Mutilation - Bioethics


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Mutilation - Bioethics

  1. 1. mu·ti·late Show Spelled[myoot-l-eyt] Show IPA –verb (used with object), -lat·ed, -lat·ing. 1. to injure, disfigure, or make imperfect by removing or irreparably damaging parts: Vandals mutilated the painting. 2. to deprive (a person or animal) of a limb or other essential part. Use mutilate in a Sentence See images of mutilate Search mutilate on the Web
  2. 2. Origin: 1525–35; < Latin mutilātus (past participle of mutilāre to cut off, maim), equivalent to mutil ( us ) maimed, mutilated + -ātus -ate1 —Related forms mu·ti·la·tion, noun mu·ti·la·tive, mu·ti·la·to·ry /ˈmyut l əˈt ɔr i, -ˈtoʊr i/ Show Spelled[myoot-l-uh-tawr- ee, -tohr-ee] Show IPA, adjective mu·ti·la·tor, noun self-mu·ti·lat·ing, adjective self-mu·ti·la·tion, noun un·mu·ti·lat·ed, adjective un·mu·ti·la·tive, adjective —Synonyms 1. damage, mar, cripple.
  3. 3.  is an act or physical injury that degrades the appearance or function of any living body, usually without causing death.
  4. 4. USAGE OF TERM The term is usually employed to describe the victims of accidents, torture, physical assault, or certain premodern forms of punishment. Mutilation can also refer to forgery of documents, letters and brochures, letters of recommendation and other pieces of evidence or testimony. Some ethnic groups practice ritual mutilation, e.g. scarification, burning, flagellation, t atooing or wheeling, as part of a rite of passage. In some cases, the term may apply to treatment of dead bodies, such as soldiers mutilated after they have been killed by an enemy.
  5. 5. USE AS PUNISHMENT Maiming, or mutilation which involves the loss of, or incapacity to use, a bodily member, is and has been practised by many societies with various cultural and religious significances, and is also a customary form of physical punishment, especially applied on the principle of an eye for an eye. The Araucanian warrior Galvarino suffered this punishment as a prisoner during the Spanish conquest of Chile. In law, maiming is a criminal offence; the old law term for a special case of maiming of persons was mayhem, an Anglo- French variant form of the word. Maiming of animals by others than their owners is a particular form of the offence generally grouped as malicious damage. For the purpose of the law as to this offence animals are divided into cattle, which includes horses, pigs and asses, and other animals which are either subjects of larceny at common law or are usually kept in confinement or for domestic purposes.
  6. 6.  USE AS PUNISHMENT Maiming, or mutilation which involves the loss of, or incapacity to use, a bodily member, is and has been practised by many societies with various cultural and religious significances, and is also a customary form of physical punishment, especially applied on the principle of an eye for an eye. The Araucanian warrior Galvarino suffered this punishment as a prisoner during the Spanish conquest of Chile. In law, maiming is a criminal offence; the old law term for a special case of maiming of persons was mayhem, an Anglo-French variant form of the word. Maiming of animals by others than their owners is a particular form of the offence generally grouped as malicious damage. For the purpose of the law as to this offence animals are divided into cattle, which includes horses, pigs and asses, and other animals which are either subjects of larceny at common law or are usually kept in confinement or for domestic purposes.
  7. 7.  Voluntary sex reassignment Some transgender people choose to undergo sex reassignment surgery as part of their gender transition. Male-to-female transgenders, mtfs (Male-to-female-sex), or transwomen may undergo castration, with or without vaginoplasty, while female to male, ftms (Female-to-male- sex), or transmen transgenders may undergo phalloplasty or metoidioplasty, with or without oophorectomy or hysterectomy. Transgender people who wish to make this surgical transition are referred to as transsexuals. Involuntary sex assignment If a baby is born with ambiguous genitalia due to an intersex condition, it may not be clear whether the child is female or male. In certain cases, the childs chromosomal makeup is neither female nor male, but a combination. In these cases, the baby is usually given a sex assignment, and in many cases, the childs genitals are surgically altered to conform to those of the assigned sex. This practice is met with strong dissent from advocates for genital integrity. As cosmetic surgery is not medically necessary for health, they argue that the individual should be free to make the choice whether to pursue cosmetic surgery upon their genitals. Advocates state that the surgery can damage the individuals ability to experience sexual arousal and can render the individual incapable of orgasm. Another concern is that sex assignment holds a significant element of guesswork, and that an individuals sex assignment may turn out to be incorrect. If, for instance, an individual is assigned female, their phallus is usually surgically reduced in size, and the shape of a vulva may be created. If, upon maturing, the individual identifies as male; their phallus is still gone, and the individual may require further surgery to try to reverse the erroneous sex assignment. Those who oppose medically unnecessary genital surgery, and genital surgery coerced or performed without consent comprise the genital integrity movement. The case of David Reimer, the victim of a botched circumcision who was raised as a girl alongside his twin brother, bears many parallels to this issue.
  8. 8.  In disease or medical necessity If the genitals become diseased, as in the case of cancer, sometimes the diseased areas are surgically removed. Biological females may undergo vaginectomy, while males may undergo penectomy.Reconstructive surgery may be performed to restore what was lost, often with techniques similar to those used in sex reassignment surgery. Similarly, during childbirth, episiotomy is sometimes performed to increase the amount of space through which the baby may emerge. Advocates of natural childbirth and unassisted birth state that this intervention is often performed without medical necessity, with significant damage to the person giving birth. Hymenotomy is the surgical perforation of an imperforate hymen. It may be performed to allow menstruation to occur. An adult individual may opt for increasing the size of her hymenal opening, or removal of the hymen altogether, to facilitate sexual penetration of her vagina.
