Table of Contents Bioethics 2013; 27(2)

Bioethics © Blackwell Publishing Ltd Volume 27, Issue 2 Pages ii - ii, 59 - 116, February 2013 The latest issue of Bioethics is available on Wiley Online Library EDITORIAL Saving Lives (page ii) Ruth Chadwick DOI: 10.1111/bioe.12014 ARTICLES USE OR REFUSE REPRODUCTIVE GENETIC TECHNOLOGIES: WHICH WOULD A ‘GOOD PARENT’ DO? (pages 59–64) JANET MALEK DOI: 10.1111/j.1467-8519.2011.01890.x THE ETHICS OF UTERUS TRANSPLANTATION (pages 65–73) RUBY CATSANOS, WENDY ROGERS and MIANNA LOTZ DOI: 10.1111/j.1467-8519.2011.01897.x STIGMATIZATION AND PUBLIC HEALTH ETHICS (pages 74–80) ANDREW COURTWRIGHT DOI: 10.1111/j.1467-8519.2011.01904.x WELLBEING, SCHIZOPHRENIA AND EXPERIENCE MACHINES (pages 81–88) DAVID RHYS BIRKS DOI: 10.1111/j.1467-8519.2011.01894.x UNCERTAIN TRANSLATION, UNCERTAIN BENEFIT AND UNCERTAIN RISK: ETHICAL CHALLENGES FACING FIRST-IN-HUMAN TRIALS OF INDUCED PLURIPOTENT STEM (IPS) CELLS (pages 89–96) RONALD K.F. FUNG and IAN H. KERRIDGE DOI: 10.1111/j.1467-8519.2011.01896.x OVERSTATING VALUES: MEDICAL FACTS, DIVERSE VALUES, BIOETHICS AND VALUES-BASED MEDICINE (pages 97–104) MALCOLM PARKER DOI: 10.1111/j.1467-8519.2011.01902.x IS PAYMENT A BENEFIT? (pages 105–116) ALAN WERTHEIMER DOI: 10.1111/j.1467-8519.2011.01892.x

On (Not) Travelling on Delta Airlines between Xmas and NY

Here's a true story befalling some 200 travellers on a Delta Airlines flight from Syracuse to Atlanta on December 22. We were scheduled to depart Syracuse at 6:40 am, accordingly many travellers booked the night before into hotels in close proximity to the airport. We pretty much showed up on time, checked diligently in, even boarded the plane in a timely fashion for our 6:40 am departure. The simple reason for this was that we needed the plane to depart in a timely fashion for most of us to catch our connecting flights to our vacation destinations (or home) in Atlanta. In my case the plan was to head to Fort Lauderdale where hotel and rental car were waiting (and had to be paid regardless of whether I would make it there or not).

Well, it turned out that Delta staff had no problems letting passengers board a plane they knew full well wasn't roadworthy so to speak, given that it arrived with a broken generator the night before. So the charade began. We were stuck for about 2 ours, some fiddling with the engine, the generator, the ice and whatnot. Eventually we were kicked off the plane (could have slept a few hours longer I thought at the time). Well, an hour or two later we were herded back on to the plane only for the crew to discover further mechanical and electrical problems. an hour or so later we were again kicked off the plane.

Meanwhile Delta had ordered a bunch of junkfood items for us, muffins, bagels and tons of the cheapest pizzas available. I understand that by US airline standards that was a kind gesture, and to be fair to Delta, the food outlets at the airport in Syracuse do simply not sell healthy food items (short of overpriced fruit salads).

We waited and waited and waited, only to be eventually told that Delta was trying to get a replacement jet and crew to Syracuse. This, of course, should have happened over night, and not in a haphazard activity late afternoon on December 22. Pretty much everyone on the plane had by then missed their connecting flights, many had in fact decided to return home and forget about their holidays altogether.

Eventually, at around 5:30 pm or so the replacement plane arrived. Delta staff quickly dumped another load of pizza on us, lest it would have to provide us with cash vouchers to purchase proper dinner in Atlanta where virtually everyone was stuck for the night. We eventually departed - irony of ironies - at 6:40 pm, a full 12 hours after our scheduled departure time to Atlanta.

Some people on the plane were stuck in their quest to reach their holiday destination for up to three days in Atlanta - it goes without saying that they were not dressed for winter, yet Delta thought nothing of it to book them into airport hotels instead of nicer downtown Atlanta hotels. So there they were over the Xmas holidays, in airport hotels in Atlanta. Why? Because of Delta's incompetence. The airline knew full-well for a full night that their plane wouldn't be able to take off, yet it chose not to act on this information when it should have (namely over night). Its own ground staff in Syracuse was flabbergasted about the airline's decision not to replace the broken-down plane over night when it could and should have.

