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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 28 Number 4 2014 pp 166–169
doi:10.1111/bioe.12093
AGAINST ANONYMITY ROBERT BAKER
Keywords abortion, after-birth abortion, anonymous authorship, disability, eugenics, infanticide, Internet, Nazi medicine, publication ethics
ABSTRACT In ‘New Threats to Academic Freedom’1 Francesca Minerva argues that anonymity for the authors of controversial articles is a prerequisite for academic freedom in the Internet age. This argument draws its intellectual and emotional power from the author’s account of the reaction to the on-line publication of ‘ After-birth abortion: why should the baby live?’2 – an article that provoked cascades of hostile postings and e-mails. Reflecting on these events, Minerva proposes that publishers should offer the authors of controversial articles the option of publishing their articles anonymously. This response reviews the history of anonymous publication and concludes that its reintroduction in the Internet era would recreate problems similar to those that led print journals to abandon the practice: corruption of scholarly discourse by invective and hate speech, masked conflicts of interest, and a diminution of editorial accountability. It also contends that Minerva misreads the intent of the hostile e-mails provoked by ‘After-birth abortion,’ and that ethicists who publish controversial articles should take responsibility by dialoguing with their critics – even those whose critiques are emotionally charged and hostile.
He that filches from me my good name . . . makes me poor indeed.3
THE ECLIPSE OF ANONYMITY IN PRINT JOURNALS During the Enlightenment, philosophers who feared that their writings could lead to exile, imprisonment or execution published anonymously or pseudonymously. Today however, intellectuals in liberal democratic societies enjoy freedom of speech and, in the absence of such threats, official ethics statements require medical and scientific journals to properly identify the authors of the
1
F. Minerva. New Threats to Academic Freedom. Bioethics 2013; DOI: 10.1111/bioe.12066. 2 A. Giubilini & F. Minerva. After-birth Abortion. Why Should the Baby Live? J Med Ethics 2013; 39: 261–263. 3 Shakespeare, W. circa 1603. Othello Act 3, sc 3, lines 155–161.
articles they publish.4 Arguing that in the Internet age authors of controversial articles encounter threats comparable to those faced by their Enlightenment precursors, Minerva proposes a return to the Enlightenment practice of permitting anonymous publication of controversial articles. In assessing proposals to return to past practices, it is prudent to recall the advice of Spanish-American philosopher George Santayana (1863–1952), who famously observed, ‘Progress, far from consisting in change, depends on retentiveness . . . Those who cannot
4
The International Committee of Medical Journal Editors (ICMJE) ethics principles state that journals must ‘ identify who is responsible for the integrity of the work . . . [as] author, or co-author.’ International Committee of Medical Journal Editors. Ethical Considerations in the Conduct and Reporting of Research: Authorship and Contributorship. http://www.icmje.org/ethical_1author.html [cited 2013 July13]. See also World Association of Medical Editors. Publication Ethics Policies for Medical Journals. http://www.wame.org/resources/publication-ethics -policies-for-medical-journals#authorship. [cited 2013 July 13].
Address for correspondence: Dr Robert Baker, Alden March Bioethics Institute, The Campus, Union College Humanities 020 Schenectady, New York 12308, USA. T: 518-388-6215 F: 518-388-8046. Email: [email protected] Conflict of interest statement: No conflicts declared © 2014 John Wiley & Sons Ltd
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remember the past are condemned to repeat it.’5 In earlier eras, articles dealing with infanticide were published in general medical journals, like the Journal of the American Medical Association (JAMA).6 From its founding by Nathan Smith Davis (1817–1904) in 1883, JAMA’s pages were enlivened by articles on the morality of animal and human experimentation, the Hippocratic Oath, researcher integrity, self-expurgation of medical texts, euthanasia and the value of human life and at the other end of the lifecycle, the ethics of birth control, craniotomy/partial birth abortion – and infanticide.7 Many of these were anonymous or pseudonymous publications. Yet in 1895 JAMA’s editor announced, ‘anonymous publications . . . will not . . . be published’.8 Following Santayana’s advice, prudence dictates that before we reintroduce anonymous publication, we reflect on what led JAMA (and other scholarly journals) to prohibit the practice. The chain of events leading up to JAMA’s prohibition on anonymous publications began in 1894 when JAMA published a letter from Professor Solomon Solis-Cohen (1857–1948), ‘As to “Nostrum” Advertisements in the Journal’.9 Cohen’s letter charged that JAMA had violated the AMA’s Code of Medical Ethics by advertising secret nostrums, i.e. medications with undisclosed ingredients. Such advertisements were considered unethical because if such medicines were ‘of real efficacy . . . concealment regarding [ingredients] is inconsistent with beneficence . . . and, if mystery alone give it value . . . such [advertisements] impl[y] . . . fraudulent avarice.’10 Cohen’s letter provoked a cascade of responses published under such pseudonyms as ‘A Conservative Voice’, ‘Integrity’, and many others. A letter by ‘Medicus’ castigated ‘these people, the ‘Hebraics’, ‘the Hebrew children 5
