only the boys are allowed to “seal the divine covenant,” so the ritual is sexist on its face.

But it’s different in different communities. Moreover, the “reasons” given by most parents are not necessarily the same as the “reasons” the practice originally came about, nor the “reasons” for which it was consciously performed (i.e., as a “cure” for masturbation) in previous eras. As the renowned anti-FGC activist Hanny Lightfoot-Klein has stated: “The [main] reasons given for female circumcision in Africa and for routine male circumcision in the United States are essentially the same. Both promise cleanliness and the absence of odors as well as greater attractiveness and acceptability.”

So what are the implications here? Given that both male and female forms of genital cutting express different cultural norms depending upon the context, and are performed for different reasons in different cultures, and even in different communities or individual families, how are we meant to assess the permissibility of either one? Do we need to interview each set of parents to make sure that their proposed act of cutting is intended as an expression of acceptable norms? If they promise that it isn’t about “sexual control” in their specific case, but rather about “hygiene” or “aesthetics” or something less symbolically problematic, should they be permitted to go ahead? But this is bound to fail. Every parent who requests a genital-altering surgery for their child – for whatever reason under the sun – thinks that they are acting in the child’s best interests; no one thinks that they are “mutilating” their own offspring. Thus it is not the reason for the intervention that determines its permissibility, but rather the consequences of the intervention for the person whose genitals are actually on the line. So what kinds of consequences follow from FGC and MGC? Let us clear up one familiar legend:

Male circumcision is “just a snip” and in any case “men don’t complain.”

Before addressing these oft-repeated claims about male genital cutting, let us reflect on the analogous female forms that tend to dominate popular discussions. The interventions associated with extreme forms of FGC are gut-wrenching to think about. Many people find FGC to be “barbaric” and “inhumane” in part because they can call to mind grotesque and vivid images of slicing and cutting—perhaps with a shard of glass—and they react with a mix of sadness, horror, and disgust. Much less disturbing, however, are the images apparently called to mind by male circumcision, as evidenced by the widely repeated (but false) declaration that circumcision is “just a snip.”

Male circumcision is never “just a snip.” It is a frequently traumatic intervention; it is usually extremely painful, even in hospital settings, since adequate analgesia is rarely given; the same is true in ritual settings; and indeed sometimes the excruciating pain of circumcision is used as a test of masculinity. As Nelson Mandela reported about his own (tribal) circumcision:

Flinching or crying out was a sign of weakness and stigmatized one’s manhood. I was determined not to disgrace myself, the group or my guardian. Circumcision is a trial of bravery and stoicism; no anaesthetic is used; a man must suffer in silence [Before] I knew it, the old man was kneeling in front of me. … Without a word, he took my foreskin, pulled it forward, and then, in a single motion, brought down his assegai [knife]. I felt as if fire was shooting through my veins; the pain was so intense that I buried my chin in my chest. Many seconds seemed to pass before I remembered the cry, and then I recovered and called out, ‘Ndiyindoda!’ ['I am a man!']

In infant circumcision, the “snip”—if there is one—only comes at the end: the foreskin must first be separated from the head of the penis, to which it is adhered throughout much of childhood, then it is either stretched out and sliced, or crushed, or torn, or even strangled to the point of necrosis. When any of these things is done with unsterilized equipment, by a medically untrained practitioner, in environments with limited access to healthcare, the risk of serious infection, loss of the penis, and death is dramatically increased. I suggest that readers of this blog watch this video (of a hospitalized, American circumcision) or this one (of a traditional Muslim circumcision) or this one (of a Jewish circumcision), or this one (of a circumcision in Uganda) so that they can permanently lay to rest the idea that circumcision is “just a snip.” It is time to retire this phrase; it should not be used any more.

As to the notion that “men don’t complain” – that is simply false. Just as some women who have undergone forms of FGC complain passionately about what was done to them without their consent, so too do some men who have undergone forms of MGC. Here are some examples of thoughtful and articulate complaints about MGC by resentful, circumcised men: here, herehere, and hereThis man lost his penis. Several thousands of men are attempting “foreskin restoration,” which is an arduous process of stretching skin from the shaft of the penis using weights, tapes, and other materials, in an attempt to “restore” some semblance of their pre-circumcised state. This is not an insignificant number. Of course, when men do complain, their feelings are often trivialized; but they continue to complain nevertheless – in increasing numbers, and ever more vocally as they find the courage to speak out.