200 passengers were severely hit by this airline misconduct during their holidays. We had significant additional costs that were caused entirely by Delta's mistakes. Just to be clear, this cannot be an argument for taking out travel insurance to cover those extra costs, because the fault for these extra costs was Delta's. Why should travellers have to insure themselves against costs incurred due to airline incompetence? Delta offered a voucher of 100$ toward future flights. It goes without saying that that voucher didn't cover the actual additional expenses incurred.

Well, we arrived eventually in Atlanta and ended up receiving a voucher for a truly terrible airport hotel (the restaurant closed early - thanks Sheraton Atlanta airport hotel - despite a large queue of passengers checking in, all of whom hungry for real food after a day's worth of Delta's junk food). True to form the hotel voucher included no meals and no internet access. We continued our trip the next morning, being among the lucky ones able to continue their journey after losing only one full day of their vacation courtesy of Delta Airlines.

This has been a shocking experience, mostly because it became clear to everyone of the 200 passengers on said flight that this all would have been avoidable if Delta had acted on the problem when it should have. Delta clearly chose the course of action it thought would be cheaper, even though this would come at significant cost to about 200 of its passengers. Eventually it saved nothing at all, a replacement jet had to be send after a day's worth of fiddling with the broken equipment in Syracuse, plus there were 200 irate passengers realizing that their all-important vacation plans meant nothing to this airline, a large number of hotel rooms booked, the list goes on.

The lesson out of this all: Delta is probably not much better or worse than any other US airline, so passengers will have to accept such misconduct until these companies are better regulated. The real lesson to me: If Xmas/NY travel is avoidable at all, don't travel during that time of the year. I had two out of two trips during that time of the year stuffed up during the last 4 years. So, it's not only that airlines charge you a lot, they also often don't deliver. A pretty miserable record.

Delta's Twitter guy or girl #DeltaAssist suggested I complain with Delta's 'not my problem', aka its complaints folks. I mentioned that that likely would mean throwing good money after bad, knowing that US airlines could not care less about customer experiences. Against my better judgment I tried anyway. I  received precisely the response that you'd expect from such an outfit:

'I understand the frustration you experienced when your plans were
disrupted due to the delay of our flight for mechanical reasons causing
you to miss your connecting flight.  I can only imagine how dissatisfied
you must have been to have your travel plans disrupted at the last
minute.

Additionally, I am truly sorry you were unhappy with the Electronic
Transportation Credit Voucher (eTCV) and hotel voucher provided.  The
gesture extended was not meant to place a value on your experience;
rather it was an attempt to make amends for your disappointment with our
service.  Respectfully, additional consideration would not be due.  I
apologize, as I understand this is not the answer you were hoping to
receive.'

My truly favorite line is this, 

'I want to thank you, again, for writing regarding flight

irregularity.  We appreciate your interest in our company and look
towards your future travel with us.'

2013 here we come

I'm off to a good start into 2013, at least on the work-related fronts. Russell Blackford and I submitted in the dying days of 2012 the final copy of our up-coming 50 Great Myths about Atheism to Wiley-Blackwell, our publisher. I have also been working diligently with Helga Kuhse and Peter Singer on the 3rd edition of Bioethics - An Anthology, which should also be out some time this year. It's going to be an 800+ pages doorstopper. The question is what to do with the remainder of my sabbatical, roughly another 9 months worth of no teaching and administrative responsibilities at the university. I need to get going on a book project on Global Health Ethics, but there's also a tempting new introductory bioethics textbook to produce that's heavily oriented toward the inclusion and utilisation of on-line networking tools. Difficult call, but a decision has to be made. I have also written a piece that's forthcoming during the next few days in the Journal of medical ethics. Using the debate on infanticide I show how bioethics journal editors come under ever-increasing scrutiny by political campaigners and other pressure groups to publish whatever it is that these campaigners and organizations deem 'right', and that we cease and desist from publishing content they disapprove of. These are worrying developments. Keep your eyes open for the article. I understand that it will be an Open Access document, but if it isn't, ask me for the pdf and I shall post it your way. With Ricardo Smalling I have co-authored a paper that also coming out in the next few days, this one in the Journal of Medical Humanities. We are looking there at the impact religiously motivated anti-gay sentiments have on the professional (or not so professional) conduct of some health care professionals. Not terribly original is our suggestion that tighter regulations are required to protect queer patients from such health care personnel's unprofessional conduct. But it had to be said. We are also taking head-on the silly idea that conscience based objections to homosexuality should be a valid reason to treat queer patients different to other patients. Right now I am revising the entry on 'Utilitarianism' for the 4th edition of the Encyclopedia of Bioethics. I had written pretty much what I thought ought to be said and passed it by a number of colleagues. I received plenty  of very constructive feed-back in the middle of the holiday season (who says academics are lazy!). During the rest of this week I will revise what I got, and then submit to the editors of the encyclopedia.