G. Santayana. The Life of Reason or the Phases of Human Progress. Volume I: Reason in Common Sense. New York: Charles Scribner and Sons; 1905. www.gutenberg.org/files/15000/15000-h/vol1.html #CHAPTER_XII_FLUX_AND_CONSTANCY_IN_HUMAN _NATURE. [cited 2013 July 20] 6 Specialized medical ethics journals are a relatively recent phenomenon. The earliest known journal specializing in medical ethics is the German journal, Ethik (1922–1938). See A. Frewer. Debates on Human Experimentation in Weimar and Early Nazi Germany As Reflected in the Journal ‘Ethik’ (1922–1938) and its Context. In: Roelcke V., Maio G., editors. Twentieth Century Ethics of Human Subjects Research: Historical Perspectives on Values, Practices, and Regulations. Stuttgart: Franz Steiner Verlag; 2004. pp. 138–150. 7 R. Baker. Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution. New York: Oxford University Press; 2013. pp. 227–228. 8 The Editors. Anonymous Publications. JAMA 1895: 24(4): 141. 9 S. Solis-Cohen. As to ‘Nostrum’ Advertisements in the Journal. JAMA 1894; 22(3): 95–96. 10 AMA. 1847. ‘Code of Medical Ethics,’ Chapter II, Article I, Section 4, in Baker R, Caplan A, Emanuel L, Latham S, editors, The American Medical Ethics Revolution: Baltimore: The Johns Hopkins University Press; 1999. Appendix C, p. 328.
of Philadelphia’,11 for daring to challenge the integrity of JAMA’s founding editor, Davis, the ‘father of the AMA’. In response, a signed letter from ‘A member of the [AMA] and a Jew . . . [protested] dragging questions of race and religion into the discussion.’12 Alarmed by this correspondence the AMA’s governing board investigated. They found JAMA guilty of advertising secret nostrums and discovered that Davis himself had authored pseudonymous correspondence defending his editorship. Consequently, they requested Davis’s resignation and appointed John B. Hamilton (1847–1898), JAMA’s second editor (1893–1898). Hamilton banned anonymous publications and implemented the policy of ‘accept[ing] no advertisements of medicinal preparations [without] a formula containing the official or chemical name of each composing ingredient.’13 The JAMA incident highlights some problematic features of anonymous publication. It shows that hate speech is not a new phenomenon that arose with the Internet. It is a natural concomitant of anonymous or pseudonymous communication irrespective of whether the medium is print, on-line social networking, or the twitterverse. Whatever the medium of communication, anonymity severs social and personal accountability for speech acts. Cloaked by anonymity users feel free to pen, type or tweet their anti-Semitic (ageist, anti-intellectual, anti-Muslim, homophobic, racist, sexist) hate speech hidden behind their hashtags or pseudonyms.14 Since their anonymous words do not endanger their standing in any community of peers, authors feel free to vent slurs and to engage in character assassination. In the JAMA letters truth was slandered because its authors were ‘Hebraics’. The JAMA case also underscores anonymity’s propensity to corrode editorial responsibility. This was the only time that Davis’s JAMA published anti-Semitic statements. He probably permitted publication of the slurs because it served his self-interest and may have believed that any blame attaching to their publication would fall on their pseudonymous author, ‘Medicus’, rather than on him as editor. Pseudonyms also allowed Davis to praise himself without alerting his readership to the conflict of interest. By severing authorship from identity anonymity encourages those with undetectable interests to make false or misleading claims in ways that made it difficult, if not impossible, to distinguish truth from untruth. Mindful of the potential abuses of anonymity Minerva proposes several safeguards: (1) Editorial review to 11
Medicus. The Advertising Question. JAMA 1894; 22(12): 438–439. G.J. Kaumheimer. He Very Properly Calls Medicus to Order. JAMA 1894; 22(13): 480. 13 JAMA. Report of the Board of Trustees. JAMA 1895; 24(20): 760. 14 S. Sengupta. Twitter Yields to Pressure in Hate Case in France. New York Times. 2013 July 31; B1, B4. 12
© 2014 John Wiley & Sons Ltd
Against Anonymity prevent publication of ‘offensive, irrational, racist, or sexist papers’;15 (2) revealing authors’ real names to journal editors, who, in turn would (3) reveal authors’ names to their supervisors (e.g. Department Chairs). Would these suffice to constrain the abuses that led to the abandonment of anonymity? Davis and other 19thcentury editors published ad-hominem-filled pseudonymous articles, comments and letters to add zest to their pages in the hope of increasing readership and advertising revenues. The search for advertising revenue also tempted Davis to flaunt the rules prohibiting advertising secret nostrums. It would be naïve to presume that 21st century editors would be more scrupulous than their 19th century predecessors, or better able to resist pressures for readership, revenues, and high impact factors – especially since dozens of editors have been caught cheating.16 Moreover, the most scrupulous of editors would have difficulty detecting conflicts of interest if articles can be published anonymously. Even without the cloak of anonymity unacknowledged conflicts of interest have become commonplace enough to bring ‘the credibility of clinical medicine to an unprecedented crisis.’17 Anonymity would compound the problem because authors with conflicting interests often fail to disclose them. Their conflicts are typically exposed through postpublication detective work by watchdog scholars who match authors’ names with those listed by companies as consultants, directors, employees, patent holders, stockholders, or as recipients of honoraria, grants and subsidized travel. In one particularly outrageous case, a journal editor was forced to resign because he failed to disclose a conflicting financial interest in a medical device lauded in a ghostwritten article, for which he claimed lead authorship, that was published in his own journal!18 Had this article19 been published anonymously or pseudonymously, none of these conflicts of interest would have been detectable. Reintroducing anonymity into medical, scholarly or scientific publications would mask conflicts of interest, making them virtually undetectable and consequently even more commonplace. As Santayana reminds us, we need not relive the past to be mindful of its lessons.