Many men do not complain, of course; but then many women who have undergone various forms of FGC do not complain either: in a survey of 3,805 Sudanese women, of whom 89% had experienced FGC, 96% said they would do it to their daughters and 90% favored the continuation of the practice generally. Yet it is enough that some men do complain, and that some women do as well: in both cases a healthy part of their body was removed, and without their informed permission. In Western societies, we teach our citizens that they have a right to bodily integrity: we forbid the tattooing of children, for example, and we tell them that adults should not so much as touch them inappropriately. In this sort of social and legal environment, complaints about having a part of one’s genitals removed without one’s own consent should be treated with serious concern. Finally:

FGM eliminates the enjoyment of sex, whereas male circumcision has no meaningful effects on sexual sensation or satisfaction.

Again, this depends. Obviously more minor forms of FGC – such as ritual ‘pricking,’ some kinds of piercing, or even removal of the vaginal lips – will not eliminate erogenous sensation; however, does this make any of these interventions permissible, if they are done without consent? The answer, in my opinion, is “no.” Even the risk of damaging sensitive nerve tissue with a ‘prick’ should be avoided unless the person taking on the risk is acting freely as an informed adult. Or what about removing “just” the clitoral hood? The clitoris might lose some sensitivity over time, as it rubs against environmental factors (just as the penile glans seems to do after male circumcision; in fact the clitoral hood and the foreskin are anatomically analogous structures), but perhaps some sensation would be preserved, and in any case sexual enjoyment cannot be reduced to stimulation of the clitoris or even ability-to-orgasm. Does that make ”clitoral unhooding” OK?

Not if it’s done without consent.

Finally, what about one of the most invasive forms of FGC – the excision of the external clitoris? According to a recent review published by the reputable Hastings Center, “Research by gynecologists and others has demonstrated that a high percentage of women who have had genital surgery [including excision] have rich sexual lives, including desire, arousal, orgasm, and satisfaction, and their frequency of sexual activity is not reduced.” Indeed, in one study, up to 86% of women who had undergone even “extreme” forms of FGC reported the ability to orgasm, and “the majority of the interviewed women (90.51%) reported that sex gives them pleasure.” These counterintuitive findings might be explained by the fact that much of the clitoris (including most of its erectile tissue) is actually underneath the skin and is therefore not removed by even the most invasive types of FGC: only the glans of the clitoris (the “part that sticks out”) can be excised. But this does not make make the surgery somehow “OK.” Every girl’s body is different, and the value she will end up placing on having in intact clitoral glans cannot be known in advance–even in cultures in which the glans is socially stigmatized. At the end of the day, if a fully-informed adult woman chooses genital surgery for herself, it may be permissible on some analyses. However, it is not permissible on children.

What about male circumcision? The same sort of reasoning applies. While the majority of circumcised men (whose circumcisions were not seriously “botched”) report that they experience sexual pleasure during intercourse, and even enjoy sex quite a lot: (a) they do not have a point of comparison, unless they were circumcised in adulthood, so they cannot know what sex would feel like had they not been circumcised (the same point applies to FGC done early enough in childhood) (b) the risk that a “botch” might in fact occur means that the surgery should be undertaken voluntarily, insofar as it is non-therapeutic in nature, (c) some men whose circumcisions did not result in “botches” may nevertheless experience adverse sexual outcomes, simply through the loss of erogenous tissue, and (d) some men’s sexual experiences are hampered via psychological mechanisms, including through the resentment they may feel at having been circumcised before they could object.

Scientists are divided over the “average” effect of (expertly performed, perfectly executed) circumcision on key sexual outcome variables. What is not controversial, however, is that any sensation in the foreskin itself is guaranteed to be eliminated by circumcision (just as any sensation in the labia or the clitoral glans will be eliminated by labiaplasty or excision, respectively), as are “any sexually-relevant functions associated with [the foreskin's] manipulation. In other words, a man without a foreskin cannot ‘play’ with his foreskin, nor can he glide it back and forth during sex. That these can be pleasurable activities, with great subjective value to genitally intact men and their partners, is uncontroversial.” Finally, the most extreme forms of male genital cutting (e.g., when it leads to penile amputation) eliminate sexual capacity altogether.

As Sara Johnsdotter has pointed out, there is no 1:1 relationship between amount of genital tissue removed (in either males or females), and subjective satisfaction while having sex, so “FGM” (and male “circumcision”)—of whatever degree of severity—will affect different people differently. Each individual’s relationship to their own body is unique, including what they find aesthetically appealing, what degree of risk they feel comfortable taking on when it comes to elective surgeries on their “private parts,” and even what degree of sexual sensitivity they prefer (for personal or cultural reasons). Thus each individual should be left to decide what to do with his or her own genitals when it comes to irreversible surgery.

