How Successful are Pap Smears?

How Successful are Pap Smears? How successful are pap smears in detecting cervical and uterine cancers? George Nicholas Papanicolaou established the Pap smear in the 18th century when he became intrigued by the guinea pigs vaginal smears as he was studying them. He quickly began to start his research on the female reproductive system, most specifically the different cytology slides he could obtain. His stake in the field was his book published in 1943, â€Å"Diagnosis of Uterine Cancer by Vaginal Smear.† It covered topics like physiological changes of a menstrual cycle, the hormones incorporated, and vaginal smears that led to his classifications of disease and malignancies. This jump started the screening for cervical cancer and can attest to a significant decline in cases of cervical cancer. Later, he published another book specific to just distinguishing between healthy and diseased tissue throughout the entire body. These two publications were just two of the four he finished in his life on top of awards and honorary degrees. (Tan, 2015) Papanicolaou was certainly a huge help in the advancement of cytology reporting. Since then, we have been able to learn and understand more about pap smears, cervical cancer and the role pap smears plays in diagnosing them. Although both cancers begin in the same area, the uterus; we can differentiate them by their pathophysiology’s. The question really stands, how successful are pap smears in detecting these cancers? This can be argued on a few bases, but sticking to the facts we can find out how successful they are, how they can be preventive, and what to expect if a woman does find herself diagnosed. Several factors can be taken into account such as the pathogenesis, level of disease, the manifestations, precipitating factors, and several more. Uterine and Cervical cancers both come with their own etiologies, epidemiology’s and prognosis. There are a few different ways to screen for cervical cancer, and this will look directly into the Pap smear procedure. The Pap smear allows for a better look into the cells in the cervix, the opening of the uterus. The test is looking for cancerous and abnormal cells that could lead to cancerous outcomes. In the test an obstetrician- gynecologist will scrape away a portion of cervix cells. The use of a speculum helps the doctor keep the walls of the cervix open to have a clear view and retrieve a good sample. The specimen will then be tested in a controlled laboratory setting where a technician will observe for abnormalities. An official cytology report will be sent to the doctor and then given back to the patient for further counsel if needed. Results will be abnormal or negative (normal). Several sources believe the Pap smear to be very accurate in the screening of cervical cancer. It also is a very preventive measure to take, as long as the patient is compliant with the doctor’s guidelines. By detecting cervical cancer early, treatment can begin to decrease the risk of spreading and growth of the tumors. Pap smears have been estimated to reduce cervical cancer rates and mortality by 80%. (Weber, 2017) In comparison, up to 80% of women diagnosed with invasive cervical cancer have not received a pap smear in the past 5 years. (Stà ¶ppler) CIN or, cervical intraepithelial neoplasia is a precancerous condition of abnormal cell growth on the cervix. Intraepithelial means that the abnormal cells are growing on the surface or the epithelial tissue of the cervix. Neoplasia is referring to the growth of new cells. Signs and symptoms can be obvious but can also resemble several conditions that females could encounter. These symptoms can include abnormal vaginal bleeding, bleeding after sexual intercourse, pelvic pain, discharge, and pain during sexual intercourse. (Stà ¶ppler) It is recommended that women start getting pap smears at the age or 21. This is most important if you are HIV positive or have a weakened immune system. (Weber, 2017)   These screenings should continue from ages 21 to 29 with cytology alone every 3 years. From ages 30-65, women should continue cytology screening every three years and add HPV testing. After 65 no screening is necessary as long past screenings are normal and no high risk is present. (Boardman, 2018) Over the years professionals have found it difficult to all be on the same page about reporting. Some levels of abnormal results can include atypia, mild, moderate, severe dysplasia, and carcinoma in situ. The creation of the Bethesda System has given one reporting system for all health care professionals. In 1988 the National Cancer Institute held a conference for the creation of this system, it was then re-evaluated in 2001. There are four major classifications that make it easier for this universal system to work. â€Å"ASC-US: This abbreviation stands for atypical squamous cells of undetermined significance. LSIL: This abbreviation stands for low-grade squamous intraepithelial lesion. Under the old system of classification, this category was called CIN grade I. HSIL: This abbreviation stands for high-grade squamous intraepithelial lesion. Under the old system of classification, this category was called CIN grade II, CIN grade III, or CIS. ASC-H: This means atypical cells are present and HSIL cannot be excluded.