Difference between revisions of "Ethics of non-therapeutic child circumcision"

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Male [[circumcision]] is the surgical removal of the [[foreskin]] (prepuce) from the human [[penis]].<ref name=sawyer_2011>{{REFbook
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|last=Sawyer
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|init=S
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|title=Pediatric Physical Examination & Health Assessment
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|pages=555-556
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|date=2011-11
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|publisher=Jones & Bartlett Publishers
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|isbn=978-1-4496-7600-1
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|url=https://books.google.com/books?id=W6eRUtlujbkC&pg=PA555
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}}</ref> The foreskin has protective, immunological, sensory, and sexual functions. The '''ethics of non-therapeutic child circumcision''' being imposed on unconsenting minors (babies and children) has been a source of ongoing controversy.<ref>{{BoyleGJ SvobodaJS PriceCP TurnerJN 2000}}</ref><ref name="RACPSumm">{{REFweb
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|url=http://www.racp.edu.au/download.cfm?DownloadFile=A453CFA1-2A57-5487-DF36DF59A1BAF527
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|title=Policy Statement On Circumcision
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|accessdate=2007-02-28
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|date=2004-09
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|format=PDF
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|publisher=[[Royal Australasian College of Physicians]]
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|quote=
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|archiveurl=https://web.archive.org/web/20080720092409/http://www.racp.edu.au/download.cfm?DownloadFile=A453CFA1-2A57-5487-DF36DF59A1BAF527
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|archivedate=2008-07-20
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}}</ref><ref name="bma2006">Committee on Medical Ethics. [https://www.bma.org.uk/advice/employment/ethics/children-and-young-people/non-therapeutic-male-circumcision-of-children-ethics-toolkit The law and ethics of male circumcision: Guidance for doctors]. London: British Medical Association 2006.</ref>
  
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Some [[Medical trade association| medical trade associations]] formerly took the position that the parents should determine what is in the best interest of the newborn, infant, or child.<ref name="AAP1999">{{REFjournal
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|last=Task force on circumcision
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|title=Circumcision policy statement
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|journal=Pediatrics
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|date=1999
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|volume=103
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|issue=3
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|pages=686-693
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|url=http://pediatrics.aappublications.org/content/103/3/686
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|DOI=10.1542/peds.103.3.686
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|pubmedID=10049981
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|pubmedCID=
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}},</ref> however the AAP has now abandoned all previous position statements on male [[circumcision]].
  
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Male [[circumcision]] is the surgical removal of the [[foreskin]] (prepuce) from the [[human penis]].<ref name=sawyer_2011>{{vcite book |author=Sawyer S |title=Pediatric Physical Examination & Health Assessment |pages=555–556 |date=November 2011 |publisher=Jones & Bartlett Publishers |isbn=978-1-4496-7600-1 |url=https://books.google.com/books?id=W6eRUtlujbkC&pg=PA555}}</ref>  The '''ethics of non-therapeutic child circumcision''' being imposed on unconsenting minors ([[babies]] and [[children]]) has been a source of ongoing [[Circumcision controversies|controversy]].<ref>{{cite journal | author = Boyle G.J., Svoboda J.S., Price C. P., Turner J.N. | year = 2000 | title = Circumcision of healthy boys: Criminal assault? | url = | journal = Journal of Law and Medicine | volume = 7 | issue = | pages = 301–310 }}</ref><ref name="RACPSumm">{{cite web|url=http://www.racp.edu.au/download.cfm?DownloadFile=A453CFA1-2A57-5487-DF36DF59A1BAF527|title=Policy Statement On Circumcision|accessdate=2007-02-28|date=September 2004|format=PDF|publisher=[[Royal Australasian College of Physicians]]|quote=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% and includes tenderness, bleeding and unhappy results to the appearance of the penis. Serious complications such as bleeding, septicaemia and may occasionally cause death (1 in 550,000). 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. |archiveurl = https://web.archive.org/web/20080720092409/http://www.racp.edu.au/download.cfm?DownloadFile=A453CFA1-2A57-5487-DF36DF59A1BAF527 |archivedate = 2008-07-20}}</ref><ref name = "BMAGuide">{{vcite web| url = http://www.bma.org.uk/ap.nsf/Content/malecircumcision2006?OpenDocument&Highlight=2,circumcision| title = The law and ethics of male circumcision - guidance for doctors| accessdate = 2006-07-01| author = Medical Ethics Committee|date=June 2006| publisher = [[British Medical Association]]|archiveurl = https://web.archive.org/web/20071112055050/http://www.bma.org.uk/ap.nsf/Content/malecircumcision2006?OpenDocument&Highlight=2,circumcision |archivedate = 2007-11-12}}</ref>
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Others say that circumcision is an infringement of the child's autonomy and should be delayed until he is capable of making the decision himself.<ref name="KNMG2010">[http://circumstitions.com/Docs/KNMG-policy.pdf Non-Therapeutic Circumcision of Male Minors]. Utrecht: Royal Dutch Medical Association, 2010.</ref> A circumcision operation may be performed at any age, so an [[intact]] boy may elect to have a [[circumcision]] whenever he wishes.
  