To summarize, if “FGM” is wrong because it “destroys sexual pleasure” – then forms of “FGM” that do not destroy sexual pleasure must (on this logic) be considered permissible, or else they should be given a different name. But if “FGM” is wrong because it involves cutting into the genitals of a vulnerable child, without a medical indication and without consent, thereby exposing the child to surgical risk (without the presence of any disease), and (in some cases) removing a healthy part of her body that she might later wish she could have experienced intact, then male circumcision is equally wrong on those grounds. This is true whether sexual pleasure is “destroyed” or whether it isn’t, and whether a complaint is made later or not.

Explaining the double standard

Given everything that has been said so far about the relevant objective “overlaps” between male and female genital cutting, why exactly have they become so compartmentalized? Rebecca Steinfeld, a political scientist at Stanford who studies ritual cutting, has speculated as follows:

Alongside the differences in harm and misperceptions about the contrasting settings and ages at which the procedures take place, the double standard stems from two further factors: sexism and ethnocentrism. Male bodies are constructed as resistant to harm or even in need of being tested by painful ordeals, whereas female bodies are seen as highly vulnerable and in need of protection. In other words, vulnerability is gendered. And little girls are more readily seen as victims than little boys. The consequence of this … is that patriarchy often allows men’s experiences to remain unquestioned.

Familiarity also creates comfort, and since MGC has been practised in the West for millennia and been routine in English-speaking countries for a century, we’re desensitised. By contrast, since FGC is geographically or culturally remote, it’s more liable to be seen as barbaric.

On this last point, Andrew DeLaney (unpublished manuscript) gives a similar analysis:

It is safe to say that [male genital cutting] is a norm in the United States, despite any activists’ efforts to raise awareness about it. In the words of one law professor describing her generation, “Everyone was circumcised.” … FGM, on the other hand, is likely a completely foreign idea to the vast majority of people living in the United States or the rest of the western world, with the only exposure to it being horrific reports that are presented based on cases or reports out of Africa. With this being the case, moral objection to the practice of FGM is taken as self-evident, with research and activism being conflated and data on FGM that is sometimes not actually investigated taken as true. All the while, [male genital cutting] occurs as a completely normalized practice.

To return to the Guardian and the Change.org petition, it is of course to be welcomed that a prominent global newspaper is campaigning to protect the rights of girls to be free from non-therapeutic, nonconsensual cutting into their genital organs. I cannot state enough that I am in support of such efforts (although I do not favor the use of the term “FGM” for the reasons I have already given). My argument has been that they should not be stopping there. Female, male, and intersex genital cutting should be done exclusively with a medical indication or with the informed consent of the individual. Children of whatever gender should not have healthy parts of their most intimate sexual organs removed, before such a time as they can understand what is at stake in such a surgery and agree to it themselves. It is time to stop the compartmentalization exhibited by Shermer and others and recognize that there is “1 cause” here: respecting children’s rights and protecting them from harm.

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Announcement: “Brave New Love” in AJOB:Neuroscience – peer commentaries due October 7

Announcement: “Brave New Love” – peer commentaries due October 7

Dear Practical Ethics readers,

The paper, “Brave new love: the threat of high-tech ‘conversion’ therapy and the bio-oppression of sexual minorities” by Brian D. Earp, Anders Sandberg, and Julian Savulescu has been accepted for publication in the American Journal of Bioethics: NeuroscienceProposals for open peer commentaries are due this Monday October 7th.

The article may be accessed here, or at the following link: http://editorial.bioethics.net. Be sure to select AJOB:Neuroscience from the drop-down menu of journals. Here is an abstract of the argument:

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Abstract: Our understanding of the neurochemical bases of human love and attachment, as well as of the genetic, epigenetic, hormonal, and experiential factors that conspire to shape an individual’s sexual orientation, is increasing exponentially. This research raises the vexing possibility that we may one day be equipped to modify such variables directly, allowing for the creation of “high-tech” conversion therapies or other suspect interventions. In this paper, we discuss the ethics surrounding such a possibility, and call for the development of legal and procedural safeguards for protecting vulnerable children from the application of such technology. We also consider the more difficult case of voluntary, adult “conversion” and argue that in rare cases, such attempts might be permissible under strict conditions.