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EXAGGERATING THE DANGERS OF PUBLICITY Minerva reports that the on-line publication of ‘Afterbirth abortion: why should the baby live?’ precipitated a cascade of Internet protests. Many protests were thoughtful critiques by physicians, parents of children with disability, and people with memories of the Nazi infanticide program Aktion T-4 (1939–1941). Others, like the following, appear more threatening: ‘your parents should have aborted you after-birth, the world would have been a much better place’; ‘if it is OK to kill babies, then it must be OK to kill academics’; ‘For your views on newborns not being people, you need to be eliminated along with your entire family. You are not human therefore you do not have a right to live’; ‘You two are perfect examples of people who should have been aborted at birth. You are advocating cold-blooded murder. Watch your backs assholes. Time for your termination.’20 Receiving such e-mails was undoubtedly traumatic. Yet analyzed in retrospect, these messages have a format familiar to any logician: one so ancient and so common that it has its own Latin sobriquet, tu quoque, literally, ‘you too!’ or ‘ the same to you!’ Read this way these so-called threats seem designed to make those who asked ‘why should the baby live?’ feel the experience of having someone ask of them, ‘why should you live?’ To be sure, read as refutation, the logic of tu quoque is fallacious. Yet what respondents, perhaps people with disability or those who love and care for them, seem to be attempting to communicate is what it feels like to have one’s very right to have been born questioned. Read this way, these e-mails are neither a logical assault on Giubilini and Minerva’s analysis nor an actual threat of physical harm; they seek to communicate the emotive impact of having someone question, ‘why should you have the right to live?’ In point of fact, no physical threat to Minerva and her colleague ever emerged, and philosophers who hold similar positions, most notably Peter Singer, have not been physically accosted.
TAKING RESPONSIBILITY FOR CONTROVERSIAL PROPOSALS 15
F. Minerva. op. cit. note 1. Nature Blogs. June 19, 2013. New Record: 66 Journals Banned for Boosting Impact Factor With Self-Citations. Available from: http:// blogs.nature.com/news/2013/06/new-record-66-journals-banned-for -boosting-impact-factor-with-self-citations.html [cited 20013 July 16]. 17 G.A. Fava. Financial conflicts of interest in psychiatry. World Psychiatry 2007; 6(1): 19–24. 18 D. Armstrong. Medical journal editor to quit in wake of disclosure oversight. Wall Street Journal 2006. August 25. B1. 19 C.B. Nemeroff, H.S. Mayberg, S.E. Krahl, et al. VNS Therapy in Treatment-Resistant Depression. Neuropsychopharmacology 2006: 31: 1345–1355. 16
© 2014 John Wiley & Sons Ltd
Ethics is not a matter of clever arguments paraded before one’s peers for their approbation. From Socrates to Singer, ethics has always been that branch of philosophy that addresses the proper way for lives to be lived, and – more to the point of Giubilini and Minerva’s paper – for deaths to be died. Many proposals advanced by moral philosophers later became matters of public policy – including policies implementing the notion that people 20
