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The Unique Harm of Bramhall’s Liver Branding

photograph of surgeon in operating room putting on gloves

In 2013, Simon Bramhall, a surgeon at the U.K.’s Queen Elizabeth Hospital Birmingham, performed a life-saving liver transplant on Patient A. Despite the surgery being a success, a few days later, the liver started failing. So, roughly a week after receiving their first liver, Patient A was back in the operating room for their second transplant, this time under the care of another surgeon. But, when this second surgeon opened up Patient A, they found something remarkable. Burned into the liver’s surface – the one that Simon Bramhall had implanted only a few days before – were two four-centimeter letters: “SB.”

Eventually, after some delay, equivocation, and the sharing of photos, it emerged that, yes, during the first operation, Bramhall had used an argon beam – used for cauterization – to sign the liver after he had transplanted it into Patient A. According to a nurse who had been present at the first surgery, when asked what he was doing, Bramhall said, “I do this.” He has since said he doesn’t recall saying this or that he must have been referencing something else if he did.

Bramhall’s rebuttal, however, is suspect. Not long after news of Bramhall’s actions emerged, a consultant anesthetist came forward and claimed that Bramhall signed his initials on another patient’s liver during a 2013 surgery, known as Patient B. Bramhall claims not to recall doing this.

Despite these revelations, Bramhall didn’t lose his job, at least not immediately. He left Queen Elizabeth Hospital Birmingham of his own accord, feeling that he was no longer welcome there, and continued to practice surgery at another institute until 2020; this is despite his 2017 admission of two counts of assault by beating concerning the liver brandings. Eventually, in 2022, the General Medical Council struck him off the medical register, arguing that his actions had undermined public trust in the medical profession.

Now, this case raises a whole host of questions, from the practical: Why did Bramhall feel the need to do this and has he done this to anyone else? to the ethical and legal: Why didn’t his colleagues immediately raise the alarm and why did it take so long for him to be charged and struck off once they did?

What I want to focus on here is not that he marked the liver unnecessarily but that he did so with a particular vision in mind. He didn’t do a squiggle, a circle, a smiley face, or something meaningless, but he used the argon beam to burn his initials into Patient A’s liver. Does this make a difference? Is it, in some sense, more harmful than if he had done another shape? Or some random letters?

First, it must be noted that the argon beam is commonly used during operation to stop bleeding, so its presence is not unusual. Also, the mark it makes is very shallow, with the beam only penetrating micrometers into the tissue. So, the amount of damage is limited. Finally, tissue can be used as a medium to test the beam’s effectiveness, meaning that the fact that the liver wasn’t pristine when Bramhall closed up Patient A isn’t an intrinsic concern.

This latter point is something which has been raised in Bramhall’s defense with Barbara Moss, a patient of Bramhall and now his co-author (they write thrillers together), arguing that:

He’s got to test the laser on the liver before he can use it – it’s a routine process. If I’m trying out a pen, I might as well just put my initial, because I can do that very quickly. The fact that he did it in a particular shape makes no difference.  

This argument seems slightly odd given that, as another surgeon has noted, such tests normally consist of a couple of dots or a small wiggle, which happens before bleeding occurs, not after as, obviously, you’d test the laser before you have need of it. However, Moss’s argument got me thinking: does the shape matter?

One could make a case for the negative. Whether it’s someone’s initials, a circle, or a couple of dots, the damage done to the liver itself is minimal at most. Any mark is confined to the organ’s surface and doesn’t impact functioning. Indeed, if it hadn’t been for Patient A’s replacement liver failing, the liver may have never been seen again, and they would have never known about the mark’s existence. So, from a rather restrictive point of view, if one is concerned with the potential for physical harm that Bramhall’s actions might have caused, then it seems that it doesn’t matter what shape he etched into the organ as any shape would have the same impact – nothing at all.

However, this would indeed be a very limited conceptualization of harm. It is now common for us to understand harm not only in a purely physical sense (getting hit with a hammer, being run over by a car) but also in a mental and cognitive sense (seeing someone get hit with a hammer, accidentally running someone over with a car). This understanding of harm emerged and became a central factor in Bramhall’s trial as, after seeing images of their branded organ, Patient A began experiencing symptoms of PTSD. This instigating factor led the Criminal Prosecution Service to charge Bramhall in the first place. It was not what he had done to the liver but what his actions had done to Patient A that mattered. So, with a broader understanding of harm, it can become easy to see how Bramhall’s actions might be considered uniquely wrong.

