This is Chapter 11 of a statement available at http://www.doctorsopposingcircumcision.org/DOC/statement0.html
Click here to view/download the complete statement in PDF form: GenitalIntegrityStatement.pdf, also available at http://www.doctorsopposingcircumcision.org/pdf/GenitalIntegrityStatement.pdf
Chapter Eleven: Medical Ethics and the Circumcision of Children
|All infants, children and adolescents – regardless of physical or mental disability – have dignity, intrinsic value, and a claim to respect, protection, and medical treatment that serves their best interests.26|
The surgical operation of male circumcision permanently and irreversibly excises and destroys a functional body part, as reported in Chapter Two.1,2
For this reason, the medical ethics associated with the operation must be scrutinized carefully and doctors who contemplate performing a circumcision must carefully consider and adhere to proper ethical conduct.
Doctors, especially in the U.S., frequently are asked to perform medically unnecessary, non-therapeutic circumcision on minors. Since minors cannot consent, special ethical rules, applicable to pediatrics, must be applied. One must always remember that the child is the patient. The doctor must consider first the well-being of the patient3 and keep the interests of the child-patient paramount.4,5
Some older authorities, e.g., American Academy of Pediatrics, simplistically maintain that non-therapeutic circumcision of a child is ethical if parents request and consent to the circumcision.6-9 As Fox & Thomson (2005) note:
Only limited consideration is given to the seemingly obvious fact that circumcision is the excision of healthy tissue from a child unable to give his consent for no demonstrable medical benefit.10
The view espoused by these older authorities is outmoded and inadequate because it fails to consider the doctor’s duties to the child, the child‘s legal rights, the child’s human rights, and limitations on the power of surrogate consent. Moreover, these statements favor parent privilege over the child’s legal rights and best interests. According to Fox and Thomson:
Particular attention is devoted to the privileging of parental choice, notwithstanding documented medical risks and the absence of conclusive evidence of medical benefit.10
This chapter considers the medical ethics of non-therapeutic circumcision of children by several ethical tests.
Doctors must respect the law11 because they are subject to the general laws.12 If a proposed circumcision operation is unlawful in a particular locale or under the existing circumstances, then it also is unethical and must not be performed. The law of the United States has been discussed in a previous chapter.
2. Human Rights
Doctors have a general duty to respect the human rights of the patient.5, 10-15 According to the World Medical Association:
“Ethics and human rights are no longer the ‘two solitudes’ that did not have much to do with each other. Increasingly, human rights organizations are recognizing the ethical dimension of their work, and organizations whose primary concern is ethics are discovering that human rights is a foundational element of ethics. …”14
Human rights are now an integral part of medical ethics. As reported in Chapter Nine, children have both general and special human rights that must be protected. As previously stated, non-therapeutic circumcision of children violates the child-patient’s human rights. Both parents and professionals have a duty to respect human rights.
The United Nations Educational, Cultural, and Scientific Organization (UNESCO), being well aware that many current medical practices are unethical because they do not comply with international human rights law, has compiled and published the Universal Declaration on Bioethics and Human Rights (2005) to guide organizations and institutions toward compliance with human rights. The Declaration provides in part:
Article 8 – Respect for human vulnerability and personal integrity
In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.15
Children are among the most vulnerable persons. This provision would require respect for their genital integrity and prohibit the non-therapeutic excision of healthy functional human tissue, such as the foreskin, from their genital organs.
3. The Cardinal Principles of Medical Ethics
The four cardinal principles of medical ethics are beneficence, non-maleficence, justice, and autonomy.16,17
Beneficence. This concerns “doing good.” We have previously demonstrated that the alleged prophylactic benefits cannot be shown to actually exist. Therefore, there is no provable beneficence to the non-therapeutic circumcision of male children, so non-therapeutic circumcision violates the principle of beneficence.
Non-maleficence. This concerns “not doing harm.” We have previously demonstrated that male circumcision is harmful, so non-therapeutic circumcision violates the principle of non-maleficence.
Justice. This concerns “treating patients fairly.” We have previously demonstrated that non-therapeutic circumcision inflicts needless injury on a patient and violates his legal right to bodily integrity and human rights. This is not fair treatment, so non-therapeutic circumcision violates the principle of justice.
Autonomy. This concerns letting the patient control his/her own treatment. Consent for the circumcision of children must be given by surrogates. In this case, the patient does not control his own treatment, so non-therapeutic circumcision violates the principle of autonomy.