  9. 9. Female genitals Cosmetic surgery of female genitalia, known as elective genitoplasty, has become pejoratively known as designer vagina. In May 2007, an article published in the British Medical Journal blasted the "designer vagina" craze, citing its popularity being rooted in commercial and media influences. Similar concerns have been expressed in Australia. Female genital cutting Female genital cutting (FGC), also known as female genital mutilation or female circumcision, refers to "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons. It is not the same as the procedures used in gender reassignment surgery or the genital modification of intersexuals. FGC is practiced throughout the world, but the practice is concentrated more heavily in Africa, Indonesia, and the Middle East. There is much controversy surrounding infibulationprocedures, due to concerns regarding the safety and consequences of the procedure. In the past several decades, efforts have been made by global health organizations, such as the WHO, to end the practice of FGC. However, because of its importance in traditional and religious life, FGC continues to be practised in many societies. Hymenorrhaphy Hymenorrhaphy refers to the practice of thickening the hymen, or, in some cases, implanting a capsule of red liquid within the newly-created vaginal tissue. The newly-created hymen is created to cause physical resistance, blood, or the appearance of blood, at the time that the individuals new husband inserts his penis into her vagina. This is done in cultures where a high value is placed on female virginity at the time of marriage. In these cultures, a woman may be punished, perhaps violently, if the community leaders deem that she was not virginal at the time of consummation of her marriage. Individuals who are victims of rape, who were virginal at the time of their rape, may elect for hymenorrhaphy.
  10. 10. Vaginoplasty and labiaplastySome women undergo vaginoplasty or labiaplasty procedur es to alter the shape of their vulvas to meet personal aesthetic standards. The surgery itself is controversial, and critics refer to the procedures as "designer vagina".
  11. 11. INFIBULATION Infibulation, in modern usage, is a practice of surgical closure of the labia majora (outer lips of the vulva) by sewing them together to partially seal the vagina, leaving only a small hole for the passage of urine and menstrual blood. The legs are bound together for approximately two weeks to allow the labia to heal into a barrier. The procedure is usually done on young girls before the onset of puberty, to ensure chastity (Chastity is sexual behavior of a man or woman acceptable to the moral norms and guidelines of a culture, civilization, or religion.). It is usually performed at the same time as removal of the clitoris. The labia minora (inner lips of the vulva) are often also removed. Infibulation is used by practitioners to render women sexually inactive, unlikely to engage in intercourse, and the visibly intact barrier of infibulation assures a husband he has married a virgin. The barrier produced by infibulation is usually penetrated at the time of a girls marriage by the forcible action of the penis of her new husband, or, if he is unsuccessful, by cutting the connected tissue surgically.
  12. 12. Description of the different typesof female genital mutilationFemale genital mutilation is usually performed by traditional practitioners, generally elderly women in the community specially designated for this task, or traditional birth attendants. In some countries, health professionals trained midwives and physicians are increasingly performing female genital mutilation. In Egypt, for example, preliminary results from the 1995 Demographic and Health Survey indicate that the proportion of women who reported having been circumcised by a doctor was 13%. In contrast, among their most recently circumcised daughters, 46% had been circumcised by a doctor.
  13. 13.  Type I In the commonest form of this procedure the clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object. Bleeding is usually stopped by packing the wound with gauzes or other substances and applying a pressure bandage. Modern trained practitioners may insert one or two stitches around the clitoral artery to stop the bleeding. Type II The degree of severity of cutting varies considerably in this type. Commonly the clitoris is amputated as described above and the labia minora are partially or totally removed, often with the same stroke. Bleeding is stopped with packing and bandages or by a few circular stitches which may or may not cover the urethra and part of the vaginal opening. There are reported cases of extensive excisions which heal with fusion of the raw surfaces, resulting in pseudo-infibulation even though there has been no stitching. Types I and II generally account for 80-85% of all female genital mutilation, although the proportion may vary greatly from country to country.
  14. 14.  Type III The amount of tissue removed is extensive. The most extreme form involves the complete removal of the clitoris and labia minora, together with the inner surface of the labia majora. The raw edges of the labia majora are brought together to fuse, using thorns, poultices or stitching to hold them in place, and the legs are tied together for 2-6 weeks. The healed scar creates a hood of skin which covers the urethra and part or most of the vagina, and which acts as a physical barrier to intercourse. A small opening is left at the back to allow for the flow of urine and menstrual blood. The opening is surrounded by skin and scar tissue and is usually 2-3 cm in diameter but may be as small as the head of a matchstick. Type IV Type IV female genital mutilation encompasses a variety of procedures, most of which are self-explanatory. Two procedures are described here. The term "angurya cuts" describes the scraping of the tissue around the vaginal opening. "Gishiri cuts" are posterior (or backward) cuts from the vagina into the perineum as an attempt to increase the vaginal outlet to relieve obstructed labour. They often result in vesicovaginal fistulae and damage to the anal sphincter. There is no mention of removing only the clitoral hood as described by Dr. Nowa Omoigui.
  15. 15. MALE GENITALSMale circumcision involves the removal of the foreskin. It may also involve frenectomy, the removal of the frenulum. A related procedure is preputioplasty, which is used as a treatment for phimosis. This procedure is most often performed upon infant boys. It has religious significance in the Jewish religion and inIslam. It spread into Western culture, and peaked in the early 80s. The bioethics of neonatal circumcision are a subject of intense debate, with circumcision advocates promoting it as beneficial, and supporters of genital integrity opposing it as harmful and/or a violation of the individuals human rights. Some adults who were circumcised as infants engage in foreskin restoration, a method of stretching the penile skin in order to partially recreate the foreskin.