2013 will see in Canada a number of exciting landmark cases being decided by the Supreme Court (well, by virtue of them coming to the Supreme Court they got to be landmark cases, of course). Among them a case where the family of a patient in persistent vegetative state wants the taxpayers to fork out 2,000 C$ per day for futile medical care vs doctors who think they'd have the last word on cessation of treatment. I am not in favour of either party here, so I am curious what the Court will make of it all. Then, of course, presumably by the middle of the year, the Court should issue a finding on the constitutionality of the criminal code prohibition of any form of assisted dying in the country. I suspect that a lot will hang on whether the judges on the Court can be persuaded by one side or the other that there is or isn't a slippery slope from decriminalizing assisted dying in some form or shape to the killing of people who do not wish to see their lives terminated.  I have seen no proof for the existence of such a slippery-slope, but who knows what the judges on the Court will make of the arguments and evidence presented to it. If you were to ask me for a prediction, I would guess that the Court will find that the absolute prohibition of assisted dying in all cases simply is too broad, and that it will open the door for decriminalization in a restricted number of clearly defined cases. But then, your guess is as good as mine.

2013 promises to be an exciting year for us bioethics and health policy wonks.

Being a good academic citizen

A lot of ink has been spilt about the pro’s and con’s of academic peer review. I am not going to add to the existing literature on this matter in this blogpost. Suffice it to say that I subscribe to the view that anonymous peer review is still the least deficient of the available mechanisms to determine the quality of a given article submission. As an editor of two international journals I am painfully aware of the fact that occasionally the quality of peer review is not as good as it should be. Usually enraged or not so enraged emails from authors give us editors an indication that one or another of the reviewers we invited to review a particular manuscript might not have been as diligent as would have been desirable.  In some of those cases we tend to embark on a second round of reviews. Either way, we depend on volunteers, also commonly known as good academic citizens, to review articles submitted to the journal. Our Editorial Board members have graciously agreed to review a minimum of four submitted articles for us in any given year, many review quite a few more submissions.

Without dependable reviewers Bioethics and Developing World Bioethics could not function and deliver high-quality outputs. One problem we encounter frequently is that it often is very difficult to find reviewers for submitted manuscripts. We know from conversation with fellow editors at other bioethics and medical ethics journals that we are not alone in this. The ‘very difficult’ refers to a number of different problems, the accumulated effects of which have a deleterious effect on our operations. For starters, too many academics are very happy to submit their manuscripts for review but they think little of returning the professional courtesy of their reviewers by responding positively to invitations to review manuscripts for the journal. As a result, some of those good academic citizens, who review diligently for us, get arguably overburdened with review requests, while those who prefer not to review content get a free ride. I wonder whether the Golden Rule might actually be more frequently written about by academic ethicists than it is actually followed by us. It is notable that junior academics tend to be more generous with their time while many (but by no means all) of the more established scholars are among the more frequent non-responders. The former also tend to provide longer, more in-depth and more constructive reviews. This, of course, is very much appreciated by authors keen to improve their papers prior to submitting their final draft for publication.

Other problems that typically delay – sometimes very significantly – decisions on submitted manuscripts have to do with invited reviewers not responding to our invitations, lagging significantly behind agreed-upon deadlines for the delivery of the reviews, not delivering promised reviews at all, but also producing reviews so devoid of critical substance that they are useless for all intent and purposes.

Part of the problem is undoubtedly that many academic institutions encourage free-riders by not giving serious credits for undertaking per reviews for academic journals, funding agencies and the like. If annual performance reviews, or tenure reviews do not include credits for such work it is understandable why academics turn down such work. This is very unfortunate indeed.  As academics we should flag this issue within our institutions with a view toward establishing formal institutional recognition of demonstrable, quantifiable services to the academic community. 

Margaret Somerville in secular garb - in the Catholic Register

Good fun, Margaret Somerville, a McGill law professor is interviewed in the Catholic Register. The main objective of the article is to figure out her 'secular stance' on assisted dying. For good measure, and presumably to ascribe expertise to her in matters bioethics, the Catholic Register describes her as a bioethics professor, yet McGill only notes her law school and her medical school professorial appointments. I was not able to find any evidence of her holding currently a formal appointment as a bioethics professor at that university. 