† (Stà ¶ppler) CIN cases are most always caused by infection with oncogenic types of HPV or, Human Papillomavirus.   There are 12 known types of high risk HPV, which are the most prevalent associations with cervical cancer. Cervical cancer results from a genital infection with HPV, a known human carcinogen. Because most HPV infections are transient or, passing in and out of existence in a patient, it causes only temporary changes in cervical cells. (National Cancer Institute, 2014)   About 90% of HPV infections clear on their own within months to years with no sequelae. (Boardman, 2108) This makes it difficult to catch the HPV infection and in turn cervical cancer. Too frequent of screenings might be problematic for several reasons. One being that treating these abnormalities thinking it was HPV but that went away anyways would cause unnecessary stress on the patient. Also, putting strain on the cervix several times in any period of time can weaken the tissue and could ultimately affect the woman’s fertility. Interestingly enough, it can take up to 20 years for a persistent infection with a high risk HPV to become cancerous. (National Cancer Institute, 2014) Low risk HPV infections rarely or almost never cause cervical cancer. (Boardman, 2018) However if lesions are found and not treated, they are more than likely to turn into cervical cancer. (National Cancer Institute, 2014) There are different levels of cervical cancer that decipher the progression on epithelial tissue. CIN grade 1 is low grade neoplasia involves around one-third of the thickness of the epithelium. CIN 2 refers to the abnormal changes in about one to two-thirds of the layer. CIN 3 is the most severe affecting over two-thirds of the epithelium. 5% of HPV infected patients will acquire CIN grade 2 or 3 lesions with three years of infection. Only 20% of CIN 3 lesions progress to invasive cervical cancer within 5 years. Only 40% of CIN 3 lesions progress to invasive cervical cancer within 30 years. Genetics can also play a role in a woman’s development of cervical cancer; genetic connection holds fewer than only 1% of cervical cancers. â€Å"Women who have an affected first degree biological relative have a two fold relative risk of developing a cervical tumor compared with women who have a nonbiologic first degree relative with a cervical tumor.† Some specific genetic factors have been shown to be in association. The tumor necrosis factor is involved with cell apoptosis and a high incidence of cervical cancer. Polymorphisms, another gene dealing with apoptosis, have been linked to the increased rate of HPV and in turn, cervical cancer. Cervical cancer is the leading cause of cancer related morbidity in developing countries, but is very uncommon in the United States. â€Å"Since 2004 rates have decreased by 2.1% per year in women younger than 50 years and by 3.1 per year in women 50 years of age and older. ACS reports 12,170 new cases of cervical cancer would be diagnosed in 2012.† Age related demographics from 2004-2006 were highest among women from 50-79. But cervical cancer is possible to be present in any sexually active woman. In terms of race, cervical cancer rates per 100,000 women in the US from 2005-2009 are across the board: Hispanic 11.8, African American 9.8, American Indian/ Alaska Native 8.1, White 8.0 and Asian/ Pacific Islander 7.2. Internationally, 500,000 women are diagnosed every year. Prognosis for cervical cancer is very good, especially when caught early. 5 year survival rates: Stage 1 greater than 90%, Stage 2 60-80%, Stage 3 approximately 50%, and stage 4 less than 30%. Treatment for this type of cancer is usually dependent on age, fertility or pregnancy plans. One procedure, LEEP, the loop electrosurgical excision procedure carries an electrical current through a wire to remove abnormal tissue. Cryotherapy freezes the abnormal tissue. Laser therapy uses a beam of light to remove or even destroy the cells. Conization can also be used with a knife and laser. (Boardman, 2018) In severe cases removal of the uterus, hysterectomy is sometimes necessary. Radiation, chemotherapy and surgery can sometimes be performed in other extreme cases. However like any screening test there is always a risk of inaccuracy in false negatives and false positives. (National Cancer Institute, 2014) In some cases a pap smear can be faulty and must be reported in an official capacity. Some examples of this could be â€Å"drying artifact’ or â€Å"excessive blood.