Bioethics of neonatal circumcision

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] 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. [cite journal |last=Benatar |first=M. |authorlink= |coauthors=D. Benatar |year=2003 |month=Spring |title=Between prophylaxis and child abuse: the ethics of neonatal male circumcision |journal=American Journal of Bioethics |volume=3 |issue=2 |pages=35–48 |pmid=12859815 |url= |accessdate= |quote= |doi=10.1162/152651603766436216 ] 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." [cite journal |last=Viens |first=A.M. |authorlink= |coauthors= |year=2004 |month=June |title=Male circumcision: Value judgment, harm, and religious liberty |journal=Journal of Medical Ethics |volume=30 |issue=3 |pages=241–247 |pmid= 15173355 |url=http://jme.bmj.com/cgi/content/full/30/3/241-a |accessdate= |quote= |doi=10.1136/jme.2003.003921 ]

Richards (1996) argues that parents only have power to consent to therapeutic procedures. [cite journal |last=Richards |first=D. |authorlink= |coauthors= |year=1996 |month=May |title=Male Circumcision: Medical or Ritual? |journal=Journal of Law and Medicine |volume=3 |issue=4 |pages=371–376 |id= |url=http://www.cirp.org/library/legal/richards/ |accessdate=2008-04-11 |quote= ] Povenmire argues that parents should not have the power to consent to neonatal non-therapeutic circumcision. [cite journal |last=Povenmire |first=R. |authorlink= |coauthors= |year=1998-1999 |month= |title=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=Journal of Gender, Social Policy and the Law |volume=7 |issue=1 |pages=87–123 |pmid=16526136 |url=http://www.cirp.org/library/legal/povenmire/ |accessdate=2008-04-11 |quote= ]

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." [cite journal |last=Canning |first=D.A. |authorlink= |coauthors= |year=2002 |month= |title=Informed consent for neonatal circumcision: an ethical and legal conundrum |journal=Journal of Urology |volume=168 |issue=4, Part 1 |pages=1650–1651 |id= |url=http://www.jurology.com/medline/record/MDLN.12356070 |accessdate= |quote= ]

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. A similar position (2004) has been taken by the College of Physicians and Surgeons of British Columbia.College of Physicians & Surgeons of British Columbia. [https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/malecircum Circumcision (Infant Male)] (2007)]

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

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." [Hellsten SK. [http://jme.bmj.com/cgi/content/full/30/3/248 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] 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". [Fox M, Thomson M. [http://jme.bmj.com/cgi/content/full/31/8/463 A covenant with the status quo? Male circumcision and the new BMA guidance to doctors.] J of Med Ethics 2005;31:463-469]

Circumcision to reduce the risk of HIV infection

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."

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."Rennie S, Muula A, Westreich D. [http://jme.bmj.com/cgi/content/full/33/6/357 Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low-income countries.] Journal of Medical Ethics 2007;33:357-361] 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." [WHO/UNAIDS Technical Consultation. [http://www.who.int/entity/hiv/mediacentre/MCrecommendations_en.pdf Male Circumcision and HIV Prevention: Research Implications for Policy and Programming] . Montreux, 6- 8 March 2007]

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.

ee also

* Circumcision
* Ethics
* Foreskin
* Human rights
* Medical ethics

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Notes