Why No Mention of Neonatal Circumcision back in June?

The redoubtable “Bear” Cox has asked why I excluded male neonatal circumcision in my June “capabilities approach” post. I did so for a number of reasons, but let me just mention a few.

First, to equate the two procedures trivializes the horror of FGM. Male
neonatal circumcision (hereinafter MNC) is in no way as invasive as FMG.
The homologous equivalent to female genital mutilation would be amputation
of the entire penis. I assure all reading this post that I am just as
opposed to THAT procedure as I am to FGM. I love my "Mr. Happy," who has been my friend through many adventures. However, penile amputation is almost never performed, whereas FGM happens to millions of young women every year. Since it almost never happens in our patriarchal world, there is no reason to mention it.

Second, I am persuaded that ALL of the COMPETENT peer reviewed studies
regarding MNC, individually and collectively, establish that the procedure
produces a modest medical benefit, to be balanced against modest medical
risk, usually in the form an undetected bleeding disorder. If anyone,
anywhere, is aware of a similar study or studies coming to the same
conclusion about FGM, often termed clitorectomy, please let me know.

An excellent summary of the state of the SCIENTIFIC literature regarding MNC may be found in Benatar and Benatar, "Between prophylaxis and child abuse: the ethics of neonatal male circumcision"; The American Journal of Bioethics - Volume3, Number (2), Spring 2003, pp.35-48. It is magisterial, and much can be gleaned from reading it, along with the decidedly adversarial responses to it from anti-MNC camp.

This leads to my third reason. I am convinced that those who oppose neonatal
male circumcision (in contrast to those who would simply PREFER not to elect
it for their sons) are either uninformed or intellectually dishonest. Here
is an example in the form of a comment on the Benatar study, noted above, by
an individual named "Rio Cruz":

"Benatar and Benatar (2003) conclude that amputating ... protective, and
sexually important tissue from a nonconsenting infant does not constitute
abuse but is rather a matter for parental discretion."

I have never, in 60 years of life, seen a more egregious example of begging
the question. And this is not an isolated instance; every single article I
can find which criticizes the practice contains an example of either the
"strawman" fallacy or the "begging the question" fallacy (usually both),
coupled with a willful refusal to examine the peer reviewed evidence on the
topic with anything remotely resembling an open mind.

Now, to another reason - my main one, actually. Look carefully at what this
"Rio Cruz" person says. He calls the foreskin "sexually important".
Channeling my inner G.E. Moore, I want to know what, exactly, that is
supposed to mean. The anti-MNCers never clearly say, which, following Moore
again, leads me to conclude that they mean nothing whatsoever. But, let's
apply the principle of charity to that statement, and try to say something
meaningful on their behalf. Perhaps what they have in mind is a claim that
the procedure of MNC produces "negative" sexual sequela in later life. I
call this the "Less Pleasure" thesis. Let's take a look at it.

The literature surrounding the possible sexual sequela of neonatal
circumcision focuses on the tactile stimulation that males receive during
sexual activity. Of chief concern is the role that the male foreskin might
(or might not) play in the "sexual pleasure" a sexually active male
experiences, and so the debate seems couched in terms of the "stimulation"
that foreskin tissue might provide, and what loss of "sensitivity"
maturation without a foreskin might cause. This is why one finds so much
discussion (and disagreement) about, for example, how "keratinized" the
glans is, how "sensitive to touch and pressure" the glans is, and how much
"highly erogenous tissue" is removed by circumcision (By "highly erogenous
tissue," I take those using the expression to mean "tissue within an
erogenous zone of the body," and by "erogenous zone" to mean a part of the
body that is associated with sexual pleasure). It is at this point, I
think, that the discussion "jumps the track," and leads to conceptual
confusion.

The discussion "jumps the track" because the analysis seems focused on
"sensation," in the sense of peripheral nerve receptor stimulation, as the
primary focus of investigation and analysis, whereas I maintain that our
best science, and scientifically informed philosophy, suggests that this is
the wrong way (albeit the "folk psychological" way) to think about sexual,
or indeed any other kind, of pleasure.