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Open Peer Commentary articles are typically between 500-1500 words and contain no more than 10 references. A guide to writing an Open Peer Commentary is available under the Resources section “Instructions and Forms” at http://editorial.bioethics.net. AJOB:Neuroscience asks that by Monday, October 7, 2013 you submit a short summary of your proposed Open Peer Commentary (no more than 1-2 paragraphs). Please submit your proposal online via the AJOB:Neuroscience Editorial site, following the instructions provided there. They ask that you do not prepare a full commentary yet. Once they have evaluated your proposal, they will contact you via email to let you know whether or not they were able to include you on the final list of those to be asked to submit an Open Peer Commentary.

You will then have until Friday, October 25, 2013 to submit your full Open Peer Commentary.

 

Teenage annihilation on an Aegean boat

An Old Bore writes:

Last week I got the boat from Athens to Hydra. It takes about 2 ½ hours, and takes you along the coast of the Argolid.

The sun shone, the dolphins leapt, the retsina flowed, the bouzoukis trembled, and we watched the sun rise over the Peloponnese. It was wonderful. At least it was for me.

Basking on the upper deck, playing Russian roulette with malignant melanoma, were four girls, all aged around 15. They saw nothing. They stretched out on bean bags, their eyes shut throughout the voyage. They heard nothing other than what was being pumped into their ears from their IPods. They would no doubt describe themselves as friends, but they didn’t utter a word to each other. They shared nothing at all apart from their fashion sense and, no doubt, some of the music. The dolphins leapt unremarked upon. We might, so far as the girls were concerned, have been cruising past Manchester rather than Mycenae. Continue reading

Let’s Talk About Death: Millennials and Advance Directives

Sarah Riad, College of Nursing and Health Sciences, University of Massachusetts Boston

Melissa Hickey, School of Nursing, Avila University 

Kyle Edwards, Uehiro Centre for Practical Ethics, University of Oxford

As advances in medical technology have greatly increased our ability to extend life, the conversation on end-of-life care ethics has become exceedingly complex. With greater options both to end life early and extend it artificially, advance directives have arisen in an effort to preserve patient autonomy in situations in which he or she becomes incapable of making a medical decision. However, most people—especially young adults—do not think to plan for such moments of incapacity and the potentiality of an untimely death. With a youthful sense of invincibility comes a lack of foresight that prevents us from confronting these issues. The reality is that unexpected events happen. When they do, it is often very difficult to imagine what a person would have wanted and make medical decisions accordingly on his or her behalf. In this post, we suggest both a transition from action-based to value-based advance directives and an interactive website that would make the contemplation of these issues and the construction of a value-based advance directive appealing to and accessible for Millennials, the 20-somethings of today.  Continue reading

Would you hand over a moral decision to a machine? Why not? Moral outsourcing and Artificial Intelligence.

Artificial Intelligence and Human Decision-making.

Recent developments in artificial intelligence are allowing an increasing number of decisions to be passed from human to machine. Most of these to date are operational decisions – such as algorithms on the financial markets deciding what trades to make and how. However, the range of such decisions that can be computerisable are increasing, and as many operational decisions have moral consequences, they could be considered to have a moral component.

One area in which this is causing growing concern is military robotics. The degree of autonomy with which uninhabited aerial vehicles and ground robots are capable of functioning is steadily increasing. There is extensive debate over the circumstances in which robotic systems should be able to operate with a human “in the loop” or “on the loop” – and the circumstances in which a robotic system should be able to operate independently. A coalition of international NGOs recently launched a campaign to “stop killer robots”.

While there have been strong arguments raised against robotic systems being able to use lethal force against human combatants autonomously, it is becoming increasingly clear that in many circumstances in the near future the “no human in the loop” robotic system will have advantages over the “in the loop system”. Automated systems already have better perception and faster reflexes than humans in many ways, and are slowed down by the human input. The human “added value” comes from our judgement and decision-making – but these are by no means infallible, and will not always be superior to the machine’s. In June’s Centre for a New American Society (CNAS) conference, Rosa Brooks (former pentagon official, now Georgetown Law professor) put this in a provocative way:
“Our record- we’re horrible at it [making “who should live and who should die” decisions] … it seems to me that it could very easily turn out to be the case that computers are much better than we are doing. And the real ethical question would be can we ethically and lawfully not let the autonomous machines do that when they’re going to do it better than we will.” (1)

For a non-military example, consider the adaptation of IBM’s Jeopardy-winning “Watson” for use in medicine. As evidenced by IBM’s technical release this week, progress in developing these systems continues apace (shameless plug: Selmer Bringsjord, the AI researcher “putting Watson through college” will speak in Oxford about “Watson 2.0″ next month as part of the Philosophy and Theory of AI conference).