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Some medical associations take the position that the parents should determine what is in the best interest of the infant or child.<ref name="AAP1999">{{vcite journal | author=Task force on circumcision | title=Circumcision policy statement | journal=Pediatrics | date=1999 | volume=103 | issue=3 | pages=686–93 | url=http://pediatrics.aappublications.org/content/103/3/686 | doi=10.1542/peds.103.3.686 | pmid= 10049981 | pmc= }}</ref> Others say that circumcision is an infringement of the child's autonomy and should be prolonged until he is capable of making the decision himself.<ref>{{Cite book|url=https://books.google.com/?id=C1T6NrSPD_AC|title=Clinical Ethics in Pediatrics: A Case-Based Textbook|last=Diekema|first=Douglas S.|last2=Mercurio|first2=Mark R.|last3=Adam|first3=Mary B.|date=2011-09-08|publisher=Cambridge University Press|isbn=9781139501835|location=|pages=43–48|language=en}}</ref><ref name="knmg.artsennet.nl2">[http://knmg.artsennet.nl/web/file?uuid=579e836d-ea83-410f-9889-feb7eda87cd5&owner=a8a9ce0e-f42b-47a5-960e-be08025b7b04&contentid=77976&elementid=771754 Non-Therapeutic Circumcision of Male Minors]. Utrecht: Royal Dutch Medical Association, 2010.</ref>
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==Medical trade association views==
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==Medical body's views==
 
 
===Australia and New Zealand===
 
===Australia and New Zealand===
 
[[File:Flag of Australia (converted).svg|thumb|upright=0.3]]
 
[[File:Flag of Australia (converted).svg|thumb|upright=0.3]]
  
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The [[Royal Australasian College of Physicians]] (2010) released a statement indicating that neonatal male circumcision "generally considered an ethical procedure", provided that 1) the child's decision makers, typically the parents, are acting in best interest of child and have been given full knowledge and 2) the procedure is performed by a competent provider, with sufficient analgesia, and does not unnecessarily harm the child or have substantial risks.<ref name=":0">[https://www.racp.edu.au/docs/default-source/advocacy-library/circumcision-of-infant-males.pdf Circumcision of Male Infants.] [[Royal Australasian College of Physicians]]. September 2010.</ref> They argue that parents should be allowed to be the primary decision-makers because providers may not understand the full psychosocial benefits of circumcision.<ref name=":0" /> Additionally, this procedure does not present substantial harm compared to its potential benefits, so parents should be allowed full decision-making capacity as long as they are educated properly.<ref name=":0" />
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The [https://www.racp.edu.au/ Royal Australasian College of Physicians] (2010) released a statement indicating that neonatal male circumcision "generally considered an ethical procedure", provided that 1) the child's decision makers, typically the parents, are acting in best interest of child and have been given full knowledge and 2) the procedure is performed by a competent provider, with sufficient analgesia, and does not unnecessarily harm the child or have substantial risks.<ref name="racp2010">[https://www.racp.edu.au/docs/default-source/advocacy-library/circumcision-of-infant-males.pdf Circumcision of Male Infants.] [[Royal Australasian College of Physicians]]. September 2010.</ref> They argue that parents should be allowed to be the primary decision-makers because providers may not understand the full psychosocial benefits of circumcision.<ref name="racp2010" /> Additionally, this procedure does not present substantial harm compared to its potential benefits, so parents should be allowed full decision-making capacity as long as they are educated properly.<ref name="racp2010"/>
  
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This statement also recognizes that waiting until the boy is of sufficient age to make his own decision would better respect his autonomy, but points out that this may interfere with a child's religious inclusion that circumcision was meant to confer.<ref name=":0" /> With neonatal male circumcision, they acknowledge that the child may later on disagree with the parents' decision <ref name=":0" /> but using the same reasoning, an uncircumcised child may also disagree with his parents' decision not to have him circumcised in infancy.<ref name=":0" />
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This statement also recognizes that waiting until the boy is of sufficient age to make his own decision would better respect his autonomy, but points out that this may interfere with a child's religious inclusion that [[circumcision]] was meant to confer.<ref name="racp2010"/> With neonatal male circumcision, they acknowledge that the child may later on disagree with the parents' decision <ref name="racp2010"/> but using the same reasoning, an [[uncircumcised]] child may also disagree with his parents' decision not to have him circumcised in infancy,<ref name="racp2010"/> but he can have a circumcision at any age.
  
 
===Canada===
 
===Canada===
 
[[File:Flag of Canada (Pantone).svg|thumb|upright=0.3]]
 
[[File:Flag of Canada (Pantone).svg|thumb|upright=0.3]]
  
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The [[Canadian Paediatric Society]] (CPS) issued a position statement on September 8, 2015, which highlighted the ethical issue surrounding the child's inability to give consent.<ref name="CPS20152">{{vcite journal|author=Sorakan ST, Finlay JC, Jefferies AL|title=Newborn male circumcision|journal=Paediatr Child Health|date=2015|volume=20|issue=6|pages=311–5|url=http://www.cps.ca/en/documents/position/circumcision|doi=|pmid=26435672|pmc=4578472}}</ref> Since children require a substituted decision maker acting in their best interests, they recommend to hold off non-medically indicated procedures, such as circumcision, until children can make their own decisions. Yet the CPS also states that parents of male newborns must receive unbiased information about neonatal circumcision, so that they can weigh specific risks and benefits of circumcision in the context of their own familial, religious and cultural beliefs.<ref name="CPS20152" />
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The [[Canadian Paediatric Society]] (CPS) issued a position statement on September 8, 2015, which highlighted the ethical issue surrounding the child's inability to give consent.<ref name="CPS2015">{{REFjournal
 +
|last=Sorakan
 +
|init=ST
 +
|last2=Finla
 +
|init2=JC
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|last3=Jefferies
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|init3=AL
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|title=Newborn male circumcision
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|journal=Paediatr Child Health
 +
|date=2015
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|volume=20
 +
|issue=6
 +
|pages=311-315
 +
|url=http://www.cps.ca/en/documents/position/circumcision
 +
|DOI=
 +
|pubmedID=26435672
 +
|pubmedCID=4578472
 +
}}</ref> Since children require a substituted decision maker acting in their best interests, they recommend deferring non-medically indicated procedures, such as [[circumcision]], until children can make their own decisions. Yet the CPS also self-servingly states that parents of male newborns must receive unbiased information about neonatal circumcision, so that they can weigh specific risks and benefits of circumcision in the context of their own familial, religious and cultural beliefs!<ref name="CPS2015"/>
  
