Ethics of Circumcision - Medical Ethics

Medical Ethics

Some medical associations take the position that the parents should determine what is in the best interest of the infant or child. The Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue, the BMA insisting that a non-therapeutic circumcision must not go ahead without the consent of both parents and, if competent, the child himself.

Commenting on the development of the 2003 British Medical Association guidance on circumcision, Mussell states that debate in society is "intensely fraught, with individuals and groups holding conflicting positions." Identifying three positions, "support," "qualified support," and "opposition," he suggests that this controversy "is also reflected within the multicultural, multifaith BMA membership." He identifies this as a difficulty in achieving consensus within the medical ethics committee. Arguments put forward in discussions, according to Mussell, included that circumcision "is a net benefit focused on concepts such as social integration and cultural acceptance", but also that it is "a net harm focused on the breach of children’s rights—the right of the child to be free from physical intrusion and the right of the child to choose in the future."

Neonatal circumcision is performed with surrogate consent, described as follows by the American Academy of Pediatrics: "The practice of medicine has long respected an adult's right to self-determination in health care decision-making. This principle has been operationalized through the doctrine of informed consent. The process of informed consent obligates the physician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives for the patient to make an informed choice. For infants and young children who lack the capacity to decide for themselves, a surrogate, generally a parent, must make such choices."

The Academy states that both parents and physicians have an ethical duty to secure the child's best interest and well-being. In the case of an individual child, however, they argue that it is often uncertain what is in their best interest. They state that in the case of circumcision, where there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, the parents ought to determine what is in the child's best interests, and that it is legitimate for parents to take into account cultural, religious, and ethnic traditions, as well as medical factors. They state that physicians should not coerce parents, but should assist parents in their decision by "explaining the potential benefits and risks and by ensuring that they understand that circumcision is an elective procedure." The Academy's Committee on Bioethics approved this policy statement.

The Royal Australasian College of Physicians comments that "The difficulty with a procedure which is not medically indicated is whether it may still be in the child’s “best interests” (that is, in the case of circumcision, decreasing the risk of UTI and penile cancer, and ensuring acceptance within a religio-cultural group) on the one hand or whether it may constitute an assault upon the child and be a violation of human rights on the other. Arguments to justify the "best interests" case are based upon data to suggest a decreased risk of medical conditions later in life, none of which, with the possible exception of UTIs in boys, requires a decision in the neonatal period, and this could be seen to be an argument to defer a decision until the individual can express his own preferences. One issue, which is agreed, is that before parents make a decision about circumcision they should have access to unbiased and clear information on the medical risks and benefits of the procedure." Views differ on whether limits should be placed on caregivers having a child circumcised.

Denniston (1996) argues that informing parents that circumcision is "in any way useful" constitutes a failure to make "relevant scientific information available to that parent." He states that "ircumcision is unnecessary and harmful: therefore, not in the infant's best interest." Benatar and Benatar argue that circumcision is "neither a compelling prophylactic measure nor a form of child abuse", and that it is therefore suited to parental discretion.

Somerville (2000) argues that the nature of the medical benefits cited as a justification for infant circumcision are such that the potential medical problems can be avoided or, if they occur, treated in far less invasive ways than circumcision. She states that the removal of healthy genital tissue from a minor should not be subject to parental discretion, or that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient, regardless of parental consent.

Viens contends that "we do not know in any robust or determinate sense that infant male circumcision is harmful in itself, nor can we say the same with respect to its purported harmful consequences." He suggests that one must distinguish between practices that are grievously harmful and those that enhance a child's cultural or religious identity. He suggests that medical professionals, and bioethicists especially, "must take as their starting point the fact that reasonable people will disagree about what is valuable and what is harmful."

Richards (1996) argues that parents only have power to consent to therapeutic procedures. Povenmire argues that parents should not have the power to consent to neonatal non-therapeutic circumcision.

Canning (2002) commented that "f circumcision becomes less commonly performed in North America the legal system may no longer be able to ignore the conflict between the practice of circumcision and the legal and ethical duties of medical specialists."

Benatar and Benatar (2003) argue that "it is far from obvious that circumcision reduces sexual pleasure," and that "it is far from clear that non-circumcision leaves open a future person’s options in every regard." They continue: "It does preserve the option of future circumcised or uncircumcised status. But it makes other options far more difficult to exercise. Transforming from the uncircumcised to the circumcised state will have psychological and other costs for an adult that are absent for a child. ... Nor are these costs “negligible”, . At the very least, they are not more negligible than the risks and costs of circumcision."

The Committee on Medical Ethics of the British Medical Association (2003) published a paper to guide doctors on the law and ethics of circumcision. It advises medical doctors to proceed on a case by case basis to determine the best interests of the child before deciding to perform a circumcision. The doctor must consider the child's legal and human rights in making his or her determination. It states that a physician has a right to refuse to perform a non-therapeutic circumcision. The College of Physicians and Surgeons of British Columbia took a similar position.

Holm (2004) states that, in the absence of "valid comparative data" on the effect of infant circumcision on adult sexual function and satisfaction, "the circumcision debate cannot be brought to a satisfactory conclusion, and there will always be a lingering suspicion that the sometimes rather strident opposition to circumcision is partly driven by cultural prejudices, dressed up as ethical arguments."

Hellsten (2004), however, describes arguments in support of circumcision as "rationalisations", and states that infant circumcision can be "clearly condemned as a violation of children’s rights whether or not they cause direct pain." He argues that, to question the ethical acceptability of the practice, "we need to focus on child rights protection."

Fox and Thomson (2005) state that in the absence of "unequivocal evidence of medical benefit", it is "ethically inappropriate to subject a child to the acknowledged risks of infant male circumcision." Thus, they believe, "the emerging consensus, whereby parental choice holds sway, appears ethically indefensible".