† The person reading the smear could feel these are factors that affect the reading. Inflammation can also be a problem in a Pap smear reading. Inflammation can be from infection or irritation. (Stà ¶ppler) Uterine cancer is defined as the any invasive neoplasm of the uterine corpus and is the most common pelvic gynecological malignancy in the United States. Uterine cancer can also be labeled endometrial cancer. The most common type of uterine cancer specifically is endometrioid adenocarcinomas. (Chiang, 2017) It is believed to have two forms; type 1 or estrogen dependent and type 2, which is estrogen independent. (Holman 2012) Uterine cancer can start in small areas or â€Å"a diffuse multifocal pattern.† Health care professionals can usually diagnose this type of cancer by the spreading pattern of the tumor. Usually the tumor will grow from the original location. This can tell the doctor how far along the cancer is. Later tumor growth is seen through myometrial invasion and movement towards the cervix. The cancer itself can take four different routes to spread outside the uterus. Direct or local extends beyond the uterus. Lymphatic, referring to exposure to the pelvic, para-aortic, and sometimes the lymph nodes. Hematologic goes further reaching the lungs, liver, and bone metastatically. Lastly, â€Å"peritoneal/ transtubular spread results in intraperitoneal implants. Staging of Uterine cancer, like most cancers, will depend on the amount of growth and spreading of the tumors. Clinical stage 1, which is the most common for patients, is strict to the uterus. Stage 2 involves a large amount of the cervix. Stage 3 â€Å" vaginal extension, adnexal mass, and/or suspicious retroperitoneal lymphadenopathy.† Stage 4 accesses the bowel and bladder and some other metastases around the body. Although pap smears are prominent for cervical cancer findings, it is not as helpful in uterine cancer. According to my findings, there are actually no screening regimens for asymptomatic women. The only screening mentioned is a transvaginal ultrasound, which â€Å"determines the thickness in postmenopausal women.† In the suspicion of abnormalities, biopsies can be taken. Uterine cancer usually includes both surgery and radiotherapy. Other treatments follow a hormone regimen. Other forms can use estrogen replacement therapy and Tamoxifen, which is usually used for breast cancer but can be used on endometrium tissue as well. (Holman 2012) Because of the early representation of the cancer, treatment is usually successful and most do not progress past stage 1. Recurrences can happen and usually do within 3 years of the original diagnoses, which occurs in half of patients. (Holman 2012)(Uterine Cancer) Symptoms of uterine cancer can range from genital discharge, pain, weight loss, and change in bladder or bowel movements. However, postmenopausal bleeding is said to diagnose up to 90% of endometrial cancers. Another clinical finding would be glandular cells from a pap smear on a postmenopausal woman. Some risk factors are obesity, nulliparity, and late menopause. Diabetes and hypertension are also conditions that. Less than 5% of this cancer is actually diagnosed when the woman is asymptomatic can increase the risk of uterine cancer. (Uterine Cancer) Most of the patients diagnosed with uterine cancer are obese, which can affect estrogen levels. (Holman 2012) Over 50,000 cases of uterine cancer are diagnosed each year, leading up to 10,000 deaths per year. In women alone, it leads to 4% of deaths related to cancer. 70-75% of cases are diagnosed at stage 1. In 2009, the survival rate for uterine cancer was 83.1%. (Chiang, 2017) A large majority of the population diagnosed are postmenopausal and ages 50-65, average age of 61. White women have the largest risk of uterine cancer in the United States compared to African American, Asian and Hispanic women. However, African American women have a larger rate of death. Interestingly, those women living in Asia or Africa have a much smaller rate of uterine cancer than Asian and African American women in the United States. Smoking actually has been shown to decrease your chance of endometrial cancer. The use of contraceptive pills has also been said to be a protective measure for women. (Holman 2012) In conclusion, Pap Smears can be resourceful ways of detecting cervical cancer but not at large uterine cancers. Pap smears are a great screening method for obstetrician- gynecologists and their patients to catch and prevent cervical cancer. By detecting cervical cancer early, prognosis is very good and very likely in most cases. These quick diagnoses from pap smears and other sources has made cervical cancer a very uncommon cancer related death for women in the United States. Unfortunately for developing countries, lack of medical resources and research has made discovering cervical cancer difficult and fatal. With the Bethesda