Yet, I am unconvinced that this gets to the nub of the issue. The idea of someone branding their initials into your internal organs is unquestionably horrifying, and I do not doubt that this could lead to PTSD, but I don’t think this fully captures the uniqueness of Bramhall’s offense. The fact that, above all other options, he chose to brand his initials into Patient A means there is something horrifyingly unique, even personable, in his actions.

To illustrate this, imagine that, to relieve the stress, two surgeons play a game of noughts and crosses (aka tic-tac-toe) on a patient’s liver, branding the game into the organ with an argon beam much like Bramhall did his initials. It’s not unreasonable to think that, upon finding out that their innards would forever carry the remnants of such a game, they would experience similar distress and symptoms as Patient A (for context, Bramhall says he knows someone who has done this very thing). The game’s presence would represent the reckless attitude such surgeons would have towards their patients and their jobs. Indeed, it would have to be someone holding an awfully cavalier attitude toward their profession to even consider such a thing. Yet, this lacks a certain degree at the core of the Bramhall case: the unabashed egotistical arrogance.

This is not to say that a surgeon who played a child’s game in the tissue of a patient’s organ wouldn’t have this critical flaw – I’m almost certain they would. Nevertheless, the imprinting of the game itself would be separate, to some degree, from the person playing it. It could have been anyone doing that. Bramhall’s initials, however, are an entirely different story. They are tied to him in a very personable way. And, yes, anyone could have put the letters SB into the patient, but someone with those initials did. If the liver hadn’t been rejected, Patient A would have spent the rest of their life walking around with a mark that intimately tied them to Bramhall; not an ambiguous game of noughts and crosses, but one of the very things that Bramhall uses to self-identify.

To emphasize this point further, imagine he branded his entire name into Patient A’s liver. The more personable and unique the mark signifying Bramhall’s actions, the worse it is (at least, that’s how it seems to me).

I suspect we will never really know why Bramhall did what he did (at least twice). He’s claimed that extreme stress led him to make the markings, but I find this doubtful. He has said that he thinks the backlash and subsequent punishment he’s received was over the top and that the GMC sought to make an example out of him. To use him as a way of warning other reckless medical professionals. This might be true. But, given the extreme power doctors hold over us – especially surgeons, who violate our bodies with our permission and are responsible for us when we are at our most vulnerable – might the example be worth making? Is it not better to make an example out of someone who did something terrible, than slap them on the wrists and potentially encourage such behavior in others?

It costs millions of pounds to train a surgeon of Bramhall’s caliber, and if nothing else, he was reportedly a technically sound surgeon. But if the cost of protecting the medical profession is his removal from it, the subsequent loss of his expertise, and all the time spent cultivating his skill, then it strikes me as a price worth paying.

I want to have faith that those who care for me will do just that, and this is fundamentally compromised if I must worry about those professionals using my flesh as an Etch A Sketch when I’m under the knife.

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Bloodstained Men and Circumcision Protest

photograph of Bloodstained Men protestor

Images of men dressed in pure white with a vibrant mark of blood around their crotch have littered front pages in past weeks. The Bloodstained Men are protesting the practice of male circumcision – removal of the foreskin from the penis. This surgical practice, although less common in many European countries, is widely accepted and largely performed for social, aesthetic, or religious reasons. The World Health Organization estimated that somewhere between 76-92% of people with penises are circumcised in the United States.

While the practice of circumcision has a long history and has been endorsed by many Western doctors, does this make it ethical?

The Bloodstained Men, and other anti-circumcision activists, would argue that it does not: circumcision is a violation of genital autonomy and is a purely aesthetic surgery that only works to detract sexual pleasure and is performed without the consent of the child. Others, meanwhile, support circumcision, citing its possible medical benefits and ability to increase social, romantic, and sexual acceptance. How can we reconcile these two conflicting views?

Consulting our ethical convictions regarding female genital mutilation (FGM) may bring some clarity on this issue. The practice of altering the female genitalia – either by removing the clitoris, parts of the labia, or closing the vagina – has long been considered a morally impermissible intervention in Western society, and on valid grounds. Still, it must be determined whether our condemnation of FGM should inform a similar objection over male circumcision.

