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Contents

1 Introduction 2 Medical views 3 Parent-centered view 4 Child-centered view 5 Human rights-centered view 6 Scandinavian View 7 Conscientious objection 8 Ethical positions 9 Conclusion 10 See also 11 External links 12 References

Introduction

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

Medical views

The American Academy of Pediatrics concluded that it has "potential benefits and risks, but is not essential to the child's well-being."[1] (http://pediatrics.aappublications.org/cgi/content/full/103/3/686) The American Medical Association classifies neonatal circumcision as an elective non-therapeutic operation.[2] (http://www.cirp.org/library/statements/ama2000/) However, one study considering protection against urinary tract infections against a number of risks found that non-circumcision produces the highest medical utility[3] (http://www.cirp.org/library/disease/UTI/chessare/), and there remains controversy over whether the procedure is beneficial or harmful (see Medical analysis of circumcision).

Some researchers believe that this tissue performs useful protective or sensory functions.[4] (http://www.cirp.org/library/anatomy/taylor/)[5] (http://www.cirp.org/library/complications/brennemann1/)[6] (http://www.cirp.org/library/complications/freud1/) [7] (http://www.cirp.org/library/general/gairdner/) [8] (http://www.cirp.org/library/complications/kunz1/) [9] (http://www.cirp.org/library/complications/persad/) [10] (http://www.cirp.org/library/complications/upadhyay1/) Others have written that removal of the foreskin has no detrimental effects sexually or psychologically, and has a number of health benefits.[11] (http://www.circs.org/library/moses/index.html) [12] (http://www.circs.org/library/wiswell4/index.html) [13] (http://www.circs.org/library/wiswell/index.html) [14] (http://www.circs.org/library/schoen3/index.html) [15] (http://www.circs.org/library/schoen4/index.html) There are also researchers who indicate the foreskin protects against meatitis, meatal ulceration, and meatal stenosis; some studies indicate that it may have sensory and erogenous functions.[16] (http://www.cirp.org/library/general/falliers1/)[17] (http://www.cirp.org/library/anatomy/winkelmann/) [18] (http://www.cirp.org/library/anatomy/taylor/)

Patient autonomy is a major principle of medical ethics.[19] (http://www.cmaj.ca/misc/bio_consent.shtml) Children cannot consent to the operation so it is done with surrogate (proxy) consent. The use of surrogate consent for child circumcision is controversial. Povenmire (1998) argues that parents should not have the power to consent to neonatal non-therapeutic circumcision.[20] (http://www.cirp.org/library/legal/povenmire/)

The three major ethical viewpoints are the parent-centered viewpoint, the child-centered viewpoint, and the human rights-centered viewpoint.

Parent-centered view

This 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. An example of this view is the 1999 Circumcision Policy Statement (1999) of the American Academy of Pediatrics.[21] (http://pediatrics.aappublications.org/cgi/content/full/103/3/686)

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. Some parents have expressed concern that the pain from the procedure is harmful, and that it is unethical that their child will be forcibly restrained during an involuntary procedure. 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.[22] (http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b103/3/686)

There is dissent from this view. Denniston, the president of Doctors Opposing Circumcision (http://faculty.washington.edu/gcd/DOC/), 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,[23] (http://faculty.washington.edu/gcd/DOC/aapletter10-15-02.html) though that Committee passed the same statement.[24] (http://www.circs.org/library/lannon) 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."[25] (http://www.cirp.org/library/legal/canning1/)

Child-centered view

Some believe that the parent-centered view is challenged by the American Academy of Pediatrics Committee on Bioethics, which places 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 that:

"the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent."[26] (http://aappolicy.aappublications.org/cgi/reprint/pediatrics;95/2/314.pdf)

And by the newer American Medical Association Principles of Medical Ethics (2001) which require:

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.[27] (http://www.ama-assn.org/ama/pub/category/2512.html)

Some interpret these to mean that circumcision is unethical because circumcision is not in the patient's best interests. However, as noted, the AAP's Committee on Bioethics do not agree, and approved the AAP's policy statement.

Guidance on the circumcision of male children has been enunciated by the Committee on Medical Ethics of the British Medical Association. That view requires medical doctors to proceed on a case by case basis to determine the best interests of the child before deciding to perform a circumcision.[28] (http://www.bma.org.uk/ap.nsf/Content/malecircumcision2003) A similar position has been taken by the College of Physicians and Surgeons of British Columbia.[29] (http://www.cirp.org/library/statements/cpsbc2004/)

Hellston expresses the view that the protection of the child's rights should govern the practice.[30] (http://jme.bmjjournals.com/cgi/content/abstract/30/3/248)

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. [31] (http://www.canadiancrc.com/circumcision/circumcision.htm).