System doctors from all over can classify cervical cancer the same way. Pap smears are very accurate, but like any screening procedure there is always the risk of false negatives or false positives. Although Pap smears haven’t been shown totally reliable to detect uterine cancer, there are several other methods to find uterine cancer. The most obvious can be the presence of postmenopausal bleeding in women, which diagnoses most of the cases. Transvaginal ultra sound can be used to determine the state of the woman’s uterine tissue. These and a few others have been said to be more reliable than Pap smears. Counterpart to ruling out Pap smear findings, one source does tell that if glandular cells are present than it might be uterine cancer. Like cervical cancer, uterine cancer is most always found in early stages or stage 1 to be exact. This early detection makes it only 4% of cancer related deaths in women. In doing my research it was clear to me that Pap smears are in fact helpful in detecting cervical cancer but not as much in uterine cancer. I only found one source that mentioned findings from a Pap smear for uterine cancer. This was entirely interesting to me because they are in very similar areas of the woman’s reproductive system. In doing more research, it makes sense that a pap smear rarely diagnoses uterine cancer because it starts inside the uterus. The cervix being much lower and away from the uterus makes it easier to obtain cells and much more reliable. Finding cervical cancer can be much more direct and easily obtained. Getting to the uterus safely is much more difficult. In further research I believe it would be interesting to look further into minimally invasive ways to detect uterine cancer. Another topic is using the any findings from a Pap smear in detecting cervical cancer to relate to prevention of uterine cancer. Lastly, the result of cervical and uterine cancer on future pregnancy or on currently pregnant women. Works Cited â€Å"Uterine Cancer.† Uterine Cancer, www.csh.org.tw/dr.tcj/educartion/f/web/Uterine%20Cancer/index.htm. Boardman, Cecelia. â€Å"Cervical Cancer.† Practice Essentials, Background, Pathophysiology, 26 Jan. 2018, emedicine.medscape.com/article/253513-overview. Chiang, Jing. â€Å"Uterine Cancer.† Background, History of the Procedure, Epidemiology, 6 Dec. 2017, emedicine.medscape.com/article/258148-overviewuterine cancer. Holman , Laura. â€Å"The Epidemiology of Endometrial Cancer.† The Epidemiology of Endometrial Cancer, 2012, www.glowm.com/section_view/heading/The%20Epidemiology%20of%20Endometrial%20Cancer/item/236. Stà ¶ppler, Melissa Conrad. â€Å"Pap Smear: Facts About the Procedure, Pain & Guidelines.†MedicineNet, www.medicinenet.com/pap_smear/article.htm#what_is_a_pap_smear_procedure. Tan, Siang Yong, and Yvonne Tatsumura. â€Å"George Papanicolaou (1883–1962): Discoverer of the Pap Smear.† Singapore Medical Journal, Singapore Medical Association, Oct. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4613936/. Weber, Michael. â€Å"Pap Smear (Pap Test): Reasons, Procedure, & Results.† Healthline, Healthline Media, 13 Mar. 2017, www.healthline.com/health/pap-smear. Should Hate Speech Be Protected as Free Speech? Should Hate Speech Be Protected as Free Speech? Question: Should hate speech be protected by the right of free speech? Introduction Hate speech is a controversial and often misinterpreted term for speech intended to degrade, intimidate, or incite violence or prejudicial action against an individual or a group of individuals based on their race, ethnicity, national origin, religion, sexual orientation, or disability. The term has been taken to cover written as well as oral communication. My starting position is that hate speech is not just one thing; there can be at least four categories of hate speech that we can address. By the end of this essay I hope to have shown sufficiently which, if any, types of hate speech could be protected by the right of free speech. Right to free speech and expression Perhaps in a different era, the two could be seen as distinct, not just by name, but also in context.[1] The right of free speech is a human, political or civil right recognised and appreciated by states and their citizens. It is the right to communicate ones opinions and ideas using ones body and property to anyone who is willing to receive them. It was included in the First Amendment to the United States Constitution.[2] Although freedom of expression is sometimes used within an identical context, it nevertheless includes any act of seeking, receiving and imparting information or ideas, regardless of the medium used. Perhaps the most commonly cited definition is the one given by the United Nations in Art.19 of their UDHR[3] adopted in 1948.