F. Minerva. op. cit. note 1, pp. 2–3.
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with disability do not have lives worthy of being lived. The roots of this policy can be traced to Plato’s Republic where it is argued that ‘If a man has a sickly constitution . . . his life was worth nothing to himself or anyone else; medicine was not meant for such people and they should not be treated, though they be richer than Midas’21 Friedrich Nietzsche (1844–1900) updated Plato’s analysis proclaiming that ‘A new responsibility should be created, that of the doctor – the responsibility of ruthlessly suppressing and eliminating degenerate life, in all cases in which the highest interests of life itself, of ascending life, demand such a course.’22 These sentiments were put before a medical audience in a Die Freigabe der Vernichtung lebensunwerten Lebens (Permitting the Destruction of Lives Unworthy of Being Lived) a book published in 1920 by a law professor, Karl Binding, (1841–1920) and a medical colleague, the psychiatrist Alfred Hoche (1865–1943).23 Like Giubilini and Minerva,24 Binding and Hoche wanted to offer parents of children born with Down’s syndrome – as they put it in the language of the era, ‘incurable idiots’ – the option of having their newborns killed because idiots are ‘just a caricature of the true man and arouse dismay in everyone.’25 They too recommended immediate infanticide, arguing, ‘It would be best to apply for death with dignity as soon as incurable idiocy has been confirmed.’26 Although initially ‘merely’ academic arguments, Binding and Hoche’s proposals became public policy when the National Socialist (Nazi) party came to power in the 1930s. Physicians like Herman Pfannmüller (1886– 1961), an admirer of Hoche (whom he had met personally), implemented these policies in the Eglfinger-Haar psychiatric hospital.27 As hospital director Pfannmüller gave tours of his facility to students. A psychology student wrote this account of how infanticide was practiced. I took part in a conducted tour . . . The asylum director . . . Pfannmüller, led us into a children’s ward. . . . [He] explained . . . ‘As a National Socialist, these 21 Plato. Circa 380 BCE. Republic, translated by Francis M. Cornford. New York: Oxford University Press. Book III, sec. 408, p. 98. 22 F. Nietzsche. [1888] The Twighlight of the Idols: Or, How to Philosophise with the Hammer. In Levy O., editor. The Complete Works of Friedrich Nietzsche: First Complete and Authorised English Translation. Ludovici AM, translator. New York NY: Russell & Russell. 1964. Vol. 16, sec. 36, p. 8. 23 K. Binding & A. Hoche. [1920], Die Freigabe der Vernichtung lebensunwerten Lebens. Sassone R. translator. Santa Ana (CA): Robert Sassone. 1975. 24 A. Giubilini & F. Minerva. After-birth Abortion. Why Should the Baby Live? J Med Ethics 2013; 39: 262. 25 Binding & Hoche. op. cit. note 23, pp. 20–21. 26 Ibid: 21. 27 M. Burleigh. Ethics and Extermination: Reflections on Nazi Genocide. Cambridge (UK) and New York: Cambridge University Press; 1997. 103.
creatures . . . naturally only represent to me a burden upon the healthy body of our nation. We don’t kill (he may have used a more circumlocutory expression . . .) with poison, injections . . . No: as you see, our method is simpler and even more natural [starvation].’ With these words, and assisted by a nurse . . . he pulled one of the children out of the bed. As he displayed the child around like a dead hare, he pointed out, with a knowing look and a cynical grin, ‘This one will last another two or three days.’ The image of this fat, grinning man, with the whimpering skeleton in his fleshy hand is still clear before my eyes.28 Neither philosophy nor society has treated people with disabilities kindly in the past, so it is understandable that these people, and those who care about them, should be viscerally apprehensive about proposals to once again offer the parents of Down’s infants the right to request infanticide. Those potentially affected by the policy have a right to confront Giubilini and Minerva with their fears and to ask why this proposal is not just another manifestation of philosophers’ historical prejudice against people with disability. They have a right to interrogate the authors about why they should expect the proposed infanticide to be implemented more humanely than the German initiative of the 1930s. They also have a right to ask the more fundamental question: why should infants with Down’s and other disabilities be regarded as having lives unworthy of being lived? Finally, they have a right to invoke the Golden Rule and ask that Giubilini and Minerva share for a moment what it feels like to have one’s very right to exist questioned. People can pose these questions – and vent their anger and anxiety – directly to Giubilini and Minerva because, as required by the ethical principles of contemporary journals, authors are required to affix their names to their publications. Minerva seeks to insulate authors from such emotive responses by cloaking authors in anonymity. Doing so, however, would undercut responsible authorship. Proposals like those of Giubilini and Minerva have a propensity to affect policy and practice.29 Consequently those whose lives are likely to be affected have a right to address the authors of these proposals directly, not only to critique them, but also to ask profoundly or profanely, tu quoque, ‘How would you feel if this was being proposed for you?’ Robert Baker is William D. Williams Professor of Philosophy at Union College and Founding Director & Professor of Bioethics, Union Graduate College-Icahn Mount Sinai Bioethics Program. 28
Ibid: 45–46. R. Baker & L. McCullough. Discourses of Philosophy and Medical Ethics. In Baker R., McCullough L., editors. The Cambridge World History of Medical Ethics. New York: Cambridge University Press; 2009. 281–312. 29
© 2014 John Wiley & Sons Ltd
Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 28 Number 4 2014 pp 166–169
doi:10.1111/bioe.12093
AGAINST ANONYMITY ROBERT BAKER
Keywords abortion, after-birth abortion, anonymous authorship, disability, eugenics, infanticide, Internet, Nazi medicine, publication ethics
ABSTRACT In ‘New Threats to Academic Freedom’1 Francesca Minerva argues that anonymity for the authors of controversial articles is a prerequisite for academic freedom in the Internet age. This argument draws its intellectual and emotional power from the author’s account of the reaction to the on-line publication of ‘ After-birth abortion: why should the baby live?’2 – an article that provoked cascades of hostile postings and e-mails. Reflecting on these events, Minerva proposes that publishers should offer the authors of controversial articles the option of publishing their articles anonymously. This response reviews the history of anonymous publication and concludes that its reintroduction in the Internet era would recreate problems similar to those that led print journals to abandon the practice: corruption of scholarly discourse by invective and hate speech, masked conflicts of interest, and a diminution of editorial accountability. It also contends that Minerva misreads the intent of the hostile e-mails provoked by ‘After-birth abortion,’ and that ethicists who publish controversial articles should take responsibility by dialoguing with their critics – even those whose critiques are emotionally charged and hostile.