Soon we will have systems that will enter use as doctor’s aides – able to analyse the world’s medical literature to diagnose a medical problem and provide recommendations to the doctor. But it seems likely that a time will come when these thorough analyses produce recommendations that are sometimes at odds with the doctor’s recommendation – but are proven to be more accurate on average. To return to combat, we will have robotic systems that can devise and implement non-intuitive (to human) strategies that involve using lethal force, but achieve a military objective more efficiently with less loss of life. Human judgement added to the loop may prove to be an impairment.

Moral Outsourcing

At a recent academic workshop I attended on autonomy in military robotics, a speaker posed a pair of questions to test intuitions on this topic.
“Would you allow another person to make a moral decision on your behalf? If not, why not?” He asked the same pair of questions substituting “machine” for “a person”.

Regarding the first pair of questions, we all do this kind of moral outsourcing to a certain extent – allowing our peers, writers, and public figures to influence us. However, I was surprised to find I was unusual in doing this in a deliberate and systematic manner. In the same way that I rely on someone with the right skills and tools to fix my car, I deliberately outsource a wide range of moral questions to people who I know can answer then better than I can. These people tend to be better-informed on specific issues than I am, have had more time to think them through, and in some cases are just plain better at making moral assessments. I of course select for people who have a roughly similar world view to me, and from time to time do “spot tests” – digging through their reasoning to make sure I agree with it.

We each live at the centre of a spiderweb of moral decisions – some obvious, some subtle. As a consequentialist I don’t believe that “opting out” by taking the default course or ignoring many of them absolves me of responsibility. However, I just don’t have time to research, think about, and make sound morally-informed decisions about my diet, the impact of my actions on the environment, feminism, politics, fair trade, social equality – the list goes on. So I turn to people who can, and who will make as good a decision as I would in ideal circumstances (or a better one) nine times out of ten.

So Why Shouldn’t I Trust The Machine?

So to the second pair of questions:
“Would you allow a machine to make a moral decision on your behalf? If not, why not?”

It’s plausible that in the near future we will have artificial intelligence that for given, limited situations (for example: make a medical treatment decision, a resource allocation decision, or an “acquire military target” decision) is able to weigh up the facts for a and make as a decision or better than a human can 99.99% of the time – unclouded by bias, with vastly more information available to it.

So why not trust the machine?

Human decision-making is riddled with biases and inconsistencies, and can be impacted heavily by as little as fatigue, or when we last ate. For all that, our inconsistencies are relatively predictable, and have bounds. Every bias we know about can be taken into account, and corrected for to some extent. And there are limits to how insane an intelligent, balanced person’s “wrong” decision will be – even if my moral “outsourcees” are “less right” than me 1 time out of 10, there’s a limit to how bad their wrong decision will be.

This is not necessarily the case with machines. When a machine is “wrong”, it can be wrong in a far more dramatic way, with more unpredictable outcomes, than a human could.
Simple algorithms should be extremely predictable, but can make bizarre decisions in “unusual” circumstances. Consider the two simple pricing algorithms that got in a pricing war, pushing the price of a book about flies to $23 million. Or the 2010 stock market flash crash. It gets even more difficult to keep track of when evolutionary algorithms and other “learning” methods are used. Using self-modifying heuristics Douglas Lenat’s Eurisko won the US Championship of the Traveller TCS game using unorthodox, non-intuitive fleet designs. This fun youtube video shows a Super Mario-playing greedy algorithm figuring out how to make use of several hitherto-unknown game glitches to win (see 10:47).

Why should this concern us? As the decision-making processes become more complicated, and the strategies more non-intuitive, it becomes ever-harder to “spot test” if we agree with them – provided the results turn out good the vast majority of the time. The upshot is that we have to just “trust” the methods and strategies more and more. It also becomes harder to figure out how, why, and in what circumstances the machine will go wrong – and what the magnitude of the failure will be.

Even if we are outperformed 99.99% of the time, the unpredictability of the 0.01% failures may be a good reason to consider carefully what and how we morally outsource to the machine.

1. Transcript available here.
For further discussion on Brooks’s talk, see Foreign Policy Magazine articles here and here.