[4] Along the same lines, Art.10 of theECHR[5]provides the right to freedom of expression, subject to certain restrictions that are in accordance with law and necessary in a democratic society. It is important to appreciate that the two are largely intertwined, and to be read separately would be of no particular value or help. For the purposes of this essay, I shall regard the two rights as two faces on the same side of a coin. Being part of a group of ideals or social goods even, the right of free speech is not specially protected from other ideals. It has to compete with such rights as right to private life, public security and democratic equality amongst others. There is no precedence that the right for free speech must always prevail. The wording of the First Amendment creates a defence for individuals and a difficulty for the state to regulate similar acts in the United States, as well as a desire to abolish the limitations already imposed by other states.[6] When may the right of free speech be limited? It can easily be imagined that the time, place and way of something being said or written or expressed in any other form is subject to scrutiny as to its appropriateness or inappropriateness respectively that is subsequently reflected in regional legislations. This is not normally objected to. There is another controversial excuse for limiting it and that has to do with its content.[7] A classic example is the prohibition of circulation of Nazi ideas in parts of Europe. This is only to be expected, considering that the UDHR was an attempt to stop the terror witnessed during that war from happening again. It is important however to understand that all is meant by limiting free speech or prohibiting hate speech is not preventing someone from exercising the right, but rather a subsequent punishment. Hate speech The prohibition of hate speech is often anathematised by the advocates for the right of free speech. Following Smolla, it can be generically defined as a speech assault based on race, ethnicity, religion and sexual orientation or preference[8]. Brison attempts to colour it even more by defining it as the speech that vilifies individuals or groups on the same basis and which is face to face vilification or constitutes a group libel[9]. Waldron also believes that hate speech is a form of group defamation[10]. I would think that defamation is more suiting as we have already accepted that hate speech can be manifested both verbally and in writing. When can free speech include hate speech? There is, of course, a number of arguments articulated to justify the importance of including hate speech in the right of free speech, however, lacking space, I will address only the four that I consider of greatest importance. Discovery of truth This argument has two distinct streams of interpretation. According to the first, we come to know more truth if we allow a â€Å"free marketplace of ideas†.[11] Advocates of the second stream claim that allowing discussions promote truth and the interests of the right for free speech more than restrictions, as it allows for comparing and contrasting arguments. Scanlon divides the possible participants in a trade of speech into speaker, audience and bystanders. The value protected by both is truth itself; the speaker has an interest in communicating an opinion; the audience and the bystanders have an interest in evaluating and challenging the said opinion. Central to this argument is the importance of reliable and truthful information since it would be detrimental to knowingly spread opinions based on the unreliable and false information.[12] Note that this argument, like the rest, covers not only the promotion of views and opinions, but also of the communication of facts that do not invite evaluation, such as the names of professors in the University of Essex’s Human Rights department. However, as Schauer points out, this value does not have an a priori precedence over other values.[13] Livelier apprehension and personal development According to J. S. Mill we come to apprehend the truth in a more lively way when we confront people who dispute our beliefs or be confronted by them respectively. â€Å"So essential is this discipline to a real understanding of moral and human subjects that, if opponents to all-important truths do not exist, it is indinspensable to imagine them and supply them with the strongest arguments which the most skilful devil’s advocate can conjure up.†[14] Eric Barendt adds: â€Å"Restrictions on what a man is allowed to say and write, or to hear or read, inhibit the growth of his personality. People will not be able to develop intellectually and spiritually, unless they are free to formulate their beliefs and political attitudes through public discussion, and in response to the criticisms of others.†[15] Greenawalt provides further input: â€Å"By affording people an opportunity to hear and digest competing positions and to explore options in conversations with others, freedom of discussion is thought to promote independent judgment and considerate decision, what might be characterized as autonomy.