Bioethics of neonatal circumcision

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The bioethics of neonatal circumcision are sometimes controversial within practicing cultures. Male circumcision involves the excision of genital tissue from the human body.

Some studies indicate that the foreskin and frenulum perform certain physiological functions among the men tested[1] [2] which would be destroyed by excision. Other studies indicate that some human males with a foreskin are at increased risk of certain diseases,[3] [4] (See medical analysis of circumcision)

Because the tissues, once excised, cannot be entirely replaced, many question the appropriateness of their removal in childhood. Non-therapeutic neonatal circumcision is sometimes performed exclusively for social or cultural reasons. Such practices and differing views are widespread in the United States.

Contents 1 Issues of consent 2 Medical ethics principles 3 Physician's right to refuse to perform surgery 4 Circumcision to reduce the risk of HIV infection 5 Conclusion 6 See also 7 External links 8 References

[edit] Issues of consent

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Within societies that practice neonatal circumcision, it is well accepted that the decision on circumcision must be made by the child's caregiver. Some argue that because of a lack of credible information about male circumcision in some societies, the ability for the caregiver to grant informed consent on behalf of their child is compromised. This may be especially true of caregivers from a religious or cultural tradition that is particularly biased towards or against circumcising infants.

There is also a problem of who should make the final decision if the parents disagree about circumcision.

[edit] Medical ethics principles

Patient autonomy is a major principle of medical ethics.[5] Children cannot consent to the operation so it is done with surrogate (proxy) consent. The use of surrogate (proxy) consent for child circumcision is controversial. Richards (1996) argues that parents only have power to consent to therapeutic procedures.[6] Povenmire (1998) argues that parents should not have the power to consent to neonatal non-therapeutic circumcision.[7]

The Committee on Bioethics of the American Academy of Pediatrics (AAP) (1997) asserts that every child should have the opportunity to grow and develop free from preventable illness or injury.[8] Genital integrity groups perceive involuntary circumcisions as injury to a child, whereas circumcision advocates do not.

The American Academy of Pediatrics Committee on Bioethics (1995) places independent responsibility on the physician. It holds that health care providers "have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses." And "the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent."[9]

The newer American Medical Association Principles of Medical Ethics (2001) states "A physician shall, while caring for a patient, regard responsibility to the patient as paramount."[10]

Together, these points indicate that proper assessment of the benefits and risks of circumcision, in order to ascertain where the patient's best interests lie, is critical to understanding the ethical position.

One viewpoint holds that non-therapeutic circumcision of male children is ethical provided that a parent grants consent for the operation after being informed of the possible benefits, known risks and alternative treatment. The Committee on Bioethics approved the 1999 Circumcision Policy statement of the American Academy of Pediatrics [11] indicating parents should make such a decision based upon information about the potential benefits and risks.[12]

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.

Parents and physicians each have an ethical duty to the child to attempt to secure the child's best interest and well-being. However, it is often uncertain as to what is in the best interest of any individual patient. In cases such as the decision to perform a circumcision in the neonatal period when there are potential benefits and risks and the procedure is not essential to the child's current well-being, it should be the parents who determine what is in the best interest of the child. In the pluralistic society of the United States, in which parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.

Physicians counseling families concerning this decision should assist the parents by explaining the potential benefits and risks and by ensuring that they understand that circumcision is an elective procedure. Parents should not be coerced by medical professionals to make this choice.[13]

Benatar and Benatar argue that parents are best suited to making the decision.[14]

Some believe this policy statement by the Task Force on Circumcision is in conflict with their previous declarations. Denniston, the president of Doctors Opposing Circumcision, commented in a letter (2002) to the president of the AAP, that the 1999 Circumcision Policy Statement is in "direct conflict" with general principles of pediatric bioethics that had previously been published by the Committee on Bioethics.[15] Canning (2002) commented that "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."[16]

This can be interpreted to mean that circumcision is unethical if circumcision is not perceived to be in the patient's best interests. The AAP's Committee on Bioethics, however, approved the AAP's 1999 circumcision policy statement.