There is a surprising dearth of recent philosophical analysis on the general
topic of pleasure. Rather, pain seems to be the usual topic of interest.
The great bulk of the modern philosophical literature on the subject of
pleasure generally centers on the work of Gilbert Ryle, produced in the late
1940's and the early 1950's, and the responses of other philosophers to
Ryle's work. This work was done when psychological research was, for the
most part, either strictly behavioristic or, alternatively, introspective.
Psychology at the time had little in the way of research findings to offer
philosophers which could shed light on the subject, so it is perhaps not
surprising that philosophical reflection and analysis on pleasure soon
faded. However, Psychology has advanced considerably in the succeeding
decades, and philosopher Mayat Aydede has revisited the subject fairly
recently and produced a splendid paper, "An Analysis of Pleasure Vis a Vis
Pain," to be found in Philosophy and Phenomenological Research, 61 (3):
537-70, 2000 (hereinafter "Pleasure Analysis.")

The language of the current discussion on the sexual sequela of neonatal
male circumcision leads one, naturally enough, to think about the issue in
terms of some relationship between the number of nerve endings in the penis,
plus or minus the foreskin, and the quantity and intensity of "sexual
pleasure." I maintain that this is the wrong way to conceptualize the issue,
in light of what Dr. Aydede, and the scientific work he cites, can tell us
about how it is that pain and pleasure happen to happen.

Aydede argues that, from a general understanding of the gate control theory
and the phenomenon of reactive dissociation, some clear conclusions can be
reached about pain. We can best understand pain, he argues, in the
following way (as drastically simplified by me.) We "feel" pain, or are "in
pain" when: 1) pain stimuli from peripheral nociceptors (pain specific
receptors, located primarily in the skin and viscera) arrive at the
somatosensory cortex and at various limbic system structures; 2) in the
somatosensory cortex, these nocioceptor generated stimuli (noxious stimuli,
for short) are identified as pain, and measured in terms of intensity and
the spatio-temporal location of the originating nociceptors; and 3)
simultaneously, in the limbic system, affective response to the noxious
stimuli, in the form of an aversive reaction, is generated. That, in a
nutshell, is how pain happens to happen, when all goes as "nature intends."

Contrast this picture, Aydede suggests, with physical pleasure. It some
ways, the process is parallel, in that the "experience" of "feeling physical
pleasure" usually begins when stimuli from receptor sites arrive at the
somatosensory cortex and the limbic system. However, a marked difference is
already at work. The arriving stimuli do not include any "pleasure" stimuli,
for the simple reason that the human body apparently has no "pleasure"
receptors, as such. We have lots of receptors, including proprioceptors,
thermal receptors, pain receptors, receptors for touch, taste, light and
smell; but no "pleasure receptors." Thus, the somatosensory cortex does not
identify anything as "pleasurable." When we "experience" pleasure, the
somatosensory cortex is busy identifing stimuli, but identifying them as,
for example, touch, taste, pressure, smell, sound, or motion; not as
pleasure. So "physical pleasure" simply is, on Aydede's model, the affective
response to those particular stimuli.

To simplify even further, we do not have pleasure experiences; rather, we
have experiences we find pleasurable. Pain is different; we have pain
experiences that we usually find, well, painful, unless someone gives us
morphine. Aydede helps us here by simplifying even further: "Put crudely,
the suggestion is not that we feel...pleasure and then desire it. It is
rather that the very feeling of pleasure metaphysically consists of our
desiring whatever...sensory information we are simultaneously processing or
reacting to." Works for me. How else can we explain what goes on in certain
nightclubs in San Francisco? How else do we explain all of that "birching"
business going on on British television (see several episodes of "Midsomer
Murders" for examples)? My goodness how they carry on over there!

Thus, if either circumcised William or uncircumcised James experiences "less
pleasure" than the other, we are not going to be able to tell by counting
the number of their respective "erotogenic receptor sites," assuming,
without deciding, that there even are such things. Instead, we will have to
determine which of them is most strongly "desiring...whatever sensory
information" they typically process/react to when engaging in sexual
activity. And this sort of study, I am afraid, is not something opponents
of MNC ever cite.

There are some peer reviewed studies which do provide some information about circumcision's sexual sequela in adults. But this evidence, such as it is,
does not reflect negatively, on balance, on male circumcision in general.
There is a study which indicates that men who have been circumcised in
adulthood find sexual activity more satisfying, overall, roughly 70% of the
time, studies which conclude that circumcised men engage in a greater
variety of sexual activities than do uncircumcised men (specifics available
upon request - email me off post, ladies), and studies which conclude that
circumcised men are less prone to erectile dysfunction than uncircumcised
men, especially in later life (more good news!). To me, these studies hardly
provide warrant for characterizing the sexual sequela of neonatal
circumcision as "negative", but I leave the reader to draw her or his own
conclusions in this particular.