†[16] The speaker here has an interest in influencing the thought and conduct of others through speech. Furthermore, according to Joseph Raz, the audience has an interest in hearing expressed ideas that may potentially reassure and validate their lifestyles. [17] Democratic participation This has been elaborated best by Cass Sunstein. â€Å"Free speech is to be protected because it facilitates the democratic articulation, aggregation and balancing of interests, and is necessary if the people are to be able to decide for themselves the candidates they think most suitable for public office and the policies that public officials should pursue. This argument links free expression with a ‘commitment to political equality’ and a ‘belief in democratic deliberation’.[18] The argument presupposes that the citizens of a democratic state have the right of free speech and are not negligent in exercising it fully. Democracy translates – loosely – into power of the people and by definition, for the sovereignty of the people to be effective, public opinions should be formulated free of any control or intervention by the government. As such, the speaker’s interest is in providing an opinion on matters of public-political life, while the main audience has an interest in hearing the views of others, and gaining an understanding of political views and preferences. The argument of the right of autonomy In considering a law that prohibits speech, Scanlon writes: â€Å"In order to be protected by such a law a person would†¦ have to concede to the state the right to decide that certain views were false and, once it had so decided, to prevent him from hearing them advocated even he might wish to†[19] He goes on to argue that that since an autonomous person’s reason is sovereign over her own decisions, it is incompatible with her autonomy to be shielded from certain evaluative views, or factual information, even if only to avoid the harm to her of coming to have false beliefs.[20] Greenwald describes such intervention as viewpoint discrimination[21], the very thing that the First Amendment is employed to counter. This corresponds to the right of the audience not to have restrictions on their range of options to choose from in order to formulate an autonomous decision. Let us now examine the kinds of hate speech Targeted vilification Speech directed at specific individuals or small group and with the intention to harm and insult the audience. The speaker consciously selects the wording for its potential to achieve just that.[22] Contrary to what Brison argues, I would argue that it should include non-face-to-face acts, such as cases when is not direct but sufficiently specific.[23] The content itself does not usually qualify adequately as an assertion of fact, expression of an evaluative opinion or even of a valid political preference, since it is usually based on false accusations. Also, the speaker cannot barricade behind the right of autonomy and argue that non-racists are privileged over racists, since having a right of autonomy does not imply having the right to be racist and furthermore clashes with the rights of others to be equally autonomous. It does not encompass the essence of the right, it does not promote the interests that the right seeks to, and it is not what is meant when the right for free speech is interpreted; therefore we can conclude that targeted vilification should not be protected by the right to free speech. Diffuse vilification This is speech directed at a friendly or of mixed sentiments but larger audience than targeted vilification, but nevertheless has the same intentions; to assault individuals based on the group they adhere to, or even the group itself, although they may not be the immediate audience.[24] It usually employs symbols or banners with group specific insults. An example would be the Nazi march in Skokie, a village with a notable population of holocaust survivals and younger Jews. There is an evident intention to cause emotional distress and so, any speech or acts employed and political symbols used could not be excused as such, but as insulting, harmful and intimidating.