Most significantly, many cite FGM as problematic in its attempt to limit sexual autonomy, maintain ideals of purity, and uphold societal expectations around sex and femininity. The intent behind the procedure, then, may be the key to our acceptance of circumcision. Circumcision has long been a religious custom in the Muslim and Jewish faiths, but gained popularity in the United States for different reasons. Most integral to its growth in practice was a belief that circumcision could cure physical and mental health issues, provide an indication of wealth and social status, and prevent masturbation. Although these reasons may have led to its popularity, they have long been proven incorrect, and now the intent behind circumcision is typically associated with ideas of cleanliness, health, or social acceptance (with a focus on genital uniformity with one’s father or peers).

Are these justifications more morally permissible than those for FGM? Like FGM, there is a historic desire to suppress sexual autonomy paired with a current desire to gain social acceptance, and in both cultures the procedure is viewed as an accepted social custom done to benefit a child in some way. It is possible, then, that an evaluation of impact, rather than intent, will prove more useful for our discussion.

FGM is denounced by its lack of medical benefits, and more broadly by its medical risks, with severe forms causing difficulties birthing, infections, and psychological trauma. Does the moral difference, then, lie in the benefits of circumcision? Possible benefits include a decreased risk for HIV or urinary tract infections, easier hygiene, and social acceptance, with the belief that uncircumcised persons will face social persecution, bullying, or romantic/sexual ostracization. Do these reasons warrant genital surgery?

Research has found that these benefits are much more slight than once believed, especially when making a consideration for policy within the United States where HIV rates are quite low and may be better addressed with proper access to condoms, the drug PREP, or comprehensive sex education. In addition, circumcision, like FGM, reduces sexual pleasure; the foreskin, much like the clitoris, houses a majority of the nerve endings in the penis, so its removal reduces sensation. It is widely known, now, that circumcision is not a medical necessity, yet the practice remains a social custom. Social reasons for circumcision may be convincing, but are also similar to those that inform FGM.

Is social normativity enough to warrant the removal or change to a perfectly healthy organ, especially if it reduces pleasure? Even if there are some medical benefits, is this a decision that should be made for a child?

This discussion really comes down to a conversation about informed consent. For surgeries under the age of 18, parents are given the authority to provide consent for their children; this sacrifice of rights is necessary to serve the medical interests of the child. In the case of circumcision, though, there is absolutely no medical necessity; it is a surgery that involves the removal of a natural part of a healthy organ, an organ that increases pleasure later in life. Should parents be able to consent to surgeries that are not medically necessary?

The value we place on bodily autonomy suggests that this is not a decision that should be made by parents, especially as it is often motivated by a desire to “fit in.” Personal autonomy and the right to control one’s own body, especially such an intimate organ, should supersede social and cultural norms. If we do decide respecting cultural customs and desires for social acceptance are more important than our ethical understanding that people should have the right to control their bodies, why do we denounce FGM?

When evaluating the two procedures, it seems as though circumcision shares many of the qualities that make FGM unethical, so shouldn’t we deem circumcision unethical as well? If we decide to continue the practice of circumcision, where must we fall on the issue of FGM? In order to come to a conclusion about circumcision, we must reckon with our moral attitudes towards FGM and determine whether our values of consent and pleasure are more important than our need to conform to social and cultural customs.

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Examining Medical Intervention and Gender Confirmation

Photograph of an exam room in a doctor's office

There has never been a time when a society was made up of people that “naturally” fit into any sort of gender binary. People have lived lives across a spectrum of societally constructed gender roles since humans lived in cultures that developed gender roles in the first place. In contemporary contexts, we have the ability to support people living according to their identities when they differ from the gender assigned at birth in new ways thanks to developments in medicine. However, there is debate about how to understand this support in terms of the role of medical intervention.

If we define appropriate medical intervention in terms of “treatment”, we are understanding medicine as fixing something that is wrong, balancing potential risk of further harm against present suffering. The appropriate role of medicine is a contentious issue, especially in societies where the costs of interventions are prohibitive when deemed superfluous in any way. A central distinction in this discussion is between treatment and enhancement. Treatment covers medical interventions aimed at making patients healthy and well, and enhancement refers to medical intervention that does not address deviation from health but rather makes the patient better than well. Insurance companies can try to rely on this distinction to determine what interventions to cover the cost of and to what extent, for treatments may delineate interventions that are “medically necessary” while enhancements typically do not.  

Cosmetic surgeries are thus deemed enhancements because there is nothing medically wrong with the patient and the intervention is taking them, arguably, to a state of “better than well”. The distinction isn’t a perfect one, as there are medical interventions that are intuitively appropriate but that don’t presume illness or deviation from health – such as contraception and obstetrics.