Evidence has never been MsSomerville's strongest point. So, without any evidence to back up her claims she declares on the Catholic website, 'One of the things that's wrong with respect to Justice (Lynn) Smith's judgment (in Carter v. Attorney General of B.C.) is that she purports to review the use of euthanasia and physician-assisted suicide in the jurisdictions that have legalized it. She said there is no problem, there is no slippery slope. Well, that's simply not right factually.' 

It turns out, in our Report on end of life decision-making in Canada we reviewed the empirical evidence on the slippery slope matter and concluded that there is no evidence that assisted dying leads us down slippery slopes to unwanted killings. Of course, we reviewed evidence, Ms Somerville is in full preaching mode. 

Ms Somerville also declares that 'The biggest group who are against euthanasia are doctors, and certainly by far not all of them are Church people.' Things are more complicated. For instance, a survey of medical specialists in Quebec reported a strong majority of medical specialists in that province coming out in favour of decriminalizing assisted dying. 

Ms Somerville is also up to her old magic tricks when framing the issue at hand: 'The pro-euthanasia people are very keen on saying there's a societal consensus, that everyone wants this. Well yes, but you've got to make sure those surveys are properly done. If you say to somebody that someone is in terrible pain and they want euthanasia, should they be able to have it? You've got to choose between saying yes to euthanasia and saying no to pain and suffering relief. What you have to do is ask people, does someone have absolute rights to all possible pain management? And the answer is yes, absolutely.' [emphasis added]

This is a true Somerville classic. The choice is, of course, not between either pain relief or euthanasia. You want good palliative care and access to assisted dying for those who do not consider their lives worth living. It's not either euthanasia or palliative care. 

She is also against equal marriage rights, because 'of its impact on kids' rights.' It goes without saying that there is no evidence that kids brought up in same sex families are in any way worse off than those who are brought up in heterosexual families, or that their 'rights' are violated in any appreciable sense. But hey, Ms Somerville is concerned. Right. How about reading up on the evidence?  I understood this to be an important concept in law, but I might be mistaken. She also notes, incredibly, that as far as she knows, homosexuality is natural 'for some people'. You just got to love her! - It is not terribly surprising, perhaps, that Ms Somerville's views, these days, are not even accepted as expert advice by the courts. As far as I can tell (her McGill website, her Wikipedia entry), this 'bioethics professor' has no formal qualifications in either ethics or bioethics.

AP drops 'homophobia'

I have been arguing for some time that it is inappropriate to label most forms of anti-gay (speech) acts as homophobic. The reason being essentially that phobias are anxiety disorders. Most of the actions described today as homophobic are simply anti-gay, those undertaking them are fully competent and the actions they engage in are not in any way expressions of anxiety disorders. Labelling them as homophobic suggests limited personal responsibility for their actions, because of the anxiety disorder link. 

I am delighted therefore that the Associated Press, in its revised style guide, asks journalists to refrain from using the term 'homophobic' or 'homophobia' precisely because these terms mislabel anti-gay actions, and because they suggest limited responsibility on the part of those who engage in anti-gay manners. AP Deputy Standards Editor Dave Minthorn explains, 'Homophobia especially -- it's just off the mark. It's ascribing a mental disability to someone, and suggests a knowledge that we don't have. It seems inaccurate. Instead, we would use something more neutral: anti-gay, or some such, if we had reason to believe that was the case.'

Why Not Sell Your Kidney for Personal Gain?

The Canadian Society of Transplantation tells on its website a story that is a mirror image of what is happening all over the world. More than two times as many Canadians are on waiting lists for transplant organs than there are suitable donor organs. Reportedly about 200 Canadians died last year while waiting for suitable organs. Most people on the waiting list are desperate for transplant kidneys. South of our border about 80,000 Americans are on waiting lists for kidney transplants. The current situation is not only unacceptable because people die preventable deaths when they could be looking forward to a productive and happy life, it is also immensely wasteful as kidney dialysis is a hugely expensive undertaking. How can we close the gap between the number of patients in need of transplant organs and the availability of suitable organs?

Dead donors

A number of different policies aimed at increasing the number of transplant organs in an ethical manner have been discussed and implemented in various countries around the world. I am personally in favor of an idea currently debated in PEI. The proposal is on the table that we should switch from an opt-in to an opt-out system of consent. The idea here is that for everyone who does not expressly refuse to donate their organs after their demise the reasonable assumption is made that they would be happy to see their organs utilized to preserve a fellow-Canadian’s life. However, some don’t like this proposition. As far as they are concerned, this is not just a question of solidarity but one of ownership. After all, nobody is entitled to take my car after my demise either, just because I have forgotten to stipulate that it should go to my loved-ones.