  16. 16. Penile subincision is a form of body modification consisting of a urethrotomy, in which the underside of the penis is incised and the urethra slit open lengthwise, from the urethral opening (meatus) toward the base. The slit can be of varying lengths. Subincision is traditionally performed around the world, notably in Australia, but also in Africa, South America and the Polynesian and Melanesian cultures of the Pacific, often as a coming of age ritual. The practice has been taken up in the western world in recent years for the purpose of sexual pleasure or aesthetics. Disadvantages include the risk of surgery, which is often self- performed, and increased susceptibility to sexually transmitted infections (STIs). The ability to impregnate (specifically, getting sperm into the vagina) may also be decreased.
  17. 17. PENIS REMOVAL / Penectomy Removal of the human penis was sometimes used as a means of demonstrating superiority: armies were sometimes known to sever the penises of their enemies to count the dead, as well as for trophies, although usually only the foreskins were taken. The practice of castration (removal of the testicles) sometimes also involves the removal of all or part of the penis, generally with a tube inserted to keep the urethra open for urination. Castration has been used to create a class of servants or slaves (and especially harem- keepers) called eunuchs in many different places and eras. In the modern era, removal of the human penis is very rare (with some exceptions listed below), and references to removal of the penis are almost always symbolic. Castration is less rare, and is performed as a last resort in the treatment of androgen-sensitive prostate cancer.
  18. 18. Infibulation Infibulation refers to suturing of the foreskin. In ancient Greece, performers infibulated themselves by using a clasp or string to foreskin and draw the penis over to one side. Male circumcision involves the removal of the foreskin. It may also involve frenectomy, the removal of the frenulum. A related procedure is preputioplasty, which is used as a treatment for phimosis. This procedure is most often performed upon infant boys. It has religious significance in the Jewish religion and in Islam. It spread into Western culture, and peaked in the early 80s. The bioethics of neonatal circumcision are a subject of intense debate, with circumcision advocates promoting it as beneficial, and supporters of genital integrity opposing it as harmful and/or a violation of the individuals human rights. Some adults who were circumcised as infants engage in foreskin restoration, a method of stretching the penile skin in order to partially recreate the foreskin. Some academics use the term male genital cutting or male genital mutilation in reference to male circumcision.
  19. 19. Types of MGM Type I - excision or injury of part or all of the skin and specialized mucosal tissues of the penis including the prepuce and frenulum (circumcision, dorsal slit without closure). Type II - excision or injury to the glans (glandectomy) and/or penis shaft, (penectomy) along with Type I MGM. Any procedure that interferes with reproductive or sexual function in the adult male. Type III - excision or destruction of the testes (castration, orchidectomy) with or without Type II MGM. Type IV - unclassified: includes pricking, piercing or incision of the prepuce, glans, scrotum or other genital tissue; cutting and suturing of the prepuce over the glans (infibulation); slitting open the urethra along the ventral surface of the penis (sub-incision); slitting open the foreskin along its dorsal surface (super-incision); severing the frenulum; stripping the skin from the shaft of the penis; introducing corrosive or scalding substances onto the genital area; any other procedure which falls under the definition of MGM given above. The most common type of male genital mutilation is excision of the foreskin (circumcision), accounting for the vast majority of all cases; the most extreme form is excision or destruction of the testes (castration), which constitutes a small percentage of all procedures.
  20. 20. The Who, What and Why of MGM In cultures where it is an accepted norm, male genital mutilation is practiced by followers of all religious beliefs as well as animists and non believers. MGM is usually performed either by a traditional practitioner, often with crude instruments and without anesthetic, or in a health care facility by qualified health personnel. The age at which male genital mutilation is performed varies from area to area. It is performed on infants a few days old, male children and adolescents and, occasionally, on mature men.
  21. 21. The reasons given by families for havingMGM performed include: Psychosexual reasons: elimination of the sensitive tissue of the foreskin and the stimulation that it provides, depriving the glans of its protective environment to reduce sexual pleasure; Sociological reasons: identification with the cultural heritage, initiation of boys into manhood, social integration and the maintenance of social cohesion; Hygiene and aesthetic reasons: the foreskin is considered dirty and unsightly and is to be removed to promote hygiene and provide aesthetic appeal; Myths: babies don’t feel pain, a foreskin is hard to keep clean, circumcision protects against certain diseases, male circumcision is less barbaric than female circumcision; Religious reasons: Most Muslim and Jewish communities practice MGM in the belief that it is demanded by the Islamic and Judaic faiths. The practice, however, predates both religions.
  22. 22. Consequences of MGMThe immediate and long-term health consequences of male genital mutilation vary according to the type and severity of the procedure performed. Immediate complications include severe pain, shock, hemorrhage, infection, excessive skin loss, skin bridges, glans deformation, bowing, meatal stenosis, loss of penis, and injury to adjacent tissue. Hemorrhage and infection can cause death. More recently, concern has arisen about possible transmission of the human immunodeficiency virus (HIV) due to the use of one instrument in multiple operations. Some researchers are also promoting MGM as a tool to combat AIDS by touting studies that show a link between medicalized circumcision and reduced rates of HIV transmission, which is likely to increase the number of forced circumcisions and related complications. Long-term consequences include scar formation, keratinization, sexual dysfunction, loss of sexual sensitivity, and increased friction and pain during sexual intercourse. Psychosexual and psychological health: Genital mutilation may leave a lasting mark on the life and mind of the man who has undergone it. In the longer term, men may suffer feelings of anger, incompleteness, anxiety, depression, and lifelong psychological trauma.
