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 replaced, there are differing views regarding the appropriateness of their removal in a healthy child who is unable to provide consent. 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

[edit] Medical ethics

Some medical associations take the position that the parents should determine what is in the best interest of the infant or child,[5][6][7][8] but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue.[9][10] The BMA insists that a non-therapeutic circumcision must not go ahead without the consent of both parents and, if competent, the child himself.[10]

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."[11]

Neonatal circumcision is performed with surrogate consent, which is appropriate according to 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.

– American Academy of Pediatrics: Circumcision Policy Statement[5]

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 not coerce parents, but should assist parents in their decision by "explaining the potential benefits and risks and by ensuring that they [the parents] understand that circumcision is an elective procedure." The Academy's Committee on Bioethics approved this policy statement.[5]

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 UTI’s 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."[12]

Views differ on whether limits should be placed on caregivers having a child circumcised.

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.[13]

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."[14]

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 "[c]ircumcision is unnecessary and harmful: therefore, not in the infant's best interest."[15] 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.[16] 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 which 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."[17]

Richards (1996) argues that parents only have power to consent to therapeutic procedures.[18] Povenmire argues that parents should not have the power to consent to neonatal non-therapeutic circumcision.[19]

Canning (2002) commented that "[i]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."[20]

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. The doctor must consider the child's legal and human rights in making his or her determination. They state that a physician has a right to refuse to perform a non-therapeutic circumcision.[10] A similar position (2004) has been taken by the College of Physicians and Surgeons of British Columbia.[21]

Holm (2004) alleges 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."[22]

Describing arguments in support of circumcision as "rationalisations", Hellsten (2004) expresses the view 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."[23] 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".[24]

[edit] Circumcision to reduce the risk of HIV infection

See also: Medical analysis of circumcision

Rennie et al (2007) remark that the results of three randomised controlled trials, showing reduced risk of HIV among circumcised men, "alter the terms of the debate over the ethics of male circumcision."[25]

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 reduced risk of catching HIV and other alleged benefits of circumcision make it worthwhile. Rennie et al argue that "it would be unethical to not seriously consider one of the most promising—although also one of the most controversial—new approaches to HIV-prevention in the 25-year history of the epidemic."[25] However, there remains a risk of HIV while engaging in unprotected sex and other high risk behaviors.

The World Health Organization (2007) describes the efficacy of circumcision as "proven beyond reasonable doubt", but states that provision of circumcision should be consistent with "medical ethics and human rights principles." They state that "[i]nformed consent, confidentiality and absence of coercion should be assured. ... Parents who are responsible for providing consent, including for the circumcision of male infants, should be given sufficient information regarding the benefits and risks of the procedure in order to determine what is in the best interests of the child."[26]

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. Others would argue that baby boys do not immediately need such protection and can choose for themselves, at a later stage, if they want a circumcision.[13]

[edit] See also

[edit] References

[edit] Notes

  1. ^ Fleiss, PM; FM Hodges, RS Van Howe (October 1998). "Immunological functions of the human prepuce" (PDF). Sexually Transmitted Infections 74 (5): 364–367. PMID 10195034. 
  2. ^ Cold, C.J.; J.R Taylor (January 1999). "The Prepuce" (PDF). British Journal of Urology 83 (Suppl. 1): 34-44. doi:10.1046/j.1464-410x.1999.0830s1034.x. PMID 10349413. 
  3. ^ Moses, S; Bailey, RC; Ronald AR (October 1998). "Male circumcision: assessment of health benefits and risks". Sexually Transmitted Infections 74 (5): 368-373. PMID 10195035. 
  4. ^ Schoen, Edgar J (1997). "Benefits of newborn circumcision: is Europe ignoring medical evidence?" ((free registration required)). Archives of Disease in Childhood 77 (3): 258-260. PMID 9370910. 
  5. ^ a b c American Academy of Pediatrics Task Force on Circumcision (March 1, 1999). "Circumcision Policy Statement" (PDF). Pediatrics 103 (3): 686–693. doi:10.1542/peds.103.3.686. ISSN 0031-4005 PMID 10049981. 
  6. ^ Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision. 1999 AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports 17. American Medical Association (December 1999). Retrieved on 2006-06-13.
  7. ^ Fetus and Newborn Committee (March 1996). "Neonatal circumcision revisited". Canadian Medical Association Journal 154 (6): 769–780.  “We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.
  8. ^ Medical Ethics Committee (June 2006). The law and ethics of male circumcision - guidance for doctors. British Medical Association. Retrieved on 2006-07-01. “Circumcision for medical purposes 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. Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.
    Non-therapeutic circumcision Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes “ritual”) circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths. There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.    ”
  9. ^ Policy Statement On Circumcision (PDF). Royal Australasian College of Physicians (September 2004). Retrieved on 2007-02-28. “The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups.…In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.…The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarizing the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.”
  10. ^ a b c Medical Ethics Committee (June 2006). The law and ethics of male circumcision - guidance for doctors. British Medical Association. Retrieved on 2006-07-01.
  11. ^ Mussell, R. (June 2004). "The development of professional guidelines on the law and ethics of male circumcision". Journal of Medical Ethics 30 (3): 254-258. doi:10.1136/jme.2004.008615. PMID 15173358. 
  12. ^ Royal Australasian College of Physicians. Policy Statement On Circumcision. [online; accessed 16 Aug 2007]
  13. ^ a b Somerville, Margaret (November 2000). "Altering Baby Boys’ Bodies: The Ethics of Infant Male Circumcision", The ethical canary: science, society, and the human spirit. New York, NY: Viking Penguin Canada, 202–219. LCCN 2001-369341. ISBN 0670893021. Retrieved on 2007-02-12. 
  14. ^ Benatar, David; Benatar, Michael (2003). "How not to argue about circumcision". American Journal of Bioethics 3 (2): W1-W9. doi:10.1162/152651603102387820. 
  15. ^ Denniston, G.C. (April 1996). "Circumcision and the Code of Ethics". Humane Health Care International 12 (2): 78-80. PMID 14986604. 
  16. ^ Benatar, M.; D. Benatar (Spring 2003). "Between prophylaxis and child abuse: the ethics of neonatal male circumcision". American Journal of Bioethics 3 (2): 35-48. doi:10.1162/152651603766436216. PMID 12859815. 
  17. ^ Viens, A.M. (June 2004). "Male circumcision: Value judgment, harm, and religious liberty". Journal of Medical Ethics 30 (3): 241-247. doi:10.1136/jme.2003.003921. PMID 15173355. 
  18. ^ Richards, D. (May 1996). "Male Circumcision: Medical or Ritual?". Journal of Law and Medicine 3 (4): 371-376. 
  19. ^ Povenmire, R. (1998-1999). "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". Journal of Gender, Social Policy and the Law 7 (1): 87-123. PMID 16526136. 
  20. ^ Canning, D.A. (2002). "Informed consent for neonatal circumcision: an ethical and legal conundrum.". Journal of Urology 168 (4, Part 1): 1650-1651. 
  21. ^ College of Physicians & Surgeons of British Columbia. Circumcision (Infant Male) (2007)
  22. ^ Holm S. Irreversible bodily interventions in children. J Med Ethics 2004;30:237
  23. ^ 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 Jun;30(3):248-53
  24. ^ Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J of Med Ethics 2005;31:463-469
  25. ^ a b Rennie S, Muula A, Westreich D. Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low-income countries. Journal of Medical Ethics 2007;33:357-361
  26. ^ WHO/UNAIDS Technical Consultation. Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6- 8 March 2007