He that filches from me my good name . . . makes me poor indeed.3
THE ECLIPSE OF ANONYMITY IN PRINT JOURNALS During the Enlightenment, philosophers who feared that their writings could lead to exile, imprisonment or execution published anonymously or pseudonymously. Today however, intellectuals in liberal democratic societies enjoy freedom of speech and, in the absence of such threats, official ethics statements require medical and scientific journals to properly identify the authors of the
1
F. Minerva. New Threats to Academic Freedom. Bioethics 2013; DOI: 10.1111/bioe.12066. 2 A. Giubilini & F. Minerva. After-birth Abortion. Why Should the Baby Live? J Med Ethics 2013; 39: 261–263. 3 Shakespeare, W. circa 1603. Othello Act 3, sc 3, lines 155–161.
articles they publish.4 Arguing that in the Internet age authors of controversial articles encounter threats comparable to those faced by their Enlightenment precursors, Minerva proposes a return to the Enlightenment practice of permitting anonymous publication of controversial articles. In assessing proposals to return to past practices, it is prudent to recall the advice of Spanish-American philosopher George Santayana (1863–1952), who famously observed, ‘Progress, far from consisting in change, depends on retentiveness . . . Those who cannot
4
The International Committee of Medical Journal Editors (ICMJE) ethics principles state that journals must ‘ identify who is responsible for the integrity of the work . . . [as] author, or co-author.’ International Committee of Medical Journal Editors. Ethical Considerations in the Conduct and Reporting of Research: Authorship and Contributorship. http://www.icmje.org/ethical_1author.html [cited 2013 July13]. See also World Association of Medical Editors. Publication Ethics Policies for Medical Journals. http://www.wame.org/resources/publication-ethics -policies-for-medical-journals#authorship. [cited 2013 July 13].
Address for correspondence: Dr Robert Baker, Alden March Bioethics Institute, The Campus, Union College Humanities 020 Schenectady, New York 12308, USA. T: 518-388-6215 F: 518-388-8046. Email: [email protected] Conflict of interest statement: No conflicts declared © 2014 John Wiley & Sons Ltd
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remember the past are condemned to repeat it.’5 In earlier eras, articles dealing with infanticide were published in general medical journals, like the Journal of the American Medical Association (JAMA).6 From its founding by Nathan Smith Davis (1817–1904) in 1883, JAMA’s pages were enlivened by articles on the morality of animal and human experimentation, the Hippocratic Oath, researcher integrity, self-expurgation of medical texts, euthanasia and the value of human life and at the other end of the lifecycle, the ethics of birth control, craniotomy/partial birth abortion – and infanticide.7 Many of these were anonymous or pseudonymous publications. Yet in 1895 JAMA’s editor announced, ‘anonymous publications . . . will not . . . be published’.8 Following Santayana’s advice, prudence dictates that before we reintroduce anonymous publication, we reflect on what led JAMA (and other scholarly journals) to prohibit the practice. The chain of events leading up to JAMA’s prohibition on anonymous publications began in 1894 when JAMA published a letter from Professor Solomon Solis-Cohen (1857–1948), ‘As to “Nostrum” Advertisements in the Journal’.9 Cohen’s letter charged that JAMA had violated the AMA’s Code of Medical Ethics by advertising secret nostrums, i.e. medications with undisclosed ingredients. Such advertisements were considered unethical because if such medicines were ‘of real efficacy . . . concealment regarding [ingredients] is inconsistent with beneficence . . . and, if mystery alone give it value . . . such [advertisements] impl[y] . . . fraudulent avarice.’10 Cohen’s letter provoked a cascade of responses published under such pseudonyms as ‘A Conservative Voice’, ‘Integrity’, and many others. A letter by ‘Medicus’ castigated ‘these people, the ‘Hebraics’, ‘the Hebrew children 5
G. Santayana. The Life of Reason or the Phases of Human Progress. Volume I: Reason in Common Sense. New York: Charles Scribner and Sons; 1905. www.gutenberg.org/files/15000/15000-h/vol1.html #CHAPTER_XII_FLUX_AND_CONSTANCY_IN_HUMAN _NATURE. [cited 2013 July 20] 6 Specialized medical ethics journals are a relatively recent phenomenon. The earliest known journal specializing in medical ethics is the German journal, Ethik (1922–1938). See A. Frewer. Debates on Human Experimentation in Weimar and Early Nazi Germany As Reflected in the Journal ‘Ethik’ (1922–1938) and its Context. In: Roelcke V., Maio G., editors. Twentieth Century Ethics of Human Subjects Research: Historical Perspectives on Values, Practices, and Regulations. Stuttgart: Franz Steiner Verlag; 2004. pp. 138–150. 7 R. Baker. Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution. New York: Oxford University Press; 2013. pp. 227–228. 8 The Editors. Anonymous Publications. JAMA 1895: 24(4): 141. 9 S. Solis-Cohen. As to ‘Nostrum’ Advertisements in the Journal. JAMA 1894; 22(3): 95–96. 10 AMA. 1847. ‘Code of Medical Ethics,’ Chapter II, Article I, Section 4, in Baker R, Caplan A, Emanuel L, Latham S, editors, The American Medical Ethics Revolution: Baltimore: The Johns Hopkins University Press; 1999. Appendix C, p. 328.