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===Denmark===
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=== [[Denmark]] ===
 
[[File:Flag of Denmark.svg|thumb|upright=0.3]]
 
[[File:Flag of Denmark.svg|thumb|upright=0.3]]
  
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The [[Danish Medical Association]] (''Lægeforeningen'') has released a statement (2016) regarding the circumcision of boys under the age of eighteen years. The organization says that the decision to circumcise should be "an informed personal choice" that men should make for themselves in adulthood.<ref>{{vcite news|author=Erin McCann|title=Danish Doctors’ Group Wants to End Circumcision for Boys|url=https://www.nytimes.com/2016/12/08/world/europe/circumcision-boys-babies.html?_r=1|work=The New York Times|date=8 December 2016}}</ref> According to Dr. Lise Møller, the chairwoman of the Doctors’ Association's Ethics Board, allowing the individual to make this decision himself when he is of age respects his right of self-determination.<ref>{{vcite news|author=|author.=|title=Danish doctors come out against circumcision.|title.=|trans_title=|url=https://www.thelocal.dk/20161205/danish-doctors-come-out-against-circumcision|format=|work=|work.=|location=The Local|edition=|workformat=|date=5 December 2016|update=|accessdate=|sectionphrase=|section=|pages=|column=|language=|agency=|publisher=|id=|quote=|notes=|harvid=|ref=}}</ref>
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The Danish Medical Association (''Lægeforeningen'') has released a statement (2016) regarding the circumcision of boys under the age of eighteen years. The organization says that the decision to circumcise should be "an informed personal choice" that men should make for themselves in adulthood.<ref>{{REFnews
 +
|first=Erin
 +
|last=McCann
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|title=Danish Doctors’ Group Wants to End Circumcision for Boys
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|url=https://www.nytimes.com/2016/12/08/world/europe/circumcision-boys-babies.html?_r=1
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|work=The New York Times
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|date=2016-12-08
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}}</ref> According to Dr. Lise Møller, the chairwoman of the Doctors’ Association's Ethics Board, allowing the individual to make this decision himself when he is of age respects his right of self-determination.<ref>{{REFnews
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|title=Danish doctors come out against circumcision
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|url=https://www.thelocal.dk/20161205/danish-doctors-come-out-against-circumcision
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|location=The Local
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|date=2016-12-05
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|accessdate=2019-11-02
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}}</ref>
  
 
===Netherlands===
 
===Netherlands===
 
[[File:Flag of the Netherlands.svg|thumb|upright=0.3]]
 
[[File:Flag of the Netherlands.svg|thumb|upright=0.3]]
  
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The [[Royal Dutch Medical Association]] (''Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst'') (KNMG) and several Dutch specialist medical societies published a statement of position regarding circumcision of male children on 27 May 2010. The KNMG argues against circumcising male minors due to lack of evidence the procedure is useful or necessary, its associated risks, and violate the child's autonomy.<ref name="knmg.artsennet.nl2"/> They recommend deferring circumcision until the child is old enough to decide for himself.<ref name="knmg.artsennet.nl2" /> The Royal Dutch Medical Association questions why the ethics regarding male genital alterations should be viewed any differently from female genital alterations, when there are mild forms of female genital alterations (like pricking the [[clitoral hood]] without removing any tissue or removing the clitoral hood altogether). They have expressed opposition to both male circumcision and all forms of female circumcision, however they do not advocate a prohibition of male circumcision and prefer that circumcisions be done by doctors instead of illegal, underground circumcisers .<ref name="knmg.artsennet.nl2" />
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The [[Royal Dutch Medical Association]] (''Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst'') (KNMG) and several Dutch specialist medical societies published a statement of position regarding circumcision of male children on 27 May 2010. The KNMG argues against circumcising male minors due to lack of evidence the procedure is useful or necessary, its associated risks, and violate the child's autonomy.<ref name="KNMG2010"/> They recommend deferring circumcision until the child is old enough to decide for himself.<ref name="KNMG2010" /> The Royal Dutch Medical Association questions why the ethics regarding male genital alterations should be viewed any differently from female genital alterations, when there are mild forms of female genital alterations (like pricking the clitoral hood without removing any tissue or removing the clitoral hood altogether). They have expressed opposition to both male circumcision and all forms of female circumcision, however they do not advocate a prohibition of male circumcision and prefer that circumcisions be done by doctors instead of illegal, underground circumcisers .<ref name="KNMG2010"/>
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On the contrary, the Dutch Council on Public Health and Care does not agree with the Royal Dutch Medical Organisation and states that they wrongly do not distinguish between male and female circumcision and that they do not take into account freedom of religion and the right of parents to raise their children according their own beliefs or convictions.<ref>{{Cite web|url=https://web.archive.org/web/20111203065953/http://rvz.net/nieuws/bericht/de-ene-besnijdenis-is-de-andere-niet-reactie-op-knmg-standpunt-jongensbesn|title=De ene besnijdenis is de andere niet. Reactie op KNMG standpunt jongensbesnijdenis {{!}} RVZ - Raad voor Volksgezondheid & Zorg|date=2011-12-03|website=web.archive.org|access-date=2019-06-14}}</ref>
 
  
 