Let's end by returning to the capabilities approach. It is entirely clear
to me that women undergoing FGM are deprived of a "capability" needed for a
fully "human" life. Joyce's Molly's "YES" is absolutely never going to
happen for them. In the case of circumcised males, however, YES happens for
them as least as often as it does for their uncircumcised cohorts, and all
of the evidence we have suggests that they yell "Oh My God", or words to
similar effect, at least as loudly, when "knocking boots". So, while MNC in
the USA is indeed a cultural phenomenon, an expression of an aesthetic
preference on the part of middle and upper class protestant women, it
deprives no one of a meaningful capability necessary to enjoy a fully
"human" life. The same cannot be said for FGM.

So I did mention FMG, but didn't mention MNC. Hope this answers Bear's question.

Labels: Capabilities Approach

  ¶ 9:15 AM 3 Comments

 

This list is in danger of suffering from disuse atrophy, which is a bad
thing, as I have reason to know.  So I decided to post something.

I just received an announcement that Martha Nussbaum will be coming to the
southern part of heaven (otherwise known as UNC-Chapel Hill) next spring to
make a presentation (title TBA) to the philosophy department.  I can't pass
up a chance to meet another philosophical rock star.  So, in anticipation of
the coming event, I sat down and read Nussbaum's "Sex and Social Justice,"
one of several of her books that relies on what she calls the "capabilities
approach" to ethical and political theorizing.

Nussbaum writes beautifully, with the goal of engaging not just
philosophers, but all thoughtful people.  Commendably, she doesn't just
theorize in a philosopher's study, but often descends in to the messy world
of day to day life as ordinary people around the world must live it, and, as
one Jesuit reviewer put it, "if you are looking for wisdom, her books are
full of the stuff."

Much of the "wisdom" is derived from her encyclopedic knowledge of the
ancient world, particularly Aristotle and the stoics.  Of course, not
everyone agrees that she "gets them right." I am not competent to
adjudicate, so I just think of it as a case of "Aristotle and Aurelius as
She Understands Them", or AASUT for short (sounds sort of like the "AHH
S..T!" that working nurses exclaim when the vein they are trying to puncture
for a blood sample blows up).

In any event, informed by AASUT, and the work of the economist Amartya Sen,
Nussbaum offers us the notion of "capabilities."  The goal here is to
specify "a life in which fully human functioning, of a kind of basic human
flourishing, will be available."  She attempts, in other words, to meet a
big challenge for eudamonian based ethical theories, that of specifying what
counts as a "good life."  Problems rush in here, for doesn't the very idea
of "basic human flourishing" smack of dreaded "essentialism"?  "Good life"
for me might be a whole different kettle of fish from "good life" for
Hitler.  In fact, I am pretty sure I would mean something different by the
term than he would.

What counts as a good life ought to matter to nursing if anything does,
especially in light of the love affair nursing has had with virtue ethics
over the years.  But, you don't have to be in nursing  very long to discover
that there are differing conceptions of the "good life"  amongst the patient
population. Some nursing scholars are lead to conclude, by the diversity of
views on the subject, locally and globally, that there is simply no such
thing as THE "good life," and any attempt by some
old-fat-white-man-ex-lawyer-now-a-nurse (like, say, me) to define the term
would be an exercise in "colonialism"; a LITTLE better than yelling "bash
the WOGs and Fuzzies, let's have another gin" - but not MUCH better.
Attempting to define "good life" for other folks turns me, apparently, into
a sort of intellectual neo-Clive let loose upon the world once more,
opressing everyone from Dublin to the Ganges (well, not Dublin - I love
Dublin.  Let's abuse them last).  Bob the nabob, minus the opium and dancing
girls (damn it, I was born too late!).

Nussbaum is not unaware of these difficulties, and gamely tackles them.  Her
efforts are impressive, and even the likes of Simon Blackburn (who does not
suffer fools lightly) admires them.  The approach is supposed to be (mostly)
culture neutral because it addresses capabilities as opposed to practices,
and so at some level or another supposedly doesn't  involve telling other
people what to do. Consider the list:

life; bodily health and integrity; senses, imagination and thought;
emotional expression; practical reason; affiliation; play; other species;
and, control over political and material environments.