of Philadelphia’,11 for daring to challenge the integrity of JAMA’s founding editor, Davis, the ‘father of the AMA’. In response, a signed letter from ‘A member of the [AMA] and a Jew . . . [protested] dragging questions of race and religion into the discussion.’12 Alarmed by this correspondence the AMA’s governing board investigated. They found JAMA guilty of advertising secret nostrums and discovered that Davis himself had authored pseudonymous correspondence defending his editorship. Consequently, they requested Davis’s resignation and appointed John B. Hamilton (1847–1898), JAMA’s second editor (1893–1898). Hamilton banned anonymous publications and implemented the policy of ‘accept[ing] no advertisements of medicinal preparations [without] a formula containing the official or chemical name of each composing ingredient.’13 The JAMA incident highlights some problematic features of anonymous publication. It shows that hate speech is not a new phenomenon that arose with the Internet. It is a natural concomitant of anonymous or pseudonymous communication irrespective of whether the medium is print, on-line social networking, or the twitterverse. Whatever the medium of communication, anonymity severs social and personal accountability for speech acts. Cloaked by anonymity users feel free to pen, type or tweet their anti-Semitic (ageist, anti-intellectual, anti-Muslim, homophobic, racist, sexist) hate speech hidden behind their hashtags or pseudonyms.14 Since their anonymous words do not endanger their standing in any community of peers, authors feel free to vent slurs and to engage in character assassination. In the JAMA letters truth was slandered because its authors were ‘Hebraics’. The JAMA case also underscores anonymity’s propensity to corrode editorial responsibility. This was the only time that Davis’s JAMA published anti-Semitic statements. He probably permitted publication of the slurs because it served his self-interest and may have believed that any blame attaching to their publication would fall on their pseudonymous author, ‘Medicus’, rather than on him as editor. Pseudonyms also allowed Davis to praise himself without alerting his readership to the conflict of interest. By severing authorship from identity anonymity encourages those with undetectable interests to make false or misleading claims in ways that made it difficult, if not impossible, to distinguish truth from untruth. Mindful of the potential abuses of anonymity Minerva proposes several safeguards: (1) Editorial review to 11
Medicus. The Advertising Question. JAMA 1894; 22(12): 438–439. G.J. Kaumheimer. He Very Properly Calls Medicus to Order. JAMA 1894; 22(13): 480. 13 JAMA. Report of the Board of Trustees. JAMA 1895; 24(20): 760. 14 S. Sengupta. Twitter Yields to Pressure in Hate Case in France. New York Times. 2013 July 31; B1, B4. 12
© 2014 John Wiley & Sons Ltd
Against Anonymity prevent publication of ‘offensive, irrational, racist, or sexist papers’;15 (2) revealing authors’ real names to journal editors, who, in turn would (3) reveal authors’ names to their supervisors (e.g. Department Chairs). Would these suffice to constrain the abuses that led to the abandonment of anonymity? Davis and other 19thcentury editors published ad-hominem-filled pseudonymous articles, comments and letters to add zest to their pages in the hope of increasing readership and advertising revenues. The search for advertising revenue also tempted Davis to flaunt the rules prohibiting advertising secret nostrums. It would be naïve to presume that 21st century editors would be more scrupulous than their 19th century predecessors, or better able to resist pressures for readership, revenues, and high impact factors – especially since dozens of editors have been caught cheating.16 Moreover, the most scrupulous of editors would have difficulty detecting conflicts of interest if articles can be published anonymously. Even without the cloak of anonymity unacknowledged conflicts of interest have become commonplace enough to bring ‘the credibility of clinical medicine to an unprecedented crisis.’17 Anonymity would compound the problem because authors with conflicting interests often fail to disclose them. Their conflicts are typically exposed through postpublication detective work by watchdog scholars who match authors’ names with those listed by companies as consultants, directors, employees, patent holders, stockholders, or as recipients of honoraria, grants and subsidized travel. In one particularly outrageous case, a journal editor was forced to resign because he failed to disclose a conflicting financial interest in a medical device lauded in a ghostwritten article, for which he claimed lead authorship, that was published in his own journal!18 Had this article19 been published anonymously or pseudonymously, none of these conflicts of interest would have been detectable. Reintroducing anonymity into medical, scholarly or scientific publications would mask conflicts of interest, making them virtually undetectable and consequently even more commonplace. As Santayana reminds us, we need not relive the past to be mindful of its lessons.