[25] A fair excuse would be that the allegedly distressed could avoid the march. To what extent this is possible depends on other factors such as prior sufficient advertising and the financial or effort overbearing on the victim’s part. This becomes more apparent when the cost to pay to avoid the distress would mean losing one’s work or avoiding communing areas or even becoming antisocial. This would clearly outweigh the interests of the speaker. Evidently, diffuse vilification promotes free speech interests at a far higher level than targeted vilification; it can take the form of honest – albeit mistaken at times – expression of political and evaluative opinions, precisely because it is not targeted but addressed to a wider audience, which could be proactively met and discussed with an opposing group. Although in its honest and fair form it should be protected by the right of free speech, in my opinion, the government has enough justification to intervene and attempt to control the manner in which it is expressed, and specifically by regulating the prohibition of speech, acts and symbols used for their potential to offend and/or to incite hatred and violence towards another social group. Advocating exclusionary policies Exclusionary policies are those that attempt to exclude certain social groups from equal participation in decision making and full enjoyment of their citizen and political rights. In its extreme form, this could include advocating genocide and ethnic cleansing.[26] The harm caused by a possible adoption and enactment of such policies is not easily outweighed, especially by the arguments for the discovery of truth and of personal development – for obvious reasons. Following the argument for democratic participation, such cases constitute political speech, or part of, which the right of free speech clearly intents to protect. However, allowing the advocating of non-democratic ideals in a democratic society brackets democracy itself. I do not accept that democracy should succumb to such hypocritical arguments. I agree with what Rosenblum terms as militant democracy who attempts to defend itself. [27] Even though state controls on political speech is restricting political equality, a democratic value, it is acceptable to do so when the speaker advocates anti-democratic values, even more so when they are advocating restriction on the political equality of others. From the perspective of the argument for autonomy, it can be argued that people should be allowed to exercise their right as rational sentient beings and consider, reflect upon, and decide for themselves which political speeches to support and which to strike down, without the need to cede their right to do so to any government.[28] However, how empirically justified is, or can, that be? What assures us that citizens will in fact make the right choices? What assures us that citizens will even bring themselves to consider such important and hard matters? Is it not the case that people who do concern themselves with such issues have a prior long time interest in them? How can we be sure that the citizens actually have the necessary mental capacities to fully comprehend the speech and its consequences? A democratic society is successful not only because of alleged equality, but also, because of alleged intellect. Following the notion of militant democracy not only there should be intervention to prohibit anti-democratic elements from exploiting democratic values, but also, there should be intervention to debunk, rebut and expose anti-democratic speeches. If the body of citizens is not able to comprehend it fully, the democratic government, assuming it is able to comprehend it, should step in. In my opinion, although this category is part of the general category of political speech, which the right of free speech intents to protect, it can take the form of anti-democratic speeches and incitement of hatred that may lead to horrid results. To this end, I conclude that this form of speech could be protected under the right of free speech, but the states should reserve their right to intervene in such circumstances that put into danger and jeopardize their very democratic nature. Harmful assertions of fact The notion that free speech should include the right to speak words that insult others, or saying what others do not like hearing, has become part of the modern society’s pop wisdom heirlooms. The combined promotion of the values of truth, democratic participations and autonomy is indispensable, even though we cannot deny that even these assertions can cause grave harm to individuals or groups. A fair objection to protecting these kinds of assertions I have found is what Margalit and Raz call the self-respect and dignity of group members, which are being threatened by such assertions.[29] This links to a reversed interest for personal development on the part of the group members, especially when it comes to social groups identified by ethnicity, where self-dignity and self-respect depends on the dignity and respect assigned to that group by others. However, can it not be said that a Kurdish minority in Turkey or the UK should be exposed for their practice of FGM[30] and to evaluative opinions and scrutiny from the rest of society about it, independently of their other dignity recognition and respect issues? In their extreme form, such factual assertions and evaluative opinions may lead to unjustified hate crimes and violence against innocent members of targeted groups. A classic example is the growing contempt that locals feel against immigrants in most countries. Even if top level surveys manage to prove that economic crisis, health system deterioration or other social harms are caused by immigrants, there is a huge leap from an empirical observation to undemocratic acts of violence. Militant democracy should step in here once again, not only to prohibit and punish such actions, but also, I would argue, to better regulate the matters revealed by such surveys.