For individuals seeking medical intervention to alter their gender presentation, this distinction is important. Typically, in order to consider intervention necessary, a suitable illness or deviation from health needs to be identified and an improvement that will result from the intervention. For instance, if you have a herniated disc and seek surgery to improve movement and alleviate pain, this fits the common conception of medically justified intervention. Elective surgeries, such as cosmetic rhinoplasty, are not seen as having a medical justification and are pursued based on preference or whim, say, and insurance companies do not cover such procedures on these grounds.

While the World Professional Association for Transgender Health (WPATH) only requires informed consent before medical support for gender affirmation procedures including hormone therapies and surgeries, the reality in the US is more restrictive. For instance, in April of 2018, the AMA Journal of Ethics argued against a prohibition in place excluding medically necessary gender affirming surgeries for veterans.

In order to qualify for surgery, Aetna requires letters from medical professionals, documentation of persistent gender dysphoria, and, depending on the treatment, the individual must have lived as their identified gender for a year with hormone therapy. In order to obtain letters from medical professionals, individuals must convince these professionals of the genuineness of their identity.[1] This has historically lead to “gate-keeping” and pressure on individuals seeking gender confirmation procedures to fit a particular narrative of gender identity and expression that medical professionals will grant warrants medical intervention: a narrative that moves medical intervention into a category with broken limbs and cancer rather than with elective interventions like liposuction and cosmetic adjustments.

Whether you are cisgender, non-binary, or trans*, consider your experience in elementary school: there is no way all of your traits, preferences, characteristics, behaviors, etc. fit neatly into a category that society has determined is gendered according to whatever gender you were assigned at birth. This is relevant, because for individuals who identify as transgender, or individuals who seek to identify as a gender that is different from that assigned at birth (be they genderqueer, non-binary, etc.), there is frequently a heavy narrative burden placed on them to justify this identity in order to receive treatment.

There is not a univocal experience for individuals who identify differently from the gender they were assigned at birth. This makes creating objective or universal standards for when gender confirmation procedures are “medically necessary” or “treatment v enhancement/elective” particularly difficult. As Andrea Long Chu articulates for The New York Times, the experience of dysphoria and the stakes of getting confirmation surgery are complicated in a way that perhaps bears more nuanced deliberation. In, “My New Vagina Won’t Make Me Happy…and it Shouldn’t Have To”, she puts pressure on the utility and justice of applying the standard cost/benefit analysis to medical intervention for gender dysphoria. As she points out, when physicians can rule out intervention considering their assessment of the risks of the procedure and the possibility that the individual will continue to experience pain and discomfort of dysphoria, it can become more difficult to justify medical intervention.  

The appropriate role of medical intervention is a politicized issue due both to the power of health insurance companies who have strong incentive to withhold coverage for intervention as well as the (too often radically) slow advance of our cultural understanding of the lived reality of members of society.

 

[[1]]  According to the AMSA, “There is much controversy surrounding transgender identity and the field of mental health. At the moment, transgender people often receive medical care under the diagnosis of ‘Gender Dysphoria’ found in the Diagnostic and Statistical Manual of Mental Disorders V, while in the past being diagnosed with ‘Gender Identity Disorder,’ now considered an outdated and incorrect term. Many people believe that transgender identity is NOT a mental disorder and should be a medical, rather than psychiatric, diagnosis. Some physicians use the diagnosis, ‘endocrine disorder otherwise unspecified,’ to avoid using a psychiatric diagnosis altogether.”

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Opposition vs. Prohibition: Should Iceland Ban Circumcision?

a Rembrandt drawing of a ritual circumcision

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

Iceland will soon vote on a bill that would criminalize infant circumcision. While the medical community is supportive, some Icelanders are concerned. It’s not so much the typical Icelandic parent who wants to retain the right to make this decision, but Jewish and Muslim leaders are concerned that a ban would intrude on core religious practices. Circumcising newborn boys is a religious commandment for both religions.

It’s a little surprising that the Icelandic physicians are united against circumcision. In 2012 the large and influential American Academy of Pediatrics issued a policy statement stating that circumcision has somewhat more health benefits than harms. There’s the pain of the procedure and the small risk of serious adverse effects, but on the other side of the ledger, a salutary effect on rates of penile cancer, urinary tract infections, and HIV infection. The AAP didn’t conclude that parents should circumcise, but on the other hand, how could it make sense for ethicists and doctors to say the opposite: that they shouldn’t, assuming that the AAP is right and circumcision is a little more beneficial than harmful?

