The last couple months have seen a flurry of reports in the media (particularly American media) regarding male circumcision and its potential health benefits. However, most of the coverage in the U.S. of male circumcision fails to discuss what I think is the most important issue, the ethics.
Before continuing, though, it is critical to discriminate between the significantly different situations under which circumcision may occur. These include therapeutic and non-therapeutic circumcisions performed on either consenting or non-consenting individuals. A therapeutic circumcision is one which is performed to treat a disease or disorder; a non-therapeutic circumcisions are those done for any other reason. Unless noted otherwise, I am only focusing on non-therapeutic, non-consensual circumcision since it’s the kind most often practiced, particularly in the United States where in my opinion the circumcision debates seem to leave out the most important question, is neonatal circumcision ethical?
One of the primary ideas that has evolved in Western law and medical ethics is the strong support of personal autonomy. Although the notions of personal autonomy developed their roots centuries ago, it has only been in the last 40 years that those ideals have made their way into the routine practice of medicine and the doctor-patient relationship. The ideas of personal autonomy have transformed the doctor-patient relationship from a paternalistic, “The doctor knows best,” model to a situation where doctors and patients work together, the patient is fully informed, and consent of the patient for treatment is obtained in all but a few, very specific circumstances such as immediate medical need.
This works well except where proxy consent is required, such as when the patient is incompetent or otherwise unable to make their own decisions (e.g. a child). In these situations, it is necessary that a proxy provide consent, but it is also necessary that other considerations be introduced into the discussion. It is necessary, for example, to examine on what basis we grant that power to make a decision for someone else and determine the additional safeguards necessary to insure that the patient gets the attention and treatment they need. There are objective limits to those powers and it’s important that these decisions made are ethical thus ensuring the best interest of the patients are maintained.
These questions have been addressed by both professional groups and ethicists. The American Academy of Pediatrics (AAP) Committee on Bioethics, for example, said in their 1995 report, Informed Consent, Parental Permission, and Assent in Pediatric Practice, that, “Parents and physicians should not exclude children and adolescents from decision-making without persuasive reasons.” The Academy goes on to say:
Such 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. Although impasses regarding the interests of minors and the expressed wishes of their parents or guardians are rare, the pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent. (emphasis added)
That is the objective needs of the child patient must be the primary focus, not the subjective preferences of his or her parents. In the context of this doctor/child/parent relationship, the doctor’s responsibility to assess the objective needs of his child patient and then present options to the child’s parents. The child’s parents can then assess those options, and using proxy consent, select what they believe is in the ‘best interest’ of the child. Indeed, the British Medical Association discussed this in, The Law and Ethics of Male Circumcision – Guidance for Doctors, where they noted:
Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate.
Dr. Margaret Somerville, a prominent medical ethicist at McGill University, noted in discussing circumcision that, “A medical-benefits or ‘therapeutic’ justification requires that overall the medical benefits should outweigh the risks and harms of the procedure required to obtain them, that this procedure is the only reasonable way to obtain these benefits, and that these benefits are necessary to the well-being of the child.” Does circumcision in the neonatal period:
- Provide benefits that exceed the risks and harms of the procedure?
- Provide benefits that can not reasonably be realized in some other way?
- Provide benefits that are necessary to the welfare of the child?
All taken together, it seems clear that from an ethical point of view, necessary qualifiers to proxy consent include objective need and utilizing proxy consent in such a way that it preserves the personal autonomy of an individual where it is practically possible. That is to say that in the case of neonatal circumcision (or any intervention performed via proxy consent), there should be an objective need and the least invasive means should be favored. If there is no objective clinical need, one cannot say that neonatal circumcision is therapeutic. And if circumcision is not therapeutic then as a medical practice, it can’t be ethical to perform.