=== Scandinavia ===
 
=== Scandinavia ===
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In 2013 children's [[ombudsmen]] from [[Sweden]], [[Norway]], [[Finland]], [[Denmark]], and [[Iceland]], along with the Chair of the Danish Children's Council and the children's spokesperson for [[Greenland]], passed a resolution that emphasized the decision to be circumcised should belong to the individual, who should be able to give informed consent.<ref name="resolution2">{{vcite web|author=Nordic Association of Children's Ombudsmen|home=|title=Let the boys decide for themselves|url=https://www.crin.org/en/library/news-archive/male-circumcision-nordic-ombudspersons-seek-ban-non-therapeutic-male|date=30 September 2013|accessdate=22 October 2013}}[] Tuesday, 1 October 2013</ref>
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In 2013 children's ombudsmen from Sweden, Norway, Finland, [[Denmark]], and Iceland, along with the Chair of the Danish Children's Council and the children's spokesperson for Greenland, passed a resolution that emphasized the decision to be circumcised should belong to the individual, who should be able to give [[informed consent]].<ref name="resolution2">{{REFweb
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|last=Nordic Association of Children's Ombudsmen
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|title=Let the boys decide for themselves
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|url=https://archive.crin.org/en/docs/English-statement-.pdf
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|date=2013-09-30
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|accessdate=2019-11-03
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}}[] Tuesday, 1 October 2013</ref>
  
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The Nordic Association of Clinical Sexologists supports the position of the Nordic Association of Ombudsmen who reason that circumcision violates the individual's human rights by denying the male child his ability to make the decision for himself.<ref>[http://nacs.eu/data/press_release001.pdf Statement on Non-Therapeutic Circumcision of Boys.]. Nordic Association of Clinical Sexologists, Helsinki, 10 October 2013.</ref>
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The Nordic Association of Clinical Sexologists supports the position of the Nordic Association of Ombudsmen who reason that circumcision violates the individual's [[human rights]] by denying the male child his ability to make the decision for himself.<ref>[http://nacs.eu/data/press_release001.pdf Statement on Non-Therapeutic Circumcision of Boys.]. Nordic Association of Clinical Sexologists, Helsinki, 10 October 2013.</ref>
  
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The medical doctors at Sørland Hospital in [[Kristiansand]], Southern [[Norway]] have all refused to perform circumcisions on boys, citing reasons of conscience.<ref>{{vcite news|author=Solrun F. Faull|title=Hospital doctors in Southern Norway will not circumcise boys|url=http://norwaytoday.info/news/hospital-doctors-southern-norway-will-not-circumcise-boys/|work=Norway Today|date=30 August 2016}}</ref>
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The medical doctors at Sørland Hospital in Kristiansand, Southern Norway have all refused to perform circumcisions on boys, citing reasons of conscience.<ref>{{REFnews
 +
|first=Solrun F.
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|last=Faull
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|title=Hospital doctors in Southern Norway will not circumcise boys
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|url=http://norwaytoday.info/news/hospital-doctors-southern-norway-will-not-circumcise-boys/
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|work=Norway Today
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|date=2016-08-30
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}}</ref>
  
 
===United Kingdom===
 
===United Kingdom===
 
[[File:Flag of the United Kingdom.svg|thumb|upright=0.3]]
 
[[File:Flag of the United Kingdom.svg|thumb|upright=0.3]]
  
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The medical ethics committee of the [[British Medical Association]] also reviewed the ethics behind circumcision. Since circumcision has associated medical and psychological risks with no unequivocally proven medical benefits, they advise physicians to keep up with clinical evidence and only perform this procedure if it's in the child best interest.<ref name=":02">Committee on Medical Ethics. [http://bma.org.uk/-/media/Files/PDFs/Practical%20advice%20at%20work/Ethics/Circumcision.pdf The law & ethics of male circumcision: guidance for doctors]; June 2006 [Retrieved 25 November 2013.].</ref> However, they acknowledge the procedure as a cultural and religious practice, which may be an important ritual for the child's incorporation into the group.<ref name=":02" /> They recognize that parents have the authority to make choices for their child, and they emphasize it is important for parents to act in their child's best interest.<ref name=":02" /> They ultimately report that views vary in their community about the benefits and risks of the procedure, and there is no clear policy for this situation.<ref name=":02" />
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====2019 revision of BMA guidance====
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Commenting on the development of the 2003 British Medical Association guidance on circumcision, Mussell (2004) reports that debate in society is highly polarized, and he attributes it to the different faiths and cultures that make up BMA.<ref name=":1">{{cite journal|last=Mussell|first=R.|authorlink=|date=June 2004|title=The development of professional guidelines on the law and ethics of male circumcision|url=http://jme.bmj.com/cgi/content/full/30/3/254|journal=Journal of Medical Ethics|volume=30|issue=3|pages=254–258|doi=10.1136/jme.2004.008615|pmc=1733857|pmid=15173358|accessdate=|quote=}}</ref> He identifies this as a difficulty in achieving consensus within the medical ethics committee. Arguments put forward in discussions, according to Mussell, included the social and cultural benefits of circumcision, the violation of the child's rights, and the violation of the child's autonomy.<ref name=":1" />
 
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====Adult circumcision====
 
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In a paper published June 2006, the [[British Medical Association]] Committee on Medical Ethics does not consider circumcision of an adult male to be controversial, provided that the adult is of sound mind and grants his personal consent after receiving all material information regarding the known risks, disadvantages, and potential benefits to be derived from the surgical operation.<ref name="BMA2006">{{vcite web |
 