Living donors

Here is where an alternative idea comes into play: perhaps we should consider incentivizing potential sources of transplant organs, ie people like you and me. I am focusing here primarily on living donor kidneys. We have reasonably persuasive data today suggesting that it is perfectly safe for most healthy people to donate kidneys. As the autonomous owners of our bodies we are entitled to make decisions with regard to how we wish to use our bodies. There are lots of things we are morally and legally entitled to do with our bodies, including engaging in risky activities like playing rugby, scuba diving in shark infested waters and many others. Strangely, when it comes to the use of our bodies for medical research or transplantation purposes, the response we get frequently from religious leaders, medical ethicists and others is that we should contribute from the goodness of our hearts, rather than from a less altruistic motive. Any sensible medical system would focus here on outcomes instead, namely a maximization of the number of available suitable transplant organs, rather then a second-guessing of vendors’ motives. Given that we already accept altruistically motivated living donor kidney donations, it does not strike me as particularly plausible that people should continue to lose their precious lives because of an unreasonable societal squeamishness when it comes to paying people for their spare kidneys for transplantation purposes. 

It is important to recognize that our current system is not working in many ways. Precious lives are unnecessarily lost year after year. Desperate patients travel overseas and obtain kidneys frequently under questionable circumstances, often exploiting vulnerable impoverished people in developing countries. The list goes on. Suffice it to say: leaving things as they are is not a cost neutral choice!

Let’s try it

What I am proposing is to run a pilot program aimed at investigating whether strictly government regulated incentives for living donor transplant kidneys would result in additional available transplant organs with a resultant decrease or elimination of the current waiting lists.  The objective of this pilot program would be two-fold: 1) develop a system that would create successful incentives for organ vendors to offer their spare kidneys while at the same time 2) ensure that sufficient safeguards are put in place to guarantee that whatever incentives are offered do not generate additional harms. Benjamin Hippen, a US based transplant specialist sums up what features a government regulated market for transplant organs should have: It prioritizes the safety of both vendors and recipients; it must be transparent with regard to risks to vendors and recipients; it must safeguard institutional integrity regarding guidelines for cooperating with kidney vendors, and last but not least it must operate under a robust legal framework.

Ottawa Atheist/Humanist/Secular Event

The Ottawa Centre for Inquiry is hosting Eschaton 2012: Celebrating Reason at the End of the World, a 'weekend gathering of scientists, philosophers, authors, academics, skeptics, rationalists, humanists, atheists, and freethinkers, where you can see presentations and join discussions on science, skepticism, gender issues, theocracy vs secularism, godless ethics, parenting beyond belief. Featured speakers include blogger PZ Myers, author Ophelia Benson, philosopher Chris DiCarlo, science education activist Eugenie Scott, and many others.'

Check out the full  programme here. The line-up of confirmed speakers (including yours truly) is here. I must say, I am looking forward to hopefully meeting in person Ophelia Benson, one of the contributors to our 50 Voices of Disbelief.

I am part of the panel on 'Godless Ethics and Godless Communities'. My offering on the day will be this:

Myths about Atheist Values

In our forthcoming book ’50 Great Myths About Atheism’ (Wiley-Blackwell 2013) Russell Blackford and I analyze a variety of commonplace myths about atheism. I will discuss four such myths that are relevant to the panel topic, namely: ‘Without God there is no morality’, ‘Atheists are moral relativists’, ‘Atheism robs life of meaning and purpose,’ and ‘Atheists deny the sanctity of human life.’ These myths are a good selection for the panel, because they look at the question of whether we need a higher authority to ground ethics, whether – in the absence of such an authority – we are bound to create secular societies bereft of any stable values, and whether that would lead to our lives becoming meaningless and vacuous. In light of recent Canadian debates about the pro’s and con’s of introducing abortion legislation it seems apt to ask finally whether atheists really callously deny the sanctity of human life. 

Hope to see you there!

Canadian Supreme Court reaches sensible decision on HIV transmission

Today the Canadian Supreme Court reached a sensible verdict on the tricky issue of the criminalisation of HIV transmission. It found - essentially - that folks who are HIV infected, on HIV medicine, and who have a low viral load (note, it is not a requirement that there is an undetectable viral load) and who use condoms, are under no obligation to disclose their HIV status to their sexual partners.

The main logic of the Court's decision is that if there is no significant risk of bodily harm (as is the case if the above mentioned conditions are met) the legal requirement to inform one's sexual partners of one's infection falls by the wayside.