  23. 23. Prevalence of MGMMost of the boys and men who have undergone genital mutilation live in 28 African countries, the Middle East, the USA, and parts of Asia. They are also found in Europe, Australia, and Canada. Today, the number of boys and men who have undergone male genital mutilation is estimated at 650 million. It is estimated that each year, a further 13 million boys are at risk of undergoing MGM.
  24. 24. THEOLOGICAL ISSUES"What does the Bible say about self-mutilation / cutting?" Answer: In the Old Testament, self-mutilation was a common practice among false religions. First Kings 18:24-29 describes a ritual in which those who worshiped the false god Baal slashed themselves with swords and spears, as was their custom. Because of the traditions of pagans, God made a law against this sort of practice. Leviticus 19:28 says, “You shall not make any cuttings in your flesh for the dead, nor tattoo any marks on you: I am the LORD.” In the New Testament, cutting oneself was associated with someone who was possessed by demons (Mark 5:2-5). It was characteristic of behavior caused by evil spirits. Today, self-mutilation is rarely used for ritualistic practices or actual demon possession, but instead usually by teen-agers and young adults who have misplaced anger and pain that they are attempting to work out in destructive ways. Instead of dealing with emotional pain, some people would rather bring themselves physical pain, which actually serves as a relief from stress. Unfortunately, though, this sense of relief is quite short-lived, and the desire to be self-destructive quickly returns.
  25. 25. The Bible doesnt talk about self-mutilation in terms of depression or anxiety, but it is very important that whoever is making a practice of this seeks immediate psychological (and hopefully Christian) counseling. They may need to obtain medication to deal with a mental illness. This behavior also indicates, or can lead to, drug and/or alcohol abuse, eating disorders, identity disorders, and suicidal thoughts or even attempts. First Corinthians 6:19 tells us how important our bodies are to the Lord. We no longer belong to ourselves, but instead we belong to Christ, who purchased us at a high price. We should not abuse the greatest gift we have been given. A person who is struggling with self-mutilation should seek immediate counsel from a pastor and/or Christian counselor. Self-mutilation is the result of an incorrect view of self and of our personal value to God. A personal relationship with Jesus Christ and a proper understanding of His love is the only true cure for self-mutilation.
  26. 26. Self Mutilation 1 Corinthians 6:19-20 Or do you not know that your body is a temple of the Holy Spirit within you, whom you have from God? You are not your own, for you were bought with a price. So glorify God in your body. Leviticus 19:28 You shall not make any cuts on your body for the dead or tattoo yourselves: I am the Lord. Deuteronomy 14:1 “You are the sons of the Lord your God. You shall not cut yourselves or make any baldness on your foreheads for the dead. 1 Peter 5:7 Casting all your anxieties on him, because he cares for you. 2 Timothy 1:7 For God gave us a spirit not of fear but of power and love and self- control. Proverbs 8:36 But he who fails to find me injures himself; all who hate me love death.” Hebrews 4:15-16 For we do not have a high priest who is unable to sympathize with our weaknesses, but one who in every respect has been tempted as we are, yet without sin. Let us then with confidence draw near to the throne of grace, that we may receive mercy and find grace to help in time of need. 1 John 1:9 If we confess our sins, he is faithful and just to forgive us our sins and to cleanse us from all unrighteousness. 1 Peter 5:6-7 Humble yourselves, therefore, under the mighty hand of God so that at the proper time he may exalt you, casting all your anxieties on him, because he cares for you.
  27. 27. ETHICAL ISSUES Ethics refers to the moral reasoning that underlies human relationships and the ways in which we treat each other. Values form the basis for ethical practices and what one country or individual holds to be important may not be viewed with the same level of esteem in another culture. The difficulty with female circumcision comes from the deeply held beliefs about the practice and the moral reasoning that is used by the people who support its continued practice. Misinformation and strongly held beliefs are usually what promotes the ongoing demand for female genital mutilation. Here are some of the myths and the corollary truths about this practice. the clitoris never stops growing and will grow uncontrollably until it hangs on the ground - completely false female circumcision improves fertility, menstruation and child bearing abilities - the opposite is true. men prefer circumcised women - it has been reported that a large number of African men have stated preferences for uncircumcised women. it is a religious requirement - this is a social and not a religious custom. There is no stated requirement within the Muslim or other religious teachings for female genital mutilation. female genital mutilation improves moral behaviour - the truth is that moral behaviour is based on reasoning and an individuals personal value system not physical attributes. female circumcision helps to control emotions and improves a womans mood, in other words women "feel better" for having had it done - The truth is that the emotional scars from this procedure include a feeling of betrayal most often directed towards the mother for having encouraged and sought out the procedure to be performed on her own daughter.All of these falsehoods stem from the assumption that an adult woman in the natural state is somehow flawed on the physical, moral, and emotional level and that female circumcision will somehow fix all of those flaws. Such assumptions are promulgated in societies where women are oppressed and do not have the same social, economic, or legal status as men.
  28. 28.  Ethical issues that face the society includes the question "How does a society protect children when a cultural practice such as female circumcision may be a normal and valued practice? " Individual rights and freedoms may be used as an argument to preserve cultural practices even when relocating to another country. However, ethical issues seldom are predicated on individual rights and freedoms alone. Ethical issues surrounding cultural practices such as female circumcision require that the society as a whole examine the moral obligation individuals have to each other and specifically to the less powerful and more vulnerable members of that society.