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author=Committee on Medical Ethics | home= | title=The law &amp; ethics of male circumcision: guidance for doctors | url=http://bma.org.uk/-/media/Files/PDFs/Practical%20advice%20at%20work/Ethics/Circumcision.pdf | date= June 2006 | accessdate= 25 November 2013.}}</ref>
 
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Circumcision of adults as a public health measure for the purpose of reducing the spread of [[Circumcision and HIV|HIV]] also involves ethical concerns such as informed consent and concerns about reducing attention paid to other measures. According to the [[Centers for Disease Control and Prevention|CDC]] website, research has documented a significant reduction of HIV/AIDS transmission when a male is circumcised.<ref>{{cite web|title=HIV and Male Circumcision {{!}} Gateway to Health Communication {{!}} CDC|url=https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/hivcircumcision.html|website=www.cdc.gov|language=en-us|date=23 February 2017}}</ref>
 
  
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====Child circumcision====
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The [[British Medical Association]], being cognizant of the [[Re B and G (children) (No 2) EWFC 3]] (2015) and [[Re L and B (CHILDREN)]] (2016) family court decisions, issued a new guidance to its member physicians in 2019. The new guidance urges its member physicians to take an extremely cautious approach to parental requests for the performance of non-therapeutic [[circumcision]] on minor boys and to ascertain that the requested non-therapeutic circumcision is in the boy's best interests.<ref name="bma2019">{{REFdocument
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In the same British Medical Association paper, circumcision of a child to treat a clear and present medical indication after a trial of conservative treatment also is not considered to be ethically questionable, provided that a suitable [[wikt:surrogate|surrogate]] has granted surrogate consent after receiving all material information regarding the known risks, disadvantages, and potential benefits to be derived from the surgical operation.<ref name="BMA2006" />
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|title=Non-therapeutic male circumcision (NTMC) of children – practical guidance for doctors
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|url=https://www.bma.org.uk/media/1847/bma-non-therapeutic-male-circumcision-of-children-guidance-2019.pdf
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|contribution=
 +
|last=Anonymous
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|first=
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|publisher=British Medical Association
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|format=PDF
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|date=2019
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|accessdate=2021-06-29
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}}</ref>
  
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====Criticism and revision of BMA statement====
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[[Antony Lempert| Lempert]] et al. (2022) criticized the 2019 BMA guidance for "serious weaknesses". They listed:
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The BMA statement of 2003 took the position that non-therapeutic circumcision of children is lawful in the United Kingdom.<ref name="BMA2003" /> British law professors Fox & Thomson (2005), citing the [[House of Lords]] case of [[R v Brown]], challenged this statement. They argued that consent cannot make an unlawful act lawful.<ref name="fox-thomson">{{vcite journal |
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# the absence of an explicit stance on the underlying ethical status of NPC, coupled with an implicit permissive stance,<br>
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author=Fox M, Thomson M | title=A covenant with the status quo? Male circumcision and the new BMA guidance to doctors | journal=J Med Ethics | date=2005 | volume=31 | issue=8 | pages=463–9 | url=http://jme.bmj.com/content/31/8/463.full | doi=10.1136/jme.2004.009340 | pmid=16076971 | pmc=1734197 }}</ref> The BMA issued a revised statement in 2006 and now reports the controversy regarding the lawfulness of non-therapeutic child circumcision and recommends that doctors obtain the consent of ''both'' parents before performing non-therapeutic circumcision of a male minor. The revised statement now mentions that male circumcision is generally assumed to be lawful provided that it is performed competently,  is believed to be in the child's best interests, and there is valid consent from both parent or the child if it is capable of expressing a view.<ref name="BMA2006" />
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# an incoherent and impracticable analysis of the child’s best interests,<br>
 +
# unbalanced guidance regarding cultural issues,<br>  
 +
# unbalanced guidance regarding scientific issues,<br>
 +
# unjustified differential treatment of children of the same sex,<br>
 +
# unjustified differential treatment of children of different sexes,<br>
 +
# problems with child safeguarding, and
 +
# problems with regulation and training,<br>
 +
# an unjustified presumption of lawfulness of NPC of minors, and<br>
 +
# failure adequately to address recent case law.<ref name="lempert2022">{{REFjournal
 +
|last=Lempert
 +
|first=Antony
 +
|init=A
 +
|author-link=Antony Lempert
 +
|last2=Chegwidden
 +
|first2=James
 +
|init2=J
 +
|author2-link=James Chegwidden
 +
|last3=Steinfeld
 +
|first3=Rebecca
 +
|init3=R
 +
|author3-link=Rebecca Steinfeld
 +
|last4=Earp
 +
|first4=Brian D.
 +
|init4=BD
 +
|author4-link=Brian D. Earp
 +
|etal=no
 +
|title=Non-therapeutic penile circumcision of minors: Current controversies in UK law and medical ethics.
 +
|journal=Clinical Ethics
 +
|location=
 +
|date=2022-05
 +
|season=
 +
|volume
 +
|issue=
 +
|article=
 +
|page=
 +
|pages=
 +
|url=https://www.researchgate.net/publication/360642209_Non-therapeutic_Penile_Circumcision_of_Minors_Current_Controversies_in_UK_Law_and_Medical_Ethics
 +
|archived=
 +
|quote=
 +
|pubmedID=
 +
|pubmedCID=
 +
|DOI=
 +
  |accessdate=2022-05-20
 +
}}</ref>
  
 
===United States===
 
===United States===
Line 62: Line 178:
  
