Cutting to the Core: Exploring the Ethics of Contested Surgeries
http://www.100md.com
《新英格兰医药杂志》
Judging from conversations I have had with clinicians, most are unaware that the high level of analysis that constitutes this anthology exists; it is deeply relevant to their work. If this book fails to reach clinicians, it will not be for lack of desire on the part of the editor, David Benatar, who names surgeons first in his discussion of intended audience. Benatar has brought together 13 articles (12 of which are new) on "contested surgeries," including genital surgeries on male and female children and children with intersex conditions, transsexual surgeries, separations of conjoined twins, limb and face transplantations, cosmetic surgeries, and placebo ("sham") surgeries.
Several contributions stand out as exceptionally novel and insightful. In a chapter examining male and female "circumcision" — or "genital cutting" or "mutilation," depending on your point of view — Dena Davis exposes astonishing asymmetries in U.S. regulatory oversight and cultural mores. Whereas even the most sanitary, slight, pain-regulated ritual nick on a girl's genitals exposes a doctor to criminal prosecution, and whereas hairdressers and nail stylists are closely regulated, mohels, who perform the Jewish ritual of circumcision on newborn boys, are subject to little oversight. Fran?oise Baylis's essay on the medical, psychosocial, and moral aspects of face transplantation was written before the first such operation took place, but this makes Baylis's work prescient rather than outdated. (She anticipated the self-serving manipulation of the media by certain surgeons.) David Neil thoroughly examines the ethics of placebo surgeries and provides practical advice on how they should be handled. For example, he proposes "that fair compensatory payouts for various complications be determined in advance and that this information be part of the consent process. . . . If it is objected that this would make surgical trials too costly, that is equivalent to an admission that the funding of such research depends on unfair cost shifting onto trial subjects."
In the preface, Benatar states that the contributors "are mostly philosophers" but that he has also included "a few lawyers, a social scientist, and a doctor or two." I would think that Benatar would have bothered to count the number of doctors, since this number seems relevant to the desired cross-disciplinary engagement. A few other problems will grate on readers devoted to evidence-based medicine. In examining the evidence for and against routine circumcision of newborn boys, Benatar and his brother Michael calculate the relative risk of penile cancer. The more important statistic here is numbers needed to treat: at least 100,000 boys have to be circumcised to avoid one case of penile cancer. An otherwise interesting article on transsexualism cites a 1979 feminist diatribe to report (incorrectly) the relative incidence of male-to-female as compared with female-to-male transsexualism. Expert article-by-article peer review — unfortunately uncommon in anthologies like this — would likely have caught these problems and would certainly have prevented publication of the claim that a girl with complete androgen insensitivity syndrome "has both male and female genitalia." Peer review also would have prevented the inclusion of a weak article on cosmetic surgery that cites but one scholarly text and one gossip magazine.
Nevertheless, the book usefully traces key themes that run throughout the practices examined, including, as Benatar notes in his intelligent introduction, the limits of paternalism, the problems with simplistic ideas of autonomy, and the shifting meanings of normality and disability. Many authors also raise excellent questions about surgeons' conflicts of interest, about the relevance of culture to decision making, and about whether patients' statements are to be believed — are conjoined twins really as well off as they claim, and what are women's real reasons for choosing to have facelifts? Especially fascinating are several authors' musings on the perceived value of different parts (relevant, for example, in limb transplantations and the separation of conjoined twins). The willingness of contributors throughout the book to address such questions makes the book particularly valuable.
Alice D. Dreger, Ph.D.
Feinberg School of Medicine, Northwestern University
Chicago, IL 60611
a-dreger@northwestern.edu(Edited by David Benatar. )
Several contributions stand out as exceptionally novel and insightful. In a chapter examining male and female "circumcision" — or "genital cutting" or "mutilation," depending on your point of view — Dena Davis exposes astonishing asymmetries in U.S. regulatory oversight and cultural mores. Whereas even the most sanitary, slight, pain-regulated ritual nick on a girl's genitals exposes a doctor to criminal prosecution, and whereas hairdressers and nail stylists are closely regulated, mohels, who perform the Jewish ritual of circumcision on newborn boys, are subject to little oversight. Fran?oise Baylis's essay on the medical, psychosocial, and moral aspects of face transplantation was written before the first such operation took place, but this makes Baylis's work prescient rather than outdated. (She anticipated the self-serving manipulation of the media by certain surgeons.) David Neil thoroughly examines the ethics of placebo surgeries and provides practical advice on how they should be handled. For example, he proposes "that fair compensatory payouts for various complications be determined in advance and that this information be part of the consent process. . . . If it is objected that this would make surgical trials too costly, that is equivalent to an admission that the funding of such research depends on unfair cost shifting onto trial subjects."
In the preface, Benatar states that the contributors "are mostly philosophers" but that he has also included "a few lawyers, a social scientist, and a doctor or two." I would think that Benatar would have bothered to count the number of doctors, since this number seems relevant to the desired cross-disciplinary engagement. A few other problems will grate on readers devoted to evidence-based medicine. In examining the evidence for and against routine circumcision of newborn boys, Benatar and his brother Michael calculate the relative risk of penile cancer. The more important statistic here is numbers needed to treat: at least 100,000 boys have to be circumcised to avoid one case of penile cancer. An otherwise interesting article on transsexualism cites a 1979 feminist diatribe to report (incorrectly) the relative incidence of male-to-female as compared with female-to-male transsexualism. Expert article-by-article peer review — unfortunately uncommon in anthologies like this — would likely have caught these problems and would certainly have prevented publication of the claim that a girl with complete androgen insensitivity syndrome "has both male and female genitalia." Peer review also would have prevented the inclusion of a weak article on cosmetic surgery that cites but one scholarly text and one gossip magazine.
Nevertheless, the book usefully traces key themes that run throughout the practices examined, including, as Benatar notes in his intelligent introduction, the limits of paternalism, the problems with simplistic ideas of autonomy, and the shifting meanings of normality and disability. Many authors also raise excellent questions about surgeons' conflicts of interest, about the relevance of culture to decision making, and about whether patients' statements are to be believed — are conjoined twins really as well off as they claim, and what are women's real reasons for choosing to have facelifts? Especially fascinating are several authors' musings on the perceived value of different parts (relevant, for example, in limb transplantations and the separation of conjoined twins). The willingness of contributors throughout the book to address such questions makes the book particularly valuable.
Alice D. Dreger, Ph.D.
Feinberg School of Medicine, Northwestern University
Chicago, IL 60611
a-dreger@northwestern.edu(Edited by David Benatar. )