  29. 29.  This obligation is recognized in countries that have child protection laws where it is recognized that children have neither the power nor the mental and emotional competence to act in their own interests and that they are vulnerable to abuses from other members of the society that have more power. In order to determine if an act is ethical the rights and values of all parties must be considered. In addition the risk of harm must be taken into consideration. Female circumcision must be considered an unethical act. It is perpetrated on an innocent child who is powerless against the strong cultural beliefs of the parents and the physical might of the adults who perform the procedure. The child does not benefit in any way and is in fact placed at considerable risk of harm, even death. Many countries have made female circumcision illegal in order to protect the female children of immigrant populations where this practice might be considered normal. Canada has a law that even makes in illegal for parents to take their daughter out of the country to have the procedure performed.
  30. 30.  In a country with specific legislation outlawing the practice of female genital mutilation, health care professionals can refuse to perform the procedure when it is requested and instead start educating parents about the negative effects it may have on their daughter. They can explore the parents motivation to have their daughter undergo this procedure and correct any false beliefs that may underlie their motivations. The majority of the states in the US do not have any laws specifically for female genital mutilation and instead rely solely on existing laws for child protection. This process requires reporting child abuse to the authorities. This is not likely to happen if the community values the practice and believes it to be necessary for a young girls well being in adulthood. Additionally, relying solely on child protection laws labels the parent an abuser for engaging in a cultural practice that is valued and normal for them. A parent who subjects a daughter to female circumcision is very often doing so under the mistaken belief that they are a good parent, and may in fact not be abusive in any other way. The truth about female circumcision is that there are no benefits to an individual or a society that even remotely supports its continued practice. The fact that parents continue to create a demand for genital cutting is evidence of the strength of cultural beliefs and values in promoting practices that are morally wrong and physically disabling.
  31. 31.  Education is the only way to change the attitudes and beliefs that keep such a practice a cultural norm. In the meantime, because of a societys moral obligation to protect children, laws should be in place to make the practice illegal. Every child has the right to an intact physical body and a future that allows full expression of their sexuality within whatever moral boundaries they choose to adopt.
  32. 32. INFANT MALE CIRCUMCISION IS NOT IN THEBEST INTERESTS OF THE HEALTH & RIGHTS OFTHE CHILD Scope of the Problem Current national rates: Australia 15%, Canada 20%, the United States 60%(3). In the U.S., over 1.25 million infants annually - more than 3,300 babies each day - one child every 26 seconds. The surgery wastes more than $250 million health care dollars annually as well as untold personnel hours. Globally, 20% of male children will be subjected to some form of non-medically indicated genital mutilation. Early and Current Rationale (U.S.) physicians thought it logical to perform genital surgery on both sexes to stop masturbation. This rationale was initiated in the English-speaking countries during the 19th Century. The current medical rationale for circumcision developed after the operation was in wide practice. To make sons resemble their circumcised fathers, to conform socially with peers, to improve hygiene, to prevent phimosis, and as prophylaxis for infant urinary tract infections, sexually transmitted diseases, AIDS, and cancer of the penis/cervix.
  33. 33.  Decision Making The circumcision decision in the U.S. is emerging as a cultural ritual rather than the result of medical misunderstanding among parents. It is more an emotional than a rational decision. Other factors affect parents’ decisions, including esthetics, cultural attitudes, social pressures and tradition. Ultimate decision may hinge on non-medical considerations. Circumcision has become cultural surgery. Foreskin Function When infant is incontinent, prepuce fulfills an essential function, to protect the glans. The foreskin is more than just penile skin necessary for a natural erection; it is specialized tissue, richly supplied with blood vessels, highly innervated, and uniquely endowed with stretch receptors. The foreskin contribute(s) significantly to the sexual response of the intact male. This mucous-membrane contact [male foreskin and female labia] provides natural lubrication...and prevents dryness responsible for painful intercourse and chafing and abrasions that allow for entry of STDs, viral/bacterial.
  34. 34.  Penile Development Development of the prepuce is incomplete in the newborn male child, and separation from the glans, rendering it retractable, does not usually occur until some time between 9 months and 3 years. (Infant) circumcision...traumatically interrupts the natural separation of the foreskin from the glans. Circumcision interferes with penile development, surgeon must tear skin from sensitive glans to permit removal. Immediate Risks and Complications Complications are often overlooked or un(der)reported. Lacerations, skin loss, skin bridges, chordee, meatitis, stenosis, urinary retention, glans necrosis, penile loss, hemorrhage, sepsis, gangrene, meningitis. Literature abounds with reports, morbidity and death from circumcision Realistic (complication) figure is 2-10%.
  35. 35.  Long-Term Adverse Outcomes Poor surgical result is not recognized until years later. Adverse consequences of infant circumcision on men’s health must be recognized by physicians, parents & legislators. Circumcision is a subtraction, removing one-third or more of entire penile skin - tragic loss of erogenous tissue. When sexually functioning tissue is removed, sexual functioning is altered. Penile changes are documented. Of 313 circumcised male respondents, 49.5% cited a sense of parental violation, 62% expressed feelings of mutilation, and 84% reported some degree of sexual harm [progressive loss of glans sensitivity, excess stimulation needed to reach orgasm, painful coitus and impotence]. Body image survey found 20% of circumcised respondents cited dissatisfaction with their circumcision. Effects of Pain Newborn infant responses to pain are similar to but greater than those in adult subjects. The persistence of specific behavioral changes after circumcision in neonates implies the presence of memory. Infant circumcision causes severe, persistent pain. Acetaminophen does not ameliorate pain of circumcision. Main structures for memory are functional in neonates and circumcision pain may have long-lasting effects. Maternal Bonding / Breastfeeding Circumcision affects mother-infant interaction. When an infant is subjected to intolerable, overwhelming pain, it conceptualizes mother as participatory and responsible regardless of mother’s intent. Consequences for impaired bonding are significant. These are the first data suggesting a protective effect of breastfeeding against UTI. Breasts also produce large quantities of a hormone (GnRH) that may aid in development of a newborn’s brain. Infants feed less frequently after circumcision; observed deterioration may contribute to breast- feeding failure. A stressful, painful event such as circumcision appears to affect the feeding patterns.