Of course, many AIDS activists will be annoyed by this decision as it maintains the criminalisation of non-disclosure in cases where someone's viral load is not low, or where someone is not using a condom at the same time that his or her viral load is low, etc.

However, this decision makes a powerful, and sensible case to people at significant risk of HIV infection to get tested, and to get on HIV medication (both to protect their health and that of people they choose to have sexual intercourse with), as well as to use condoms each time they have sex with people they have not disclosed their HIV status to. In fact, this line of reasoning was developed in a paper I published in 2011. You can find it here, the argument runs from p. 310ff.

It might be worth noting that this decision by the Court was unanimous, something quite remarkable, considering the Harper government's recent appointment of four judges to the Court.

Bad news for anti-euthanasia campaigners

One can understand why anti-euthanasia campaigners get ever more desperate in their campaign strategies. After all, they can't be entirely honest with us any longer about their true motives, namely their religious convictions that just are not shared by most of us. So they have resorted to go on and on and on about the dangers of sliding down a slippery slope from voluntary to non-voluntary euthanasia, endless warnings about abuses of all kinds, stuff like that. They even publish agitprop papers in scientific outlets. An example as good as any is an article by Ottawa palliative care specialist Jose Pereira in Current Oncology that consist to a large extent of empirically false claims 'supported' by references that do not sustain his claims. As far as stooping low is concerned, anti-euthanasia campaigners do not seem to know what shame is all about, they certainly seem to have none. Remarkably the online outlet that chose to publish Mr Pereira's agitprop piece has so far refused to publish what would be a very long list of corrections to Pereira's error ridden article. The interested public, coming across Pereira's piece in medical databases, is still downloading his stuff without being notified about the long list of errors the article contains, even though the editors of the online publication are very much aware of these mistakes. I do wonder why basic principles of editorial professionalism seem to be of no concern to them. For what it's worth, in my considered view as an experienced editor of a large international bioethics journal, Pereira's piece should have been retracted a long long time ago. I encourage you to read his article as well as the second piece I link to above (by Jocelyn Downie and colleagues - they're showing how error-ridden this article really is).

One of the biggest current claims by anti-choice campaigners is that vulnerable elderly are at grave risk of being abused, should voluntary euthanasia ever come about. The thing is, of course, there is exactly zero evidence that  the decriminalisation of assisted dying has resulted in abuse of anyone, including vulnerable elderly. Today the New York Times has a remarkable line on this particular matter. It writes about a medical doctor, 67 year old Dr Wesley, a patient suffering from ALS, a disease that in effect lays waste to our muscles while leaving our mind intact, as the New York Times so aptly describes. The article notes, 'Dr. Wesley is emblematic of those who have taken advantage of the law. They are overwhelmingly white, well educated and financially comfortable. And they are making the choice not because they are in pain but because they want to have the same control over their deaths that they have had over their lives.' None of this is any news to pro-choice campaigners, but this kind of information doesn't suits the anti-choice crowd's scare campaigns, so you will undoubtedly hear more about vulnerable elderly and abuse and horror etc etc. All this in the service of subjugating secular societies' citizens to religious dictates as to how our lives must end. 

Against male circumcision on religious or cultural grounds

There is something surreal about the current debates that are taking place in some European countries about male circumcision. Well, it is not so much male circumcision as such, but the circumcision of very young Jewish and Muslim boys in Germany and the Netherlands. In Germany a court has recently declared circumcision on non-medical grounds illegal – much like female genital mutilation is illegal in the country. The court’s rationale was, essentially, that male circumcision for religious or cultural purposes is akin to assault or battery. If there is no overriding clinical benefit to the child undergoing the surgery, it is not justifiable to proceed with it.

In the Netherlands the Royal Dutch Medical Association has recently come forward arguing that male circumcision should be discouraged. The association notes in a report that a large number of complications resulting from circumcision are known, including ‘infections, bleeding, sepsis, necrosis, fibrosis of the skin, urinary tract infections, meningitis, herpes infections, meatisis, meatal stenosis, necrosis and necrotising complications, all of which have led to the complete amputation of the penis.’ Even deaths have been reported. There is also some evidence that circumcision diminishes pleasure during sexual intercourse and generally has a negative impact on the enjoyment of sex. The results of a large cross-sectional study in Denmark, published in 2011, reveal that ‘circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment.’ It appears to be the case that that male circumcision is not a cost neutral, risk-free activity.