[31] Despite all these, harmful assertions of fact can be seen as promoting the interests embraced by the right of free speech. Even with harmful – but not extreme – assertions, an available remedy would be counter speech instead of restriction. This is possible because they are not mere vilification, but truthful and empirical assertions of honest intentions and therefore do not cause emotional distress.[32] In my opinion, a government should not be able to intervene by prohibiting the expression of such assertions, but they should be allowed to prohibit and punish individuals who misinterpret such assertions from resulting to hate crimes such as racial attacks. By saying this, one may think that I refuse to consider what some call group libel as hate speech worthy of being punished. This is not the case, since libel, defamation in general, is harmful yet untrue assertion. Even though some may disagree as to the context of vilification, I take it to also have an element of faulty accusations. Conclusion I do not see hate speech to have just one singular face. As I have shown, it can be manifested in many different ways, which can in turn be judged on different grounds. Therefore it is inapplicable to argue that it should be either protected under the right for free speech in its entirety, or not at all. I am of the opinion that some forms of hate speech should be protected by the right of free speech, because of the benefits bestowed to society. Some other forms should not be protected; states should take steps to better inform citizens about the different shades of hate speech and democratically establish legal frameworks to punish the ones that fall on the negative side of the spectrum. [1] Due to the frustratingly large portion of the first draft of my essay spent on citing relevant treaties and articles defining the two rights, and assuming that the reader is familiar with them already, I have decided to include the definitions in footnotes, as they do not count towards the total word count. I do realise that this is inelegant, but I am exercising my right of autonomy to promote my personal interest, namely of not being penalised. Forgive me. [2] First Amendment to the United States Constitution reads as follows â€Å"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.† [3] United Declaration of Human Rights [4] Article 19 of the UDHR states that â€Å"Everyone has the right to freedom of opinion and expression; this right Includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers.† [5] European Convention on Human Rights [6] UK: Sec. 18 (1) of thePublic Order Act of 1986; France: Sec 24 of the Press Law of 1881; Denmark: Article 266 (b) of the Danish Criminal Code; The Netherlands: Articles 137 (c) and 137 (d) of the Dutch Criminal Code [7] i.e. the grounds cited in ICCPR and ECHR are content relevant. [8] Smolla, 1991, 152 [9] Brison, 1998, 313 [10] Waldron, 2009, 1600-1601 [11] Justice Holmes’ obiter dictum in Abrams v. United States, 250 U. S. 616 (1919). [12] Cohen (1993: 211, 229). [13] Schauer (1982: 23, 33). [14] Mill [15] Barendt (1985: 14). [16] Greenawalt (1989a: 143-5). [17] Raz (1991: 311). [18] Sunstein (1993: xvi-xvii). [19] Scanlon (1972: 217). [20] Ibid. [21] Greenawalt (1995: 32). [22] Greenawalt (1995: 49). [23] i.e. threatening letters, vandalism and so on and so forth. [24] But may be bystanders. [25] The fact that a march in virtually every other village or even a march in the same place but without the symbols would not constitute diffuse vilification but would rather be political speech only proves the dishonest intentions of the marchers. (Feinberg 1985: 86). [26] With notable examples the anti-Semitic speeches in Nazi Germany, anti-Greek and anti-Armenian speeches in Turkey, 1910-1922 [27] Nancy Rosenblum (2008: 412-455). [28] i.e. the ban of Nazi parties from political life in Denmark [29] Margalit and Raz (1990: 119). [30] Female Genital Mutilation [31] Although not relevant to this essay, I would argue that the right of free move and work is a lot like the right to free speech in the sense that it is important but militant democracy should intervene to prevent it from harming a democratic state. A failed example of this would be Italy’s policy which only allowed a very limited percentage of immigrants. Surely, a middle position would be more successful. [32] For example, a Kurdish should have been able to reflect upon the issue of FGM before encountering an adversary of the practice.