  36. 36.  Questionable Benefits Good hygiene can offer many advantages over circumcision. Circumcision has no significant effect on the incidence of common sexually transmitted diseases (STDs). Circumcision is not harmless and cannot be recommended without unequivocal proof of benefit. Not one confirmed UTI case in a normal male infant. All cases in infants with clear urinary birth defects. Antimicrobial management of UTI in infants is routine and outcome generally good. It is inappropriate at this time to recommend circumcision as a routine medically indicated procedure. Reported benefits in preventing cancer and infant UTIs are insignificant compared to surgical risks. Performing 100,000 mutilative procedures on newborns to possibly prevent cancer in one elderly man is absurd.
  37. 37.  Medical Ethics It must be recognized that the child is normal as born and that circumcision inflicts loss of a normal body part and leaves a scar. This is contrary to the motto of medicine, “First Do No Harm.” The unnecessary removal of a functioning body organ in the name of tradition, custom or any other non-disease related cause should never be acceptable to the health profession...and breaches fundamental medical ethics. Children too young to give consent must be treated as individuals. The child must live with the outcome of decision. Obstetrical Involvement Seventy-four percent (74%) of the Ob/Gyns surveyed perform circumcision. Ob-Gyn fees for circumcision range to $400, averaging $137 nationwide. Ob-Gyns not aware of preputial structure & function or growing numbers of men undergoing foreskin restoration. Restoration Movement In North America many circumcised men are now becoming aware of the mutilation and the harm this has done to them, and some are seeking methods of replacing the lost prepuce. At the root of this reaction lies an awareness that a perfectly normal, healthy -- indeed, the most sensually responsive -- part of their penis was surgically amputated when too young/helpless to consent, refuse or resist.
  38. 38. Children’s Rights All childhood circumcisions are violations of human rights. ...It is the moral duty of educated professionals to protect health and rights of those with little or no social power to protect themselves. Circumcision is an issue of self-determination and autonomy. Imperative that children have the right to own their reproductive organs and to preserve natural sexual function. Circumcisions for personal preference of the parent(s) deny the infant the basic right to respect and autonomy. Every an assault on a child’s sexuality and a violation of his right to an intact body. Why Does It Continue? Americans culturally acclimated/regard foreskin as non- essential, pathologic. Cultural, social and historical perspectives around infant circumcision control physicians and parents.
  40. 40.  Organ transplant surgery is a common complicated surgery. There are many complications that may arise for an individual that is undergoing an organ transplant surgery. Understanding what such a surgery entails is an important factor to understand in order to appreciate how it can be a complicated surgery. Organ transplant surgery can occur for several different reasons. The main reason that such a surgery occurs is because there are organs within an individual’s body that are not functioning properly. When organs do not function properly within the body, the body’s main reaction is to start to shut down. This can lead to a lot of complications, especially if the body cannot regularly maintain itself. Without an organ transplant, many individuals will pass away from the complications of the organs that they currently have.
  41. 41. DEFINITION Organ donation is the removal of the tissues of the human body from a person who has recently died, or from a living donor, for the purpose of transplanting. Organs and tissues are removed in a surgical procedure. People of all ages may be organ and tissue donors. At the time of death the organ, tissue, or eye recovery agency will make a determination, based on the persons medical and social history, of which organs/tissues are suitable for transplantation. Organ donation typically takes place after brain death, the irreversible loss of all brain functions, including the brain stem. Tissue donation can take place after brain death or cardiac death (the irreversible loss of cardiovascular function). The laws of different countries allow potential donors to permit or refuse donation, or give this choice to relatives. The popularity of donations varies substantially among countries.
  42. 42. Transplantable Organs The organs that can be donated include: Heart Patients with severe heart failure who cannot be helped any longer with medication and/or surgery may benefit from a heart transplant. Liver Patients with liver failure may benefit from a liver transplant. Pancreas Patients with severe diabetes or renal failure may benefit from a pancreas transplant. Kidney Patients with kidney failure on dialysis may benefit from a kidney transplant. Most kidney donations are from donors considered brain dead however a small percentage of kidney donations come from living donors. Usually from a family member. Lungs Patients whose lungs cannot function properly with medication and/or surgery may benefit from a lung transplant. Small Bowel (Intestine) Patients who suffer small bowel damage, either from infection or trauma, may benefit from a small bowel transplant. Damage to the small bowel will hinder a patient from absorbing enough food to survive.
  43. 43. Organ Donation Process Donor Identification1. The physician pronounces brain death after evaluation, testing, and documentation of patients condition. Each state has its own criteria for determining brain death.2. Hospital staff refers the potential donor to the Organ Procurement Organization for the initial evaluation.3. The OPO will then perform chart evaluation and key information gathering. This includes a thorough examination of the patients past medical and current condition. The social history will be assessed after the family has expressed interest in the potential donation. Obtaining ConsentAfter the OPO determines a patient meets criteria for donation, the consent process proceeds as follows:1. Death is explained to the family. The physician or nursing staff usually informs the family of the death initially. The OPO staff ensures that the family understands the brain death situation. (The potential donor must be maintained on a ventilator so the family may believe the patient is still alive, even though brain death has been determined)2. The options for donation are carefully explained to the family. At this point all potential donations are discussed (Tissue, Eye, Skin, etc) so the family is not approached multiple times for each donation option.)3. If informed consent is obtained from the legal next of kin or legal power of attorney, consent forms are read, signed, and witnessed.4. A thorough questionnaire regarding the potential donors medical and social history is presented to the family.5. Consent is obtained from the Medical Examiner/Coroner in the event that a donation may hinder a death investigation.