Hellsten expresses the view that the protection of the child's rights should govern the practice.[17]

Leading national codes of medical ethics require doctors to respect the human rights of the patient.[18] [19] [20] [21] Jacqueline Smith, a researcher at The Netherlands Institute of Human Rights believes that non-therapeutic male neonatal circumcision violates the human rights of the infant.[22] Gulbrandsen claimed that The Norwegian Council for Medical Ethics determined that ritual child circumcision violates important principles of medical ethics.[23] The organisation, Attorneys for the Rights of the Child, which campaigns against circumcision, has published a table of what it considers to be human rights violated by neonatal or child circumcision.[24]

The Canadian Children's Rights Council position states:

Our position is that all children should be protected from all forms of genital mutilation (circumcision of all types) including but not limited to, circumcision that doesn't affect sexual function or that may be viewed by others as sexual enhancement surgery. Male circumcision does affect sexual function. [25].

Some men who were circumcised during infancy feel that their human rights have been violated.[26] Some have felt assaulted by the procedure. At a conference on genital integrity in Australia, organised by the organisation NOCIRC, Gregory J. Boyle, of Bond University, Queensland, stated that "Male circumcision is tantamount to sexual assault".[27] [28]

Guidance on the circumcision of male (2003) has been enunciated by the Committee on Medical Ethics of the British Medical Association. That view 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.[29] The doctor must consider the child's legal and human rights in making her determination. A similar position (2004) has been taken by the College of Physicians and Surgeons of British Columbia.[30]

Scandinavian nations take the strictest view of child circumcision. As previously stated, Gulbrandsen claimed[31] that the Norwegian Council for Medical Ethics reported to the board of the Norwegian Medical Association that the circumcision of boys is not consistent with principles of medical ethics. Some others hold this view [32]. The Norwegian Children’s Ombudsman says circumcisions should cease at public hospitals.[33] Similarly, the Finnish Central Union for Child Welfare takes the position that the non-therapeutic circumcision of boys may not be acceptable because it violates bodily integrity.[34] Sweden has passed a law that restricts the practice of circumcision to be performed by qualified professionals, as is usually the case in the US.[35] One interpretation of a statement by the Danish Council for Children says that circumcision violates human rights.[36]

[edit] Physician's right to refuse to perform surgery

A physician, except in emergencies, may choose whom to serve.[37] A physician who attends a child-patient must "have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses,[38] and he must always act in the best interests of the child and avoid ineffective or harmful treatment.[39] A physician has no obligation to provide ineffective or inappropriate treatment.[40] For these reasons, a physician has an absolute right to conscientiously object to the performance of a non-therapeutic circumcision, or indeed any other non-essential surgery. Some common grounds would be the physician's belief that circumcision violates the patient's right to bodily integrity, or other rights, is not in the best interests of the patient, or that the operation is immoral or unethical.[41] [42]

[edit] Circumcision to reduce the risk of HIV infection

Scientific studies tend to show that circumcision can to some extent reduce the risk of contraction of HIV by a male through sexual contact. Others[43] have found no correlation between the two, or "a moderate protective effect"[44] of the non-circumcision against HIV infection. A systematic review of the many studies investigating the issue found that: "Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV."[45] There is some ethical debate over whether or not the apparent possibility of risk reduction against HIV infection is enough to justify medical circumcision of a child.

Supporters of circumcision argue that using circumcision and other available means to halt the spread of HIV is in the common good. They argue that the a reduced risk of catching HIV other alleged benefits of circumcision make it worthwhile. However, circumcision does not prevent HIV infection. The threat remains while engaging in unprotected sex and other high risk behaviors.