 
==== American Academy of Pediatrics ====
 
==== American Academy of Pediatrics ====
−
The American Academy of Pediatrics currently has no official stance on neonatal circumcision.<ref>{{Cite journal|last=Circumcision|first=Task Force On|date=2012-09-01|title=Circumcision Policy Statement|url=https://pediatrics.aappublications.org/content/130/3/585|journal=Pediatrics|language=en|volume=130|issue=3|pages=585–586|doi=10.1542/peds.2012-1989|issn=0031-4005|pmid=22926180}}</ref><ref>{{Cite web|url=https://pediatrics.aappublications.org/content/pediatrics/130/3/e756.full.pdf|title=TECHNICAL REPORT Male Circumcision|last=AAP}}</ref>
+
The [[American Academy of Pediatrics]] currently has ''no'' official stance on neonatal circumcision. The previous statement expired in 2017 and has not been reaffirmed.<ref>{{REFjournal
 +
|last=Task Force On Circumcision
 +
|date=2012-09-01
 +
|title=Circumcision Policy Statement
 +
|url=https://pediatrics.aappublications.org/content/130/3/585
 +
|journal=Pediatrics
 +
|language=en
 +
|volume=130
 +
|issue=3
 +
|pages=585-586
 +
|DOI=10.1542/peds.2012-1989
 +
|issn=0031-4005
 +
|pubmedID=22926180
 +
}}</ref><ref>{{REFweb
 +
|url=https://pediatrics.aappublications.org/content/pediatrics/130/3/e756.full.pdf
 +
|title=TECHNICAL REPORT Male Circumcision
 +
|last=AAP
 +
}}</ref>
  
 
=====Criticism=====
 
=====Criticism=====
−
The expired American Academy of Pediatrics (AAP) position statement on male circumcision (2012) has attracted significant critical comment, including from the AAP itself.
+
The expired American Academy of Pediatrics (AAP) position statement on male circumcision (2012) attracted significant critical comment during its brief life, including from the AAP itself.
  
−
In a dissenting paper, Frisch et al point out "Circumcision fails to meet the criteria to serve as a preventive measure for UTI [...] As a preventive measure for penile cancer, circumcision also fails to meet the criteria for preventive medicine [...] circumcision for HIV protection in Western countries fails to meet the criteria for preventive medicine [...] Circumcision fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children."
+
In a dissenting paper, Frisch et al. (2013) point out "Circumcision fails to meet the criteria to serve as a preventive measure for UTI [...] As a preventive measure for penile cancer, circumcision also fails to meet the criteria for preventive medicine [...] circumcision for [[HIV]] protection in Western countries fails to meet the criteria for preventive medicine [...] Circumcision fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children."
  
−
Frisch et all conclude that "The AAP report2 lacks a serious discussion of the central ethical dilemma with, on 1 side, parents’ right to act in the best interest of the child on the basis of cultural, religious, and health-related beliefs and wishes and, on the other side, infant boys’ basic right to physical integrity in the absence of compelling reasons for surgery. Physical integrity is 1 of the most fundamental and inalienable rights a child has. Physicians and their professional organizations have a professional duty to protect this right, irrespective of the gender of the child."
+
Frisch et al. conclude that "The AAP report lacks a serious discussion of the central ethical dilemma with, on one side, parents’ right to act in the best interest of the child on the basis of cultural, religious, and health-related beliefs and wishes and, on the other side, infant boys’ basic right to physical integrity in the absence of compelling reasons for surgery. Physical integrity is one of the most fundamental and inalienable rights a child has. Physicians and their professional organizations have a professional duty to protect this right, irrespective of the gender of the child."
  
−
Van Howe & Svoboda (2013) criticize their statement because it failed to include important points, in accurately analyzed and interpret current medical literature, and made unsupported conclusions.<ref>{{Cite journal|last=Howe|first=Robert S. Van|last2=Svoboda|first2=J. Steven|date=2013-07-01|title=Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision|url=https://jme.bmj.com/content/39/7/434|journal=Journal of Medical Ethics|language=en|volume=39|issue=7|pages=434–441|doi=10.1136/medethics-2013-101346|issn=0306-6800|pmid=23508208}}</ref>
+
[[Robert S. Van Howe|Van Howe]] & [[J. Steven Svoboda|Svoboda]] (2013) criticize the AAP statement because it failed to include important points, in accurately analyzed and interpret current medical literature, and made unsupported conclusions.<ref>{{REFjournal
 +
|last=Van Howe
 +
|first=Robert S.
 +
|init=RS
 +
|author-link=Robert S. Van Howe
 +
|last2=Svoboda
 +
|first2=J. Steven
 +
|init2=JS
 +
|author2-link=J. Steven Svoboda
 +
|date=2013-07-01
 +
|title=Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision
 +
|url=https://jme.bmj.com/content/39/7/434
 +
|journal=Journal of Medical Ethics
 +
|language=en
 +
|volume=39
 +
|issue=7
 +
|pages=434-441
 +
|DOI=10.1136/medethics-2013-101346
 +
|issn=0306-6800
 +
|pubmedID=23508208
 +
}}</ref>
  