The idea has initial plausibility - take, say, control over the political
environment.  It doesn't rule out of court an Islamic republic, for example,
provided the folks living there want to live in one and have some say in
choosing that form of life.  But not every "post-colonialist" is likely to
be persuaded.  For instance, some cultures are not too ginned up about
giving women even certain "capabilities."  There are societies which deny
women substantial capabilities viz. affiliation, bodily integrity, thought
and environment.  The capabilities approach would declare them illegitimate,
and therefore is, arguably, "colonialist".

To this criticism from the left flank, there are at least three replies.
First reply: who speaks for the culture in question - the girls who want to
go to school, or keep their clitoris, but who are not allowed to, or the
(male) mullahs, elders and/or warlords who won't let them?  Maybe what the
culture "really" wants IS compatible with the "capabilities" approach.

Second reply: maybe these silly savages are just ignorant.  Maybe they don't
know that women are actually smarter than men, on average, and so OUGHT to
go to school if anyone does, or they've misunderstood their own scripture,
or they don't understand enough about human physiology to comprehend that
eumenorrhea is normal and healthy and occurs for homeostatic reasons, or
that it is a bad idea to mutilate female genitalia with or without antsepsis
and anesthesia for any number of reasons, or ... I could go on for while,
but you get the general idea.  Sort of a Millian style argument, like the
one he gave against Bentham's "equality of pleasures" position.

Third reply: this provides a repugnant conclusion/reductio ad absurdum
refutation of post-colonialist arguments. Simply put, IF post-colonial
theory countenances, in any shape, form or fashion, stuff like female
circumcision, obligatory suicide of widows, "honor" killing of women, etc.,
then so much the worse for post-colonial theory.  What's wrong with the idea
that cultures, like individuals, make mistakes?

Assaults could be mounted from the right flank as well.  While emphasizing
"capabilities" is not AS blatantly egalitarian/redistributionist as say, a
Rawlsian program of equal distribution of all social "goods", it is still
going to involve some "taking from the rich" and "giving to the poor".
Noziak-style libertarians will, therefore, still object.  First reply: a
capabilities approach is consistent with unequal distributions of wealth so
beloved by libertarians - it just assures equality of opportunity to the
fullest extent possible, not equality of achievement. You get to keep, in
other words, what you fairly earn; capabilities approaches are simply trying
to give everyone, to the extent possible, the same chance you have.  It
can't give everyone a great voice and a lucrative concert career, for
example, but it can make it possible for everyone who has a great voice to
have music lessons. After the lessons it's up to you.  How could even Mrs.
Thatcher or Ronald Regan object to that?

Second reply: All the "capabilities approach" is doing is assuring some sort
of compliance with the "Lockean proviso", which says that you, or Bill
Gates, or Madonna can take as much of the world's riches as you want, so
long as you do so fairly and leave "enough and as good" for everyone else.
Most libertarians accept the Lockean proviso.  It is hard to know exactly
what that proviso comes to, in today's world, but maybe some sort of
"capabilities approach" captures the spirit of what Locke had in mind.

Interesting stuff.  But what, one asks, has this got to do with Nursing?
Nothing, if Nursing affords no valuable and unique perspective on questions
such as how should healthcare resources be distributed, o what constitutes
"disease" or "disability".  But, if it does have such a perspective, this
might be one way to articulate it that is in some meaningful sense
"transcultural."

Also, it seems to me that this sort of analysis of social justice and human
flourishing mirrors, in some interesting ways, the ways in which various
nursing processes analyze the individual's health.  The parallels with
Orem's theory are especially striking.  Perhaps Plato was on to something in
suggesting that the healthy person and the healthy society are structurally
similar.

One VERY bright young Don in the UK, Lorella Terzi at Roehampton University,
is doing some interesting work on this approach in the context of education
and learning disability.  See, for example, her ‘Beyond the Dilemma of
Difference: the capability approach on disability and special educational
needs’ in Journal of Philosophy of Education , 39 (3), pp.443-459.

I don't think it is absurd to think that there may be parallels between
questions surrounding  the delivery of educational services to the learning
disabled and the delivery of nursing services to the physically disabled, or
to the care of the sick in general.

Thoughts, anyone?

Labels: Capabilities Approach

  ¶ 8:56 PM 1 Comments