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EXAGGERATING THE DANGERS OF PUBLICITY Minerva reports that the on-line publication of ‘Afterbirth abortion: why should the baby live?’ precipitated a cascade of Internet protests. Many protests were thoughtful critiques by physicians, parents of children with disability, and people with memories of the Nazi infanticide program Aktion T-4 (1939–1941). Others, like the following, appear more threatening: ‘your parents should have aborted you after-birth, the world would have been a much better place’; ‘if it is OK to kill babies, then it must be OK to kill academics’; ‘For your views on newborns not being people, you need to be eliminated along with your entire family. You are not human therefore you do not have a right to live’; ‘You two are perfect examples of people who should have been aborted at birth. You are advocating cold-blooded murder. Watch your backs assholes. Time for your termination.’20 Receiving such e-mails was undoubtedly traumatic. Yet analyzed in retrospect, these messages have a format familiar to any logician: one so ancient and so common that it has its own Latin sobriquet, tu quoque, literally, ‘you too!’ or ‘ the same to you!’ Read this way these so-called threats seem designed to make those who asked ‘why should the baby live?’ feel the experience of having someone ask of them, ‘why should you live?’ To be sure, read as refutation, the logic of tu quoque is fallacious. Yet what respondents, perhaps people with disability or those who love and care for them, seem to be attempting to communicate is what it feels like to have one’s very right to have been born questioned. Read this way, these e-mails are neither a logical assault on Giubilini and Minerva’s analysis nor an actual threat of physical harm; they seek to communicate the emotive impact of having someone question, ‘why should you have the right to live?’ In point of fact, no physical threat to Minerva and her colleague ever emerged, and philosophers who hold similar positions, most notably Peter Singer, have not been physically accosted.
TAKING RESPONSIBILITY FOR CONTROVERSIAL PROPOSALS 15
F. Minerva. op. cit. note 1. Nature Blogs. June 19, 2013. New Record: 66 Journals Banned for Boosting Impact Factor With Self-Citations. Available from: http:// blogs.nature.com/news/2013/06/new-record-66-journals-banned-for -boosting-impact-factor-with-self-citations.html [cited 20013 July 16]. 17 G.A. Fava. Financial conflicts of interest in psychiatry. World Psychiatry 2007; 6(1): 19–24. 18 D. Armstrong. Medical journal editor to quit in wake of disclosure oversight. Wall Street Journal 2006. August 25. B1. 19 C.B. Nemeroff, H.S. Mayberg, S.E. Krahl, et al. VNS Therapy in Treatment-Resistant Depression. Neuropsychopharmacology 2006: 31: 1345–1355. 16
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Ethics is not a matter of clever arguments paraded before one’s peers for their approbation. From Socrates to Singer, ethics has always been that branch of philosophy that addresses the proper way for lives to be lived, and – more to the point of Giubilini and Minerva’s paper – for deaths to be died. Many proposals advanced by moral philosophers later became matters of public policy – including policies implementing the notion that people 20
F. Minerva. op. cit. note 1, pp. 2–3.
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with disability do not have lives worthy of being lived. The roots of this policy can be traced to Plato’s Republic where it is argued that ‘If a man has a sickly constitution . . . his life was worth nothing to himself or anyone else; medicine was not meant for such people and they should not be treated, though they be richer than Midas’21 Friedrich Nietzsche (1844–1900) updated Plato’s analysis proclaiming that ‘A new responsibility should be created, that of the doctor – the responsibility of ruthlessly suppressing and eliminating degenerate life, in all cases in which the highest interests of life itself, of ascending life, demand such a course.’22 These sentiments were put before a medical audience in a Die Freigabe der Vernichtung lebensunwerten Lebens (Permitting the Destruction of Lives Unworthy of Being Lived) a book published in 1920 by a law professor, Karl Binding, (1841–1920) and a medical colleague, the psychiatrist Alfred Hoche (1865–1943).23 Like Giubilini and Minerva,24 Binding and Hoche wanted to offer parents of children born with Down’s syndrome – as they put it in the language of the era, ‘incurable idiots’ – the option of having their newborns killed because idiots are ‘just a caricature of the true man and arouse dismay in everyone.’25 They too recommended immediate infanticide, arguing, ‘It would be best to apply for death with dignity as soon as incurable idiocy has been confirmed.’26 Although initially ‘merely’ academic arguments, Binding and Hoche’s proposals became public policy when the National Socialist (Nazi) party came to power in the 1930s. Physicians like Herman Pfannmüller (1886– 1961), an admirer of Hoche (whom he had met personally), implemented these policies in the Eglfinger-Haar psychiatric hospital.27 As hospital director Pfannmüller gave tours of his facility to students. A psychology student wrote this account of how infanticide was practiced. I took part in a conducted tour . . . The asylum director . . . Pfannmüller, led us into a children’s ward. . . . [He] explained . . . ‘As a National Socialist, these 21 Plato. Circa 380 BCE. Republic, translated by Francis M. Cornford. New York: Oxford University Press. Book III, sec. 408, p. 98. 22 F. Nietzsche. [1888] The Twighlight of the Idols: Or, How to Philosophise with the Hammer. In Levy O., editor. The Complete Works of Friedrich Nietzsche: First Complete and Authorised English Translation. Ludovici AM, translator. New York NY: Russell & Russell. 1964. Vol. 16, sec. 36, p. 8. 23 K. Binding & A. Hoche. [1920], Die Freigabe der Vernichtung lebensunwerten Lebens. Sassone R. translator. Santa Ana (CA): Robert Sassone. 1975. 24 A. Giubilini & F. Minerva. After-birth Abortion. Why Should the Baby Live? J Med Ethics 2013; 39: 262. 25 Binding & Hoche. op. cit. note 23, pp. 20–21. 26 Ibid: 21. 27 M. Burleigh. Ethics and Extermination: Reflections on Nazi Genocide. Cambridge (UK) and New York: Cambridge University Press; 1997. 103.
creatures . . . naturally only represent to me a burden upon the healthy body of our nation. We don’t kill (he may have used a more circumlocutory expression . . .) with poison, injections . . . No: as you see, our method is simpler and even more natural [starvation].’ With these words, and assisted by a nurse . . . he pulled one of the children out of the bed. As he displayed the child around like a dead hare, he pointed out, with a knowing look and a cynical grin, ‘This one will last another two or three days.’ The image of this fat, grinning man, with the whimpering skeleton in his fleshy hand is still clear before my eyes.28 Neither philosophy nor society has treated people with disabilities kindly in the past, so it is understandable that these people, and those who care about them, should be viscerally apprehensive about proposals to once again offer the parents of Down’s infants the right to request infanticide. Those potentially affected by the policy have a right to confront Giubilini and Minerva with their fears and to ask why this proposal is not just another manifestation of philosophers’ historical prejudice against people with disability. They have a right to interrogate the authors about why they should expect the proposed infanticide to be implemented more humanely than the German initiative of the 1930s. They also have a right to ask the more fundamental question: why should infants with Down’s and other disabilities be regarded as having lives unworthy of being lived? Finally, they have a right to invoke the Golden Rule and ask that Giubilini and Minerva share for a moment what it feels like to have one’s very right to exist questioned. People can pose these questions – and vent their anger and anxiety – directly to Giubilini and Minerva because, as required by the ethical principles of contemporary journals, authors are required to affix their names to their publications. Minerva seeks to insulate authors from such emotive responses by cloaking authors in anonymity. Doing so, however, would undercut responsible authorship. Proposals like those of Giubilini and Minerva have a propensity to affect policy and practice.29 Consequently those whose lives are likely to be affected have a right to address the authors of these proposals directly, not only to critique them, but also to ask profoundly or profanely, tu quoque, ‘How would you feel if this was being proposed for you?’ Robert Baker is William D. Williams Professor of Philosophy at Union College and Founding Director & Professor of Bioethics, Union Graduate College-Icahn Mount Sinai Bioethics Program. 28
Ibid: 45–46. R. Baker & L. McCullough. Discourses of Philosophy and Medical Ethics. In Baker R., McCullough L., editors. The Cambridge World History of Medical Ethics. New York: Cambridge University Press; 2009. 281–312. 29
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