−
Frisch et al. (2013) pointed out the difference of the AAP's statements in comparison to other Western countries, such as Canada, Australia, and various European countries.<ref name=":03">{{Cite journal|last=Frisch|first=M.|last2=Aigrain|first2=Y.|last3=Barauskas|first3=V.|last4=Bjarnason|first4=R.|last5=Boddy|first5=S.-A.|last6=Czauderna|first6=P.|last7=de Gier|first7=R. P. E.|last8=de Jong|first8=T. P. V. M.|last9=Fasching|first9=G.|date=2013-04-01|title=Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision|journal=Pediatrics|language=en|volume=131|issue=4|pages=796–800|doi=10.1542/peds.2012-2896|pmid=23509170|issn=0031-4005}}</ref> They attribute this to cultural bias since non-therapeutic male circumcision is prevalent in the United States. They also criticized the strength of the health benefits the statement had claimed, such as protection from HIV and other STIs.<ref name=":03" /> The American Academy of Pediatrics responded that because about half of American males are circumcised and half are not, there may be a more tolerant view concerning circumcision in the US, but that if there is any cultural “bias” among the AAP taskforce who wrote the Circumcision Policy statement, it is much less important than the bias Frisch et al. may hold because of clear prejudices against the practice that can be found in Europe. The AAP elaborately explained why they reached conclusions regarding the health benefits of circumcision that are different from the ones reached by some of their European counterparts.<ref>{{Cite journal|last=Circumcision|first=Task Force On|date=2013-04-01|title=Cultural Bias and Circumcision: The AAP Task Force on Circumcision Responds|url=https://pediatrics.aappublications.org/content/131/4/801|journal=Pediatrics|language=en|volume=131|issue=4|pages=801–804|doi=10.1542/peds.2013-0081|issn=0031-4005|pmid=23509171}}</ref>
+
Frisch et al. (2013) pointed out the difference of the AAP's statements in comparison to other Western countries, such as Canada, Australia, and various European countries.<ref name="frisch2013">{{REFjournal
 +
|last=Frisch
 +
|init=M
 +
|last2=Aigrain
 +
|init2=Y
 +
|last3=Barauskas
 +
|init3=V
 +
|last4=Bjarnason
 +
|init4=R
 +
|last5=Boddy
 +
|init5=SA
 +
|last6=Czauderna
 +
|init6=P
 +
|last7=de Gier
 +
|init7=RPE
 +
|last8=de Jong
 +
|init8=TPVM
 +
|last9=Fasching
 +
|init9=G
 +
|date=2013-04-01
 +
|title=Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision
 +
|url=https://pediatrics.aappublications.org/content/131/4/796
 +
|journal=Pediatrics
 +
|language=en
 +
|volume=131
 +
|issue=4
 +
|pages=796-800
 +
|DOI=10.1542/peds.2012-2896
 +
|pubmedID=23509170
 +
|issn=0031-4005
 +
}}</ref> They attribute this to cultural bias since non-therapeutic male circumcision is prevalent in the United States. They also criticized the strength of the health benefits the statement had claimed, such as protection from [[HIV]] and other STIs.<ref name="frisch2013"/> The American Academy of Pediatrics responded that because about half of American males are [[circumcised]] and half are not, there may be a more tolerant view concerning circumcision in the US, but that if there is any cultural “bias” among the AAP task force who wrote the Circumcision Policy statement, it is much less important than the bias Frisch et al. may hold because of clear prejudices against the practice that can be found in Europe. The AAP elaborately explained why they reached conclusions regarding the health benefits of circumcision that are different from the ones reached by some of their European counterparts.<ref>{{REFjournal
 +
|last=Task Force On Circumcision
 +
|date=2013-04-01
 +
|title=Cultural Bias and Circumcision: The AAP Task Force on Circumcision Responds
 +
|url=https://pediatrics.aappublications.org/content/131/4/801
 +
|journal=Pediatrics
 +
|volume=131
 +
|issue=4
 +
|pages=801-804
 +
|DOI=10.1542/peds.2013-0081
 +
|issn=0031-4005
 +
|pubmedID=23509171
 +
}}</ref>
  
 
====American Medical Association Journal of Ethics====
 
====American Medical Association Journal of Ethics====
 
In August 2017, the American Medical Association ''Journal of Ethics'' featured two separate articles challenging the morality of performing non-therapeutic infant circumcision.
 
In August 2017, the American Medical Association ''Journal of Ethics'' featured two separate articles challenging the morality of performing non-therapeutic infant circumcision.
  
−
Svoboda argues against non-therapeutic circumcision.<ref name=":05">{{Cite journal|date=2017-08-01|title=Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury|journal=AMA Journal of Ethics|language=en|volume=19|issue=8|pages=815–824|doi=10.1001/journalofethics.2017.19.8.msoc2-1708|pmid=28846521|issn=2376-6980|last1=Svoboda|first1=J. S.}}</ref> He states that this decision should be considered in the context of benefit vs risk of harm, rather than simply risk-benefit due to the non-therapeutic nature of the procedure.<ref name=":05" /> He states that benefits do not outweigh the risks, and also claims that foreskin removal should be considered a sexual harm.<ref name=":05" /> He also goes on to conclude that non-therapeutic circumcision largely violates the physician's duty to respect a patient's autonomy since many procedures take place before a patient is able to freely give consent himself.<ref name=":05" />
+
Svoboda argues against non-therapeutic circumcision.<ref name="svoboda2017">{{REFjournal
 +
|date=2017-08-01
 +
|title=Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury
 +
|journal=AMA Journal of Ethics
 +
|language=en
 +
|volume=19
 +
|issue=8
 +
|pages=815-824
 +
|DOI=10.1001/journalofethics.2017.19.8.msoc2-1708
 +
|pubmedID=28846521
 +
|issn=2376-6980
 +
|last1=Svoboda
 +
|first1=J.S.
 +
}}</ref> He states that this decision should be considered in the context of benefit vs risk of harm, rather than simply risk-benefit due to the non-therapeutic nature of the procedure.<ref name="svoboda2017"/> He states that benefits do not outweigh the risks, and also claims that foreskin removal should be considered a sexual harm.<ref name="svoboda2017"/> He also goes on to conclude that non-therapeutic circumcision largely violates the physician's duty to respect a patient's autonomy since many procedures take place before a patient is able to freely give consent himself.<ref name="svoboda2017"/>
  