On the other side of the equation is what the World Health Organisation describes as ‘compelling evidence’ that circumcision reduces the HIV infection risk of adult males to a significant extent. This has led some to suggest population level circumcision of males in sub-Saharan African countries. A public health argument might plausibly be made for such a policy in areas with high HIV prevalence. However, neither Germany nor the Netherlands are located in sub-Saharan Africa. The prevalence of HIV/AIDS is thankfully quite low in those countries, and there is no reason to suggest that this is going to change any time soon.

Male as well as female genital mutilation are predominantly religiously or culturally motivated practices. Remarkably, the two world religions that tend to be so often at loggerheads, namely Islam and Judaism, both fervently support male mutilation while supporters of female genital mutilation will only be able to find support among Islamic scholars. I am not an expert in world religions and I have little doubt that theological arguments over what Judaism’s and Islam’s holy documents prescribe are likely possible, even among well-intentioned experts. Leaving theological arguments aside, however, there is a strong cultural consensus in Jewish and Muslim communities that male circumcision is something good.

Both in Germany and in the Netherlands representatives of the Islamic and Jewish faiths respectively charged those arguing against male circumcision with unfair discrimination. Indeed, one Rabbi reportedly went on the record claiming that the German court’s decision was ‘perhaps the most serious attack on Jewish life in Europe since the Holocaust.’ As has been noted by bioethics scholars quite a few times, we should be very suspicious if the holocaust argument is deployed in support or against something. Quite likely there is no reasonable argument to be had, hence the Nazi argument is wheeled in in order to discredit whatever it is that someone has a bone to pick with.

Of course, it is always possible that the motives of some of those arguing against circumcision are driven by ulterior intentions. You would have reason, for instance, to be suspicious if a Christian intelligent design organization hired an ex-Muslim atheist to campaign against Islam. However, it is surprising that it did not occur to these religious lobbyists that child welfare and fundamentally the child’s right to her bodily integrity are of paramount importance. In liberal Western democracies they rightly trump parental religious beliefs. The only issue that should matter in these debates is the affected children’s welfare. Religion or other cultural convictions, no matter how strongly felt, should not even enter into the equation. We do not permit Jehovah’s witnesses to prevent their off-spring from receiving blood transfusions when this is medically indicated. Why not? Simply put: we apply a child’s best interest standard. Best interest, when considered in a medical context, by necessity refers to health related concerns. It’s a legal standard applied, for instance in Canada. There is no good reason to deviate from this standard to accommodate the religious traditions of Muslims or Jews. It is also worth noting that we usually give parents significant room to make parental decisions on behalf of their children, precisely because we believe that they usually know what is in their children’s best interest. That might even explain why the paternalism-in-medicine doctrine has its roots in the idea of a good parent (well, father) doing what is in his child’s best interest, even if the child disagrees. In the case under consideration, however, it is clear that the motives driving the parents derive their strength from religious or cultural convictions rather than from empirical evidence in support of the need for a surgical intervention in every male child.  

Surprisingly, in Germany major political parties from the centre right Christian Democrats to the Liberals as well as the leftish German Labour Party fell over one another promising to introduce legislation aimed at safeguarding purported parental rights to mutilate their children’s genitals for religious reasons. The Greens were expressly more concerned about ‘religious freedom’ than about child welfare. The parliamentarians expressed worries that otherwise Muslim and Jews just could not live any longer in Germany. Strangely the same concern does not seem to apply to Jehovah’s Witnesses who are forced to adapt their religious practices to German law protecting children against parental abuse. The parliament passed a resolution asking the government to create legislation aimed at permitting male circumcision as long as it occurs without ‘unnecessary pain’. The German foreign minister reportedly thought the parliament’s vote demonstrated that Germany is a cosmopolitan and tolerant society, when arguably it demonstrated that the country’s politicians are readily prepared to subjugate child welfare concerns to concerns about alleged religious freedoms. Interestingly enough, the same parliamentarians had no problems protecting women against female genital mutilation with an argument suggesting that it is ‘sittenwidrig’, ie against German customs or morals. This, of course, is question begging. How is female genital mutilation any more sittenwidrig than male genital mutilation? In a historical sense it is arguably against German customs as there is no such tradition in Germany, but history cannot as such provide normative guidance. Female genital mutilation clearly causes more harmful consequences, but these cuts might possibly also be undertaken without causing unnecessary (sic!) pain, and that seems to be the odd yardstick against which male circumcision is held. One cannot help but wonder, what other bodily parts the German parliamentarians might in the future see fit to be removed lawfully as long as the removal does not cause unnecessary (sic!) pain and as long as some religious ritual or other is attached to it.