Some ethicists add a fifth principle:
Proportionality.17,18 This concerns having benefits that are proportionate to the risks and losses. The nebulous and mythical benefits of male circumcision are completely disproportionate to the known risks, disadvantages, and permanent injury of circumcision. Male non-therapeutic circumcision violates the prinicple of proportionality.17
Non-therapeutic circumcision of children violates all five principles of medical ethics.
4. Provision of Futile or Ineffective Treatment
Non-therapeutic circumcision is performed on healthy persons. Under this circumstance, there can be no effect, so the treatment is both ineffective and futile. Physicans have no duty to provide futile or ineffective treatment.19-21
5. Misuse of Medical Resources
Physicians have an ethical duty to conserve medical resources and use them wisely.17,22-24 The provision of non-therapeutic circumcision wastes medical resources, such as physician time, hospital space, insurance money, and medical staff. Provision of medically unnecessary, non-therapeutic circumcision may consume resources needed for the medically necessary treatment of other patients.
6. Surrogate Consent
The necessity for consent by surrogates poses many ethical problems. Competent adult patients have full powers to consent to treatment, but surrogates have limited powers. The American Academy of Pediatrics states that the surrogate is limited to providing “informed permission for diagnosis and treatment of children.”25 Non-therapeutic child circumcision is neither diagnosis nor treatment and falls outside parental power to consent.
Both parents and physicians must act in the best interests of the child.15, 25-30 Doctors must, in considering the best interests of the child, remember that parents have a primary duty to the child to protect his bodily integrity. The best interests of the child must include the protection of his legal right to bodily integrity, except when the presence of clear and present clinically identifiable disease makes invasion of the child’s bodily integrity necessary. Therefore, there should be an assumption that protection of the child’s bodily integrity is in his best interests, unless proven otherwise by clear and convincing evidence.
In surrogate consent for therapeutic circumcision, the necessary prerequisites are:
- a physical complaint, followed by
- a diagnosis by a medical doctor, followed by
- a medical recommendation for treatment, followed by
- a trial of conservative treatment,5 followed by
- a recommendation for circumcision, only after conservative treatment fails, and where circumcision is proven to be effective, followed by
- presentation of all relevant material information,5,25,26,28,30,31 followed by
- granting of consent by his representative.32
These would be present in the case of therapeutic circumcision, but the first five would be glaringly absent in the case of non-therapeutic circumcision at parental request. A consent obtained without these prerequisites would lack validity. Performance of a circumcision without valid consent would be unethical.
7. Patient Exploitation
Some doctors may exploit the presence of the foreskin by performing a circumcision simply to collect a fee for the procedure. According to the Boston Globe, quoting Thomas E. Wiswell, M.D. (the advocate of male circumcision to prevent UTI):
“I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it,” says Wiswell. “Each one is that much money. Heck, if you do 10 a week, that’s over $1,000 a week, and they don’t take that much time.””33
Patient exploitation is a violation of human rights and is unethical.33,34
8. Duties to Child-Patients
Doctors 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.”25 “The principal obligation of the physician is to the individual patient rather than to society or the healthcare system.”26Doctors have a duty to act in the best interests of their child-patient.5 25-30 Genital integrity provides the highest state of health and well-being,17 36therefore, doctors have an ethical duty to their child-patients to protect and preserve the genital integrity of their child-patients by abstaining from performing circumcision at parental request.
9. Preservation of the Child’s Right to an Open Future.
Although infant boys are not competent at birth, they will, in the vast majority of instances, be competent later. The principle of autonomyrequires that parents, to whom the care of the child is entrusted, preserve as many of the child’s future options as possible. Joel Feinburg writes:
“… if the violation of a child’s autonomy right-in-trust cannot always be established by checking the child’s present interests, a fortiori it cannot be established by checking the child’s present desires or preferences. It is the adult he is to become who must exercise the choice, more exactly, the adult he will become if his basic options are kept open and his growth ‘natural’ or unforced, In any case, that adult does not exist yet, and perhaps he never will. But the child is potentially that adult, and it is that adult who is the person whose autonomy must be protected, now (and in advance).37
Parents and doctors, therefore, have a duty to the child to preserve the child’s options in adult life. A circumcision in childhood forecloses the child’s right to opt for genital integrity in adult life, so a non-therapeutic circumcision unethically violates the child’s right to an open future.
Child circumcision was introduced into medical practice in the nineteenth century.38 Medical ethics has changed over the years, especially since the advent of the human rights era. In this chapter, non-therapeutic circumcision of children has been subjected to nine tests by contemporary standards of medical ethics. It has failed all nine. Although non-therapeutic circumcision of children remains a common practice, under contemporary standards of medical ethics, it has become unethical and needs to cease. Medical societies have a duty to revise their guidance regarding non-therapeutic male circumcision to reflect 21st century medical ethics. Similarly, medical doctors, hospitals, and other institutions have a duty to change their practices regarding non-therapeutic circumcision of children to protect their genital integrity.
- Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291–5. [Full Text]
- Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34–44. [Full Text]
- Principle 1. CMA Code of Ethics. Ottawa: Canadian Medical Association, 2004. [Full Text]
- Council on Ethical and Judicial Affairs. Principle VIII, Principles of Medical Ethics. Chicago: American Medical Association, 2001. [Full Text]
- Committee on Medical Ethics. The law & ethics of male circumcision – guidance for doctors. London: British Medical Association, 2006. [Full Text]
- Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. (CPS) Canadian Medical Association Journal 1996; 154(6): 769–80. [Full Text]
- Task Force on Circumcision, American Academy of Pediatrics. Circumcision policy statement. Pediatrics 1999;103(3):686–93. [Full Text]
- Council on Scientific Affairs, American Medical Association. Neonatal circumcision. Chicago: American Medical Association, December 1999. [Full Text]
- Beasley S, Darlow B, Craig J, et al. Position statement on circumcision. Sydney: Royal Australasian College of Physicians, 2004. [Full Text]
- Fox M, Thomson M. Short changed? The law and ethics of male circumcision. Int J Children’s Rights 2005;13:161–81. [Full Text]
- Council on Ethical and Judicial Affairs. Principle I, Principles of Medical Ethics. Chicago: American Medical Association, 2001. [Full Text]
- Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 21. [Full Text]
- Principle 9. CMA Code of Ethics. Ottawa, Canadian Medical Association, 2004. [Full Text]
- Ethics Unit. Ethics and Human Rights, Ferney-Voltaire, France, World Medical Association, 2006. [Full Text]
- Intergovernmental Bioethics Committee. Universal Declaration on Bioethics and Human Rights. Adopted by the General Conference of the United Nations Educational, Scientific and Cultural Organization on 19 October 2005. [Full Text]
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York, NY: Oxford University Press; 1989.
- Clark PA. To circumcise or not to circumcise?: a Catholic ethicist argues that the practice is not in the best interest of male infant. Health Prog 2006;87(5):30-9. [Full Text]
- Directive 33. Ethical and Religious Directives for Catholic Health Care Services, 4th ed. Washington, DC: U.S. Conference of Catholic Bishops, 2001, pp. 19–20. [Full Text]
- Weijer C, Singer PA, Dickens BM, Workman S. Bioethics for clinicians: 16. Dealing with demands for inappropriate treatment. Can Med Assoc J 1998;159:817–21. [Full Text]
- Opinion E-8:20, Code of Medical Ethics. Chicago: American Medical Association. [Full Text]
- Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 46. [Full Text]
- Principle 44. CMA Code of Ethics. Ottawa: Canadian Medical Association, 2004. [Full Text]
- Williams J. Resource Allocation. In: Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 68–73. [Full Text]
- Opinion E-4.04 Economic Incentives and Levels of Care. Chicago: American Medical Association. [Full Text]
- American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314–7. [Full Text]
- Bioethics Committee, Canadian Paediatric Society. Treatment decisions regarding infants, children and adolescents. Paediatr Child Health 2004;9(2):99–103. [Full Text]
- Principle 29. CMA Code of Ethics. Ottawa, Canadian Medical Association, 2004. [Full Text]
- Principle 3d. Code of Ethics. Barton, ACT: Australian Medical Association, 2006. [Full Text]
- College of Physicians and Surgeons of British Columbia. Infant Male Circumcision. In: Resource Manual for Physicians. Vancouver, BC: College of Physicians and Surgeons of British Columbia, 2004. [Full Text]
- Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 49. [Full Text]
- Seeking patients’ consent: the ethical considerations. London, General Medical Council, 1998. [Full Text]
- Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 42–3. [Full Text]
- Lehman BA. The age old question of circumcision. Boston Globe, Boston, Massachusetts, 22 June 1987:41,43. [Full Text]
- Principle 2. CMA Code of Ethics. Ottawa: Canadian Medical Association, 2004. [Full Text]
- Principle 1.1h. Code of Ethics. Barton, ACT: Australian Medical Association, 2004. [Full Text]
- Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004;24:584–601. [Full Text]
- Feinberg J. The right to an open future. In: Whose Child? Children’s Right, Parental Authority and State Power, Rowman and Littlefield, Totowa, New Jersey, 1980, p. 124 et seq.
- Gollaher DL. From ritual to science: the medical transformation of circumcision in America. J Soc Hist 1994;28(1):5–36. [Full Text]