−
Reis and Reis's article explore the role physicians play in neonatal circumcision.<ref name=":14">{{Cite journal|date=2017-08-01|title=Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries?|journal=AMA Journal of Ethics|language=en|volume=19|issue=8|pages=825–833|doi=10.1001/journalofethics.2017.19.8.msoc3-1708|pmid=28846522|issn=2376-6980|last1=Reis-Dennis|first1=S.|last2=Reis|first2=E.}}</ref> They state that if physicians outline all the currently known risks and benefits of the procedure to the parents and believes the procedure is indeed medically indicated, they cannot be held accountable for any harm from the procedure.<ref name=":14" /> However, they still advise against physicians recommending unnecessary, irreversible surgeries, which is a category circumcision falls in frequently.<ref name=":14" />
+
Reis and Reis's article explore the role physicians play in neonatal circumcision.<ref name="reis-reis2017">{{REFjournal
 +
|date=2017-08-01
 +
|title=Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries?
 +
|journal=AMA Journal of Ethics
 +
|language=en
 +
|volume=19
 +
|issue=8
 +
|pages=825-833
 +
|DOI=10.1001/journalofethics.2017.19.8.msoc3-1708
 +
|pubmedID=28846522
 +
|issn=2376-6980
 +
|last=Reis-Dennis
 +
|first=S.
 +
|last2=Reis
 +
|first2=E.
 +
}}</ref> They state that if physicians outline all the currently known risks and benefits of the procedure to the parents and believes the procedure is indeed medically indicated, they cannot be held accountable for any harm from the procedure.<ref name="reis-reis2017"/> However, they still advise against physicians recommending unnecessary, irreversible surgeries, which is a category circumcision falls in frequently.<ref name="reis-reis2017"/>
  
−
== Other views ==
+
== Journal of Medical Ethics ==
 +
<!--
 
===JME symposium on circumcision, June 2004===
 
===JME symposium on circumcision, June 2004===
−
The ''[[Journal of Medical Ethics]]'' published a "symposium on circumcision" in its June 2004 issue.<ref name="symposium">{{vcite journal |
+
The ''Journal of Medical Ethics'' published a "symposium on circumcision" in its June 2004 issue.<ref name="symposium2004">{{REFjournal
−
author= | title=Symposium on Circumcision | journal=J Med Ethics | date=2004 | volume=30 | issue=3 | pages=237–263 | url=http://jme.bmj.com/content/30/3.toc#Symposiumoncircumcision Symposium on circumcision | doi= | pmid= | pmc= }}</ref> The symposium published the original version (2003) of the BMA policy statement and six articles by various individuals with a wide spectrum of views on the ethicality of circumcision of male minors. In the introduction, Holm (2004) states:
+
|title=Symposium on Circumcision
 +
|journal=Journal of Medical Ethics
 +
|date=2004
 +
|volume=30
 +
|issue=3
 +
|pages=237-263
 +
|url=http://jme.bmj.com/content/30/3.toc#Symposiumoncircumcision Symposium on circumcision
 +
}}</ref> The symposium published the original version (2003) of the BMA policy statement and six articles by various individuals with a wide spectrum of views on the ethicality of circumcision of male minors. In the introduction, Holm (2004) states:
  
 
<blockquote>
 
<blockquote>
−
"It is therefore very interesting that the piece of evidence we really need to have in order to be able to assess the status of circumcision is singularly lacking. We simply do not have valid comparative data concerning the effects of early circumcision on adult sexual function and satisfaction. Until such data become available, 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."<ref name="holm">{{vcite journal | author=Holm S | title=Irreversible bodily interventions in children | journal=J Med Ethics | date=2004 | volume=30 | issue= | pages=237 | url=http://jme.bmj.com/content/30/3/237.full | doi=10.1136/jme.2004.009001 | pmid=15173353 | pmc=1733860}}</ref>
+
"It is therefore very interesting that the piece of evidence we really need to have in order to be able to assess the status of circumcision is singularly lacking. We simply do not have valid comparative data concerning the effects of early circumcision on adult sexual function and satisfaction. Until such data become available, 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."<ref name="holm">{{REFjournal
 +
|last=Holm
 +
|init=S
 +
|title=Irreversible bodily interventions in children
 +
|journal=Journal of Medical Ethics
 +
|date=2004
 +
|volume=30
 +
|page=237
 +
|url=http://jme.bmj.com/content/30/3/237.full
 +
|DOI=10.1136/jme.2004.009001
 +
|pubmedID=15173353
 +
|pubmedCID=1733860
 +
}}</ref>
 
</blockquote>
 
</blockquote>
  
 
Hutson (2004) states:
 
Hutson (2004) states:
 
<blockquote>
 
<blockquote>
−
"The most fundamental principle of surgery is that no operation should be done if there is no disease, as it cannot be justified if the risk of the procedure is not balanced by the risk of a disease. Even when patients have significant disease, potentially dangerous operations can hardly be justified if their risks are much greater than the disease itself. The problem for routine circumcision is that since there is no disease, no complication whatsoever can be tolerated, since the risks of the procedure are not being balanced against the risks of any present disease."<ref name="hutson">{{vcite journal |
+
"The most fundamental principle of surgery is that no operation should be done if there is no disease, as it cannot be justified if the risk of the procedure is not balanced by the risk of a disease. Even when patients have significant disease, potentially dangerous operations can hardly be justified if their risks are much greater than the disease itself. The problem for routine circumcision is that since there is no disease, no complication whatsoever can be tolerated, since the risks of the procedure are not being balanced against the risks