  44. 44.  Evaluation and Maintenance of Potential DonorAfter the proper consent process is complete and the patient is considered adonor, the evaluation and maintenance process proceeds as follows:1. Tests are performed to determine blood type (ABO) and DNA (HLA Typing).2. Tests are performed to rule out any transmissible diseases.3. Transplantable organs are evaluated for suitability and stability.4. Hemodynamic (Circulation of oxygen-rich blood) functions are stabilized.5. Organ recipients are identified.6. Transplant teams are mobilized. In organ donation, the surgery team responsible for the transplant is the team mobilized for the recovery. The OPO does not perform the organ recovery.
  45. 45.  Evaluation and Maintenance of Potential Donor After the proper consent process is complete and the patient is considered a donor, the evaluation and maintenance process proceeds as follows: Tests are performed to determine blood type (ABO) and DNA (HLA Typing). Tests are performed to rule out any transmissible diseases. Transplantable organs are evaluated for suitability and stability. Hemodynamic (Circulation of oxygen-rich blood) functions are stabilized. Organ recipients are identified. Transplant teams are mobilized. In organ donation, the surgery team responsible for the transplant is the team mobilized for the recovery. The OPO does not perform the organ recovery.
  46. 46. LEGISLATION Opt-in vs. opt-out There are two main systems for voluntary systems "opt in" (anyone who has not given consent is not a donor) and "opt out" (anyone who has not refused is a donor). In some systems, family members may be required to give consent or refusal, or may veto a potential recovery even if the donor has consented. Because of various factors contributing to the rate of transplantations in a country, including the rate of living donors, hospital connectivity, and demand, there is no direct correlation between the legislative system and the rate of donation. While some countries with an opt-out system like Spain (34 donors per million inhabitants) or Austria (21 donors per million inhabitants) have high donor rates and some countries like Germany (16 donors) or Greece (6 donors) with opt-in systems have lower rates, Sweden, which has an opt-out system has a low rate as well (15 donors) figures. DrRafael Matesanz, President of the Spanish National Transplant Organisation, has acknowledged Spains legislative approach is likely not the primary reason for the countrys success in increasing the donor rates, starting in the 1990s.
  47. 47. Bioethical issues Since the mid-1970s, bioethics, a relatively new area of ethics, has emerged at the forefront of modern clinical science. Many philosophical arguments against organ donation stem from this field. Generally, the arguments are rooted in either deontological or teleological ethical considerations. Deontological issues Pioneered by Paul Ramsey and Leon Kass, few modern bioethicists disagree on the moral status of organ donation. Certain groups, like the Roma (gypsies), oppose organ donation on religious grounds, but most of the worlds religions support donation as a charitable act of great benefit to the community. Issues surrounding patient autonomy, living wills, and guardianship make it nearly impossible for involuntary organ donation to occur. From a philosophical standpoint, the primary issues surrounding the morality of organ donation are semantical in nature. The debate over the definitions of life, death, human, and body is ongoing. For example, whether or not a brain-dead patient ought to be kept artificially animate in order to preserve organs for procurement is an ongoing problem in clinical bioethics. Further, the use of cloning to produce organs with an identical genotype to the recipient has issues all its own. Cloning is still a controversial topic, especially considering the possibility for an entire person to be brought into being with the express purpose of being destroyed for organ procurement. While the benefit of such a cloned organ would be a zero-percent chance of transplant rejection, the ethical issues involved with creating and killing a clone may outweigh these benefits. However, it may be possible in the future to use cloned stem-cells to grow a new organ without creating a new human being. A relatively new field of transplantation has reinvigorated the debate. Xenotransplantation, or the transfer of animal (usually pig) organs into human bodies, promises to eliminate many of the ethical issues, while creating many of its own. While xenotransplantation promises to increase the supply of organs considerably, the threat of organ transplant rejection and the risk of xenozoonosis, coupled with general anathema to the idea, decreases the functionality of the technique. Some animal rights groups oppose the sacrifice of an animal for organ donation and have launched campaigns to ban them.
  48. 48.  Theleological issues On teleological or utilitarian grounds, the moral status of "black market organ donation" relies upon the ends, rather than the means. In so far as those who donate organs are often impoverished and those who can afford black market organs are typically well-off, it would appear that there is an imbalance in the trade. In many cases, those in need of organs are put on waiting lists for legal organs for indeterminate lengths of time — many die while still on a waiting list. A consequence of the black market for organs has been a number of cases and suspected cases of organ theft including murder for the purposes of organ theft. Proponents of a legal market for organs say that the black-market nature of the current trade allows such tragedies and that regulation of the market could prevent them. Opponents say that such a market would encourage criminals by making it easier for them to claim that their stolen organs were legal. Legalization of the organ trade carries with it its own sense of justice as well. Continuing black- market trade creates further disparity on the demand side: only the rich can afford such organs. Legalization of the international organ trade could lead to increased supply, lowering prices so that persons outside the wealthiest segments could afford such organs as well. Exploitation arguments generally come from two main areas: Physical exploitation suggests that the operations in question are quite risky, and, taking place in third-world hospitals or "back-alleys," even more risky. Yet, if the operations in question can be made safe, there is little threat to the donor. Financial exploitation suggests that the donor (especially in the Indian subcontinent and Africa) are not paid enough. Commonly, accounts from persons who have sold organs in both legal and black market circumstances put the prices at between $150 and $5,000, depending on the local laws, supply of ready donors and scope of the transplant operation. In Chennai, India where one of the largest black markets for organs is known to exist, studies have placed the average sale price at little over $1,000. Many accounts also exist of donors being postoperatively denied their promised pay.[17] The New Cannibalism is a phrase coined by anthropologist Nancy Scheper-Hughes in 1998 for an article written for The New Internationalist. Her argument was that the actual exploitation is an ethical failing, a human exploitation; a perception of the poor as organ sources which may be used to extend the lives of the wealthy.