Critics of non-therapeutic circumcision argue that advocating circumcision to prevent HIV infection may detract from other efforts to prevent the spread of the virus such as using condoms. They argue that a child's sexual behaviour as an adult is very difficult to predict, as is the future of HIV and treatment or prevention of AIDS. If the child chooses to remain celibate or if a couple remain faithful to each other, or if HIV is eliminated by the time the child is an adult, the surgery would not have been needed. Moreover, they argue that circumcising a child strictly to protect him from HIV infection may be seen as permission, or even entitlement to engage in dangerous sexual practices.

[edit] Conclusion

People in non-practicing cultures may disapprove of the practice of male neonatal circumcision. In contrast, the bioethics of the circumcision of male infants and children are encouraged or sometimes disputed in practicing cultures. Within such cultures, there is no clear consensus regarding the ethicality of the non-therapeutic circumcision of male children.

[edit] See also

• Circumcision
• Ethics
• Foreskin
• Human rights
• Medical ethics

[edit] External links

• American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-7. URL: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;95/2/314.pdf

• David Richards. Male Circumcision: Medical or Ritual? 3 Journal of Law and Medicine 371 (1996). URL: http://www.cirp.org/library/legal/richards/

• Ross Povenmire. Do Parents Have the Legal Authority to Consent to the Surgical Amputation of Normal, Healthy Tissue From Their Infant Children?: The Practice of Circumcision in the United States. 7 Journal of Gender, Social Policy & the Law 87 (1998-1999). URL: http://www.cirp.org/library/legal/povenmire/

• Task Force on Circumcision. Circumcision Policy Statement. Pediatrics URL: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b103/3/686

• Council on Ethical and Judicial Affairs. Principles of Medical Ethics. Chicago: American Medical Association, 2001. URL: http://www.ama-assn.org/ama/pub/category/2512.html

• Gulbrandsen P. Rituell omskjæring av gutter. [Ritual circumcision of boys.] Tidsskr Nor Lægeforen [Journal of the Norwegian Medical Association] 2001;121(25):2994. URL: http://www.cirp.org/library/ethics/gulbrandsen1/

• Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003. URL: http://www.bma.org.uk/ap.nsf/Content/malecircumcision2003

• College of Physicians and Surgeons of British Columbia. Policy Manual: Infant Male Circumcision. Vancouver, BC: College of Physicians and Surgeons of British Columbia, 2004. URL: http://www.cirp.org/library/statements/cpsbc2004/

• Hellsten SK. Rationalising circumcision: from tradition to fashion, from public health to individual freedom—critical notes on cultural persistence of the practice of genital mutilation. J Med Ethics 2004;30:248-53. URL: http://jme.bmjjournals.com/cgi/content/full/30/3/248

• Benatar M, Benatar D. Between prophylaxis and child abuse: the ethics of neonatal male circumcision. Am J Bioeth 2003 Spring;3(2):35-48 URL: http://www.circs.org/library/benatar2/index.html

• Benatar D, Benatar M. How not to argue about circumcision. Am J Bioeth 2003 Spring;3(2):W1 URL: http://www.circs.org/library/benatar/index.html

• Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J Med Ethics 2005;31(8):463-9. http://jme.bmjjournals.com/cgi/content/full/31/8/463

• Holm S. Irreversible bodily interventions in children. J Med Ethics 2004;30:237 http://jme.bmjjournals.com/cgi/content/full/30/3/237

• Short RV. Male circumcision: a scientific perspective. J Med Ethics 2004;30:241 http://jme.bmjjournals.com/cgi/content/full/30/3/241

• Viens AM. Value judgment, harm, and religious liberty. J Med Ethics 2004;30:241-247 http://jme.bmjjournals.com/cgi/content/full/30/3/241-a

• Mussell R. The development of professional guidelines on the law and ethics of male circumcision. J Med Ethics 2004;30:254-258 http://jme.bmjjournals.com/cgi/content/full/30/3/254

[edit] References

• Margaret Somerville. The Ethical Canary: Science, Society and the Human Spirit. Toronto: Penguin, 2000: pp. 202-19. (ISBN 0-670-89971-2)
• Freeman MD. A child's right to circumcision. BJU Int. 1999 Jan;83 Suppl 1:74-8.