Human rights-centered view

Leading national codes of medical ethics require doctors to respect the human rights of the patient.[32] (http://www.cma.ca/index.cfm/ci_id/2419/la_id/1.htm) [33] (http://www.cirp.org/library/legal/BMA-human-rights/) [34] (http://www.ama-assn.org/ama/pub/category/2512.html) [35] (http://www.legeforeningen.no/index.db2?id=297) Jacqueline Smith, a researcher at The Netherlands Institute of Human Rights (http://www.uu.nl/uupublish/homerechtsgeleer/onderzoek/onderzoekscholen/sim/english/18199main.html) believes that non-therapeutic male neonatal circumcision violates the human rights of the infant.[36] (http://www.cirp.org/library/legal/smith/) Gulbrandsen claimed that The Norwegian Council for Medical Ethics determined that ritual child circumcision violates important principles of medical ethics.[37] (http://www.cirp.org/library/ethics/gulbrandsen1/) 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.[38] (http://www.arclaw.org/)

Some men, who were neonatally circumcised, feel that their human rights have been violated.[39] (http://bmj.bmjjournals.com/cgi/content/full/312/7027/377/a) Some men have felt assaulted by the procedure. At a conference on genital integrity in Australia, organised by the organisation NOCIRC, psychology professor Boyle, of Queensland's Bond University, stated that "Male circumcision is tantamount to sexual assault".[40] (http://www.iol.co.za/index.php?click_id=117&art_id=qw976165381448C625)

Scandinavian View

Scandinavian nations take the strictest view of child circumcision. As previously stated, Gulbrandsen claimed[41] (http://www.cirp.org/library/ethics/gulbrandsen1/) 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 (http://www.legeforeningen.no/index.db2?id=297). Some others hold this view [42] (http://www.tidsskriftet.no/pls/lts/PA_LTS.Vis_Seksjon?vp_SEKS_ID=419642). The children’s ombudsman says circumcisions should cease at public hospitals.[43] (http://www.cirp.org/news/dagsavisen06-26-03/) 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.[44] (http://www.cirp.org/library/statements/finland2003/) 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.[45] (http://www.cirp.org/news/bbc10-01-01/) One interpretation of a statement by the Danish Council for Children says that circumcision violates human rights.[46] (http://www.cirp.org/news/bornradet12-04-03/)

Conscientious objection

A physician, except in emergencies, may choose whom to serve.[47] (http://www.ama-assn.org/ama/pub/category/2512.html) 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,[48] (http://www.cirp.org/library/ethics/AAP/) and he must always act in the best interests of the child and avoid ineffective or harmful treatment.[49] (http://www.cps.ca/english/statements/B/b86-01.htm) A physician has no obligation to provide ineffective or inappropriate treatment.[50] (http://www.cmaj.ca/cgi/content/abstract/159/7/817) For these reasons, a physician has an absolute right to conscientiously object to the performance of a non-therapeutic circumision, 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.[51] (http://www.bma.org.uk/ap.nsf/Content/malecircumcision2003) [52] (http://www.cirp.org/library/statements/cpsbc2004/)

Ethical positions

Since the boy's genitals will grow to be a man's genitals, the ethical debate includes aspects of health, religion, law, human rights, and free will. Excluding cases of any medical diagnosis, a person may hold any of the following perspectives with regard to any acts of infant circumcision:

• Infant circumcision is ethical and always justifiable
• Infant circumcision is ethical, but should be a parental choice
• Infant circumcision is unethical, but does not require sanctions
• Infant circumcision is unethical and always abusive

The first two viewpoints tend to reflect the ethics of circumcision advocacy, whereas the last two tend to reflect the ethics of genital integrity.

Conclusion

People in non-practicing cultures may dislike 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. There is no clear consensus regarding the ethicality of the non-therapeutic circumcision of male children.

See also

• Ethics

• Human rights

• Medical ethics

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://www.cirp.org/library/ethics/AAP/

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

• Council on Ethical and Judical 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.<i> London: British Medical Association, 2003. URL: http://www.bma.org.uk/ap.nsf/Content/malecircumcision2003

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

• Hellston 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/abstract/30/3/248

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.