Germany as well as other countries would be well advised to reconsider permitting religiously or otherwise culturally motivated irreversible surgical body modifications of children that serve no uncontroversial medically beneficial purpose. If a competent adult or a mature minor wanted to go ahead with circumcision, a case could easily be made to respect such wishes. However, in the case of children the child’s –medically understood - welfare should take precedence over parents’ religious convictions. That is how most societies rightly address this problem with respect to Jehovah’s Witnesses’ prohibition of blood transfusions and that is how we should handle it with regard to genital mutilations of the various kinds that are popular among particular religions. Parenthood should not be confused with unrestricted ownership, neither by parents nor by parliamentarians trying to accommodate religious convictions. It is surprising that using children as mere means to satisfy parental religious or cultural needs should be considered acceptable in the 21^st century version of Immanuel Kant’s homeland.

Truvada and HIV Pre-exposure Prophylaxis

So the US FDA has finally approved Truvada as an HIV Pre-Exposure Prophylactic (or PrEp if you fancy acronyms). I am not sure what to make of this, to be honest. The proposition here is to prescribe a chemotherapeutic to perfectly healthy people so they can protect themselves against HIV, at a cost of 13900 US$ per annum. What other protections are available? Use condoms. If you've sex with someone who's HIV positive and you want to have unsafe sex, make sure they're on HAART. If they are, the additional protection daily chemotherapy would offer to perfectly health people is close to non-existent and certainly not worth the cost paid. If you live in a society with high HIV prevalence, the odds are that it's a developing country. Your healthcare system should likely not even consider paying for such a prevention strategy, it's simply not cost effective, considering competing health needs in your society.

The drug was tested mostly on folks in high-risk groups who engage in somewhat unusual high-risk behaviour such as having plenty of unprotected sex with folks they do not know or folks they know to be HIV infected (the press release says nothing about the question of whether the latter group included folks who were known by their risk-taking participants to be on HAART), sex workers, etc. So, if you happen to belong to a group of people who engage in high-risk sexual behavior, you likely are disciplined enough to take daily chemotherapeutic drugs to compensate for your risk-taking. Really? This explains probably a 42% efficacy when compared to the placebo control. Adherence might have been a bit of an issue there...  That might also explain why the FDA requires Gilead to keep track of everyone who's (supposedly ) taking Truvada and gets infected anyway. Drug resistance seems a serious concern. Little seems to be known about pregnancy and Truvada, so that's being tested while the drug is being marketed. - Who knows, there might be a market in this high-risk segment of the population, even though it seems unreasonable to me that someone who enjoys such thrills should go on chemotherapy while healthy. Might they might not better wait until they're infected? Equally, in societies where the prevalence of HIV is very high (say, Sub-Saharan Africa), is the proposition to hook large numbers of perfectly health people on these heavy hitting drugs, 'just in case'?

As I said, I'm not sure what to make of this, but I am surprised about the logic of prescribing chemotherapy to healthy individuals as a 'just in case' strategy. Good for the shareholders of Gilead, the maker of Truvada though. You're making money off 'treating' the healthy... To be fair, it is anything but unusual that healthy people are being subjected to treatment in prevention efforts. Just think of flu vaccines, Hep B vaccination and so on and so forth. However, in the case under consideration the proposition is lifelong chemotherapy. That has quite a different ring and quality to it. We should take our time to discuss the pro's and con's of such a prevention strategy carefully, instead of diving headlong into it.

Sick and tired of Calgary Stampede Animal Abuse

I am sick and tired of the animal abuse that continues to take place during the Calgary Stampede. The third year running horses, forced to participate in Stampede events, got killed in accidents. This time the accident was taped. Suffice it to say that it is truly gruesome, not at all surprising, and that one can only hope that whatever weak animal protection laws Canada has in place are sufficient to bankrupt those responsible for running this idiotic event.  One of the horse owners was displayed on TV, crying, describing the shock at the loss of his horses and calling them akin to being family members. He said, 'They're just like humans, they're our family. It's just devastating for our whole family. It's hard to take.' Quick question to you Sir: Would you also subject your other family members to participation in events where deadly accidents are an annual occurrence? If you do, perhaps you might want to seek professional help somewhere, because clearly you are terribly irresponsible with regard to your interactions with your family members.

A word, perhaps, to spectators in Calgary: Give that deadly accidents are an annual occurrence during the Stampede, it stands to reason that you're attracted to blood sports resulting in the gruesome deaths of sentient non-human animals.  If you're into that sort of thing, why not attend sporting events where humans volunteer in risk-taking, as opposed to events where animals are being forced into risking their lives for your entertainment needs?

There is no excuse whatsoever for continuing this 'tradition' with its ever increasing death toll!