Of all the common purported benefits, the only one relevant to an infant is a supposed reduced risk of urinary tract infection in the first year of life. An estimate by the Royal Australasian College of Physicians (RACP) shows that at least 144 circumcisions would be required to prevent one treatable UTI in the first year of life. Chronic renal disease, the more worrisome condition, occurs far less frequently, and is typically the result of abnormalities of the urinary tract. A recently written editorial to the Sydney Morning Herald by Dr. David Forbes, chairman of pediatrics and child health policy and advocacy committee for the RACP, touched on UTIs as they relate to circumcision, noting: “Our changing understanding of the relationship between urinary tract infection and chronic renal disease further weakens the case for routine circumcision.” Considering that UTIs are both rare in boys and treatable, it is difficult to see how such a benefit can justify circumcision in the neonatal period.
Perhaps this is why doctors in the U.S. have shifted their focus to STIs. However, the story here isn’t much different. Setting aside the fact that infants and children don’t need such protection, most large-scale cross-sectional studies (here, here, here, and here) have found little, if any, evidence to support the notion that circumcision is especially effective as a prophylaxis against STIs in first world countries. In fact, data derived from the same studies that have been used to demonstrated a benefit against HIV and HPV also showed no significant benefit against syphilis, gonorrhea, chlamydia, or trichomonas, each of which is treatable.
Of primary recent focus has been HIV and HPV; though, information regarding these two STIs are almost always reported without the appropriate context. For example, when discussing HPV, it is rare to note how common HPV infection is, how rare HPV related cancers are in men, the fact that of the approximately 11,000 cases of cervical cancer diagnosed in the US, over half haven’t ever had a Pap smear and up to 10% haven’t had a Pap smear in more than five years. The Pap test by itself has reduced incidence of cervical cancers by over 75% since its introduction and the incidence continues to be reduced at rate of about 4% per year; perhaps most importantly, there are now not just one but two vaccines available (one that is also available for men) which are in excess of 90% effective against the types of HPV responsible for most of these types of cancers.
The recent news about a potential HIV benefit tends to also exclude context. For example, it isn’t typically made clear that the purported benefit only affect female to male transmission which is by far the least common mode of sexual transmission in most countries outside parts of Africa. A rough estimate suggests that heterosexual American males who are not IV drug users have a lifetime chance of contracting HIV on the order of hundredths of a percent. The Australian Federation of AIDS Organization, in response to an article by Alex Wodak promoting neonatal circumcision, recently put the figure on the lifetime risk of HIV infection in a heterosexual Australian male who doesn’t use IV drugs at 0.02%, noting that, “This very low risk means that the population health benefit of an intervention like generalized circumcision programs would be negligible.” It is difficult to fathom routine infant circumcision on the basis that it might reduce the typical man’s lifetime risk of HIV infection by a few hundredths of a percent. If a male values this minor reduction, he is of course able to choose non-therapeutic circumcision for himself as an adult when the ethical complication involved in proxy consent no longer apply.
The potential benefits that American parents cite when justifying infant circumcision pertain to maladies that can be prevented with less invasive, more effective, methods or can be easily treated should they occur. As exemplified above with respect to HIV, the actual risks faced by males that can be reduced by circumcision are quite low. Whether or not the potential benefits cited are sufficient to justify an irreversible, non-indicated intervention can only be adequately evaluated against the associated risks of surgery using the subjective preferences of the individual affected by the circumcision. Were we were innocent of infant circumcision, it is difficult to believe that such a procedure would gain any support for regular use given what is known today. The lack of clear objective medical need makes routine infant circumcision simply unethical.
Joseph Peterson (Washington, D.C.) has only relatively recently become involved in this issue due mainly to what seems to be significant amount of misinformation American parents have about intact boys as well as the fact that, outside some very specific circumstances, he firmly believes that circumcision is a personal decision that can only be made by the individual. Joe is one of many regular contributors to the Case Against Circumcision forum at Mothering.com as ‘Fellow Traveler’ to provide parents with the information they need to say no to circumcision and later protect their intact boys. Joe is willing to refer or provide similar information to parents at GAB through the comments or by email: firstname.lastname@example.org, or through the CAC forum.
This article is apart of GAB’s Circumcision Series.