Casinos should say: ‘Enough. Go home.’

Over about 14 months, Harry Kakavas lost $20.5 million in a casino in Melbourne. It could have been worse. He put about $1.5 billion on the table. He sued the casino. It knew or should have known, he said, that he was a pathological gambler. It shouldn’t have continued to take his money. It should have protected him from himself. Nonsense, said the High Court of Australia.

Here’s why:

Even if, contrary to the findings of the primary judge, the appellant did suffer from a psychological impairment, the issue here is whether, in all the circumstances of the relationship between the appellant and Crown, it was sufficiently evident to Crown that the appellant was so beset by that difficulty that he was unable to make worthwhile decisions in his own interests while gambling at Crown’s casino. On the findings of fact made by the primary judge as to the course of dealings between the parties, the appellant did not show that his gambling losses were the product of the exploitation of a disability, special to the appellant, which was evident to Crown.

Equitable intervention to deprive a party of the benefit of its bargain on the basis that it was procured by unfair exploitation of the weakness of the other party requires proof of a predatory state of mind. Heedlessness of, or indifference to, the best interests of the other party is not sufficient for this purpose. The principle is not engaged by mere inadvertence, or even indifference, to the circumstances of the other party to an arm’s length commercial transaction. Inadvertence, or indifference, falls short of the victimisation or exploitation with which the principle is concerned.‘ (paras 160-161 of the judgment).

So it all turned on findings of fact (it wasn’t ‘sufficiently evident’ that his losses were the result of a disability, and if they were, they weren’t the product of a disability ‘special to the appellant.’)

That last criterion is interesting. The court seems to be implying that everyone who puts themselves in the position of losing large amounts of money in a casino is necessarily not quite right in the head. To establish liability you need a degree of vulnerability over and above that possessed by the ordinary punter. By accepting the trial judge’s finding that Kakavas did not suffer from a ‘psychological impairment’, the court was presumably saying: ‘Right: so Kakavas is weak and easily exploited: but that’s true of everyone who walks through the door, buys some chips and sits down at the table. That sort of weakness is within the general bell curve of human flabbiness. But Kakavas wasn’t particularly, dramatically, visibly weak.’ Continue reading

Cry havoc and let slip the robots of war?

Stop killer robots now, UN asks: the UN special rapporteur on extrajudicial, summary or arbitrary executions Christof Heyns has delivered a report about Lethal Autonomous Robots arguing that there should be a moratorium on the development of autonomous killing machines, at least until we can figure out the ethical and legal issues. He notes that LARs raise far-reaching concerns about the protection of life during war and peace, including whether they can comply with humanitarian and human rights law, how to device legal accountability, and “because robots should not have the power of life and death over human beings.”

Many of these issues have been discussed on this blog and elsewhere, but it is a nice comprehensive review of a number of issues brought up by the new technology. And while the machines do not yet have fully autonomous capabilities the distance to them is chillingly short: dismissing the issue as science fiction is myopic, especially given the slowness of actually reaching legal agreements. However, does it make sense to say that robots should not have the power of life and death over human beings?

Continue reading

Cultural bias and the evaluation of medical evidence: An update on the AAP

By Brian D. Earp

Follow Brian on Twitter by clicking here.

Cultural bias and the evaluation of medical evidence: An update on the AAP

Since my article on the American Academy of Pediatrics’ recent change in policy regarding infant male circumcision was posted back in August of 2012, some interesting developments have come about. Two major critiques of the AAP documents were published in leading international journals, one in the Journal of Medical Ethics, and a second in the AAP’s very own PediatricsIn the second of these, 38 distinguished pediatricians, pediatric surgeons, urologists, medical ethicists, and heads of hospital boards and children’s health societies throughout Europe and Canada argued that there is: “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.”

The AAP took the time to respond to this possibility in a formal reply, also published in Pediatrics earlier this year. Rather than thoughtfully addressing the specific charge of cultural bias, however, the AAP elected to boomerang the criticism, implying that their critics were themselves biased, only against circumcision. To address this interesting allegation, I have updated my original blog post. Interested readers can click here to see my analysis.

Finally, please note that articles from the Journal of Medical Ethics special issue on circumcision are (at long last) beginning to appear online. The print issue will follow shortly. Also be sure to see this recent critique of the AAP in a thoughtful book by JME contributor and medical historian Dr. Robert Darby, entitled: “The Sorcerer’s Apprentice: Why Can’t the US Stop Circumcising Boys?”

– BDE 

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