  49. 49. POLITICAL ISSUES There are also controversial issues regarding how organs are allocated between patients. For example, some believe that livers should not be given to alcoholics in danger of reversion, while others view alcoholism as a medical condition like diabetes. Faith in the medical system is important to the success of organ donation. Brazil switched to an opt-out system and ultimately had to withdraw it because it further alienated patients who already distrusted the countrys medical system. Allowing or forbidding payment for organs affects the availability of organs. Generally, where organs can not be bought or sold, quality and safety are high, but supply is not adequate to the demand. Where organs can be purchased, the supply increase somewhat, but safety declines, as families and living donors have an incentive to conceal unfavorable information.
  50. 50. PRISON INMATESIn the United States, prisoners are not discriminated against as organ recipients and are equally eligible for organ transplants along with the general population. A 1976 U.S. Supreme Court case ruled that withholding health care from prisoners constituted “cruel and unusual punishment.” United Network for Organ Sharing, the organization that coordinates available organs with recipients, does not factor a patient’s prison status when determining suitability for a transplant. An organ transplant and followup care can cost the prison system up to one million dollars. If a prisoner qualifies, a state will allow compassionate early release to avoid high costs associated with organ transplants.
  51. 51. Religious viewpointsAll major religions accept organ donation in at least some form on either utilitarian grounds (i.e., because of its life-saving capabilities) or deontological grounds (e.g., the right of an individual believer to make his or her own decision). Most religions, among them the Roman Catholic Church, support organ donation on the grounds that it constitutes an act of charity and provides a means of saving a life, although certain bodies, such as the popes, are not to be used. Some religions impose certain restrictions on the types of organs that may be donated and/or on the means by which organs may be harvested and/or transplanted. For example, Jehovahs Witnesses require that organs be drained of any blood due to their interpretation of the Hebrew Bible/Christian Old Testament as prohibiting blood transfusion, and Muslims require that the donor have provided written consent in advance. Orthodox Judaism considers organ donation obligatory if it will save a life, as long as the donor is considered dead as defined by Jewish law. A few groups disfavor organ transplantation or donation; notably, these include Shinto and those who follow the folk customs of the Gypsies.
  52. 52. THEOLOGICAL VIEWS Question: "What does the Bible say about organ donation?" Answer: The Bible does not specifically address the issue of organ transplantation. Obviously, organ transplants would have been unknown in Bible times. However, there are verses that illustrate broad principles that may apply. One of the most compelling arguments for organ donation is the love and compassion such an act demonstrates toward others. The mandate to "love your neighbor" was stated by Jesus (Matthew 5:43), Paul (Romans 13:9), and James (James 2:8), but it can actually be traced all the way back to Leviticus 19:18. From the earliest days in the Old Testament, Gods people were commanded to demonstrate a love for God as well as for their neighbors. Being willing to donate an organ from our own bodies would seem to be an extreme example of selfless sacrifice for another. Paul, in writing to the Corinthians, provided some insight as to the difference between the physical body at death (which may be disposed of in a variety of ways), and the spiritual body of the resurrection (1 Corinthians 15:35-49). He used the analogy of the difference between a seed and the product of that seed to illustrate the difference between the earthly body and the resurrected body. He then went on to comment: "It is sown a natural body; it is raised a spiritual body. There is a natural body, and there is a spiritual body" (v. 44). If we believe that the bodies raised at the resurrection represented simply a "reoccupation" of our earthly bodies, then we possess a false concept of our resurrection as presented in the Bible. We are told that the earthly body "that of flesh and blood" will not enter into the heavenly inheritance (1 Corinthians 15:50). Based on these facts, Christians should not fear or reject organ donation merely in an attempt to keep the physical body intact for the resurrection.
  53. 53. Additional thoughts on organ donation and organ harvesting
  54. 54. The legitimate argument against organ donation arises from the process of organ harvesting. There is nothing ethically wrong in recovering organs from the dead, but most successful organ transplants require that any prospective organs be kept alive with blood and oxygen flowing through them until they are removed from the body. This dilemma is troublesome, because we cannot, and must not, support the termination of life in favor of organ donation. The medical profession has traditionally used cessation of heart and lung activity to mark the point of death. Medical technology had progressed to a point where it is possible to sustain (via a respirator) heart and lung activity for days or even weeks after a patient had irreversibly lost all brain function. There has been a push in some medical circles to harvest organs when the patient has lost higher brain functions but is still alive. In 1994, the Council on Ethical and Judicial Affairs of the American Medical Association (AMA) issued its updated opinion that it is "ethically permissible" to use babies born without higher brain functions as organ donors.
  55. 55. As Christians, we can support organ donation only in those cases in which death has been determined by every criterion "including complete loss of brain function" rather than just by one or two criteria. God forbids intentional killing (James 2:10-11); thus we must carefully determine, in light of the teachings found within God"s Word, whether a respirator is simply oxygenating a corpse or sustaining a living human being. Then we must act accordingly. Since most transplants come from donors who have been declared neurologically dead, it is important that we fully understand the criteria the medical profession is using to define brain death. Only when a patient is determined to be irreversibly and completely brain dead should he or she be considered a candidate for organ donation.