The thought of some critics of the practice is that even if circumcision is more good for boys than bad, it takes more than a small balance of benefits over costs to justify removing a body part. Circumcising a boy isn’t like drawing a little blood or removing an infected appendix. The part in question is perfectly healthy and normal and will later be experienced by a boy as a part of his personal body surface. If he gets to keep it, he will most likely later think his foreskin is his to keep or to remove. Thus, there is a “body integrity” case to be made that parents shouldn’t circumcise their babies, even if the AAP’s cost-benefit analysis is correct.

And so, the Icelandic physicians are right to support a ban? Not so fast! A ban would stop a moral wrong, I am prepared to say (I make the “body integrity” argument in my book The Philosophical Parent), but it would impinge on two important things—a person’s autonomy as a parent and their autonomy when it comes to matters of religion or conscience. Now, parental and religious autonomy aren’t absolute; they don’t trump everything. Uncontroversially, the state doesn’t allow parents to be abusive and doesn’t allow every conceivable religious practice, whatever the associated harms (to self, others, animals, the environment, etc.). But circumcision, however suspect, does seem like the wrong kind of thing for the state to forbid.

The problem with state involvement is the subtlety of the argument against circumcision. It does seem to me that it takes more than a small balance of benefits over costs to justify the removal of a normal, healthy body part destined to be experienced by boys and men as “mine.” But I can’t go further and claim it must seem the same way to any reasonable person, as I can with other harms. If the Church of the Missing Toe wants to chop off the small toe of newborn boys, it will be all to the good and perfectly appropriate if the state forbids it. I think ritual toe amputation is wrong and expect anyone else to see it in the same way. But it’s far more subtle and negotiable whether a procedure can be both slightly beneficial, on balance—as circumcision is, according to the AAP—and also morally wrong. It seems misguided for the state to force everyone to behave in accordance with just one of the multiple positions on circumcision that are open to reasonable, well-informed people.

While I do think there are respect-worthy ways of defending circumcision, it’s difficult to see how the religious defense can be among them. The religious defense has nothing to do with costs and benefits. It has to do with ancient scriptures and the notion that a religion should be “marked in the flesh” (Genesis 17). It’s also about parents demonstrating commitment to a religion by doing something difficult. (The medieval Jewish philosopher Maimonides said the point of circumcision was precisely that it is a “hard, hard thing” for a parent to impose on a child, and so a good test of the parent’s religious commitment.) As much as these ideas seem venerable and familiar just because of their long history, how can they be any more respectable than the doings of the Church of the Missing Toe?

So, should Iceland ban religious circumcisions and protect non-religious circumcisions—of which there are very few? It would be an odd and unusual law that prohibits doing something for one reason but allows it for another. After all, the better reason is “available,” whether it’s motivating the agent or not. And so I conclude: no to the ban. Considering that there are not-obviously-wrong medical reasons for foreskin removal, parents should be able to choose it.

But then there’s the how and the when. There may be reasons to circumcise worthy of respect—that’s at least how some reasonable people see it. But surely there are no reasons to circumcise painfully that are worthy of respect. Muslim parents typically have their boys circumcised in hospitals or doctor’s offices, just like non-religious parents. This is not uncommon among Jews as well. In a medical setting, lidocaine injections are available and commonly used (at least in the US).

But among Jews, the more observant have the procedure performed by a “mohel” in a religious ceremony (a “bris”) in the home. These are highly skilled practitioners who work very quickly using traditional tools and techniques but can also offer all the pain relief that’s available in a doctor’s office—lidocaine ointment or even injections. Orthodox mohels, though, reject intrusions on traditional practice. There is no pain relief during the procedure. A religious practice or not, withholding pain relief during a surgical procedure is impossible to defend. The right way forward seems to me to be regulating the way circumcision is performed, not prohibiting it altogether.

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Respecting the Dead: The Case of Charles Byrne, the Irish Giant

Charles Byrne died quite young, at the age of 22, and quite tall, at approximately seven feet, eight inches. This is still tall for today, but must have been more impressive during Mr. Byrne’s short life in the late 18th century. According to an Ohio State University researcher, the average height for men in Northern Europe in the 17th and 18th centuries was only about five feet, five inches. Today, the average height for men in Northern Ireland has been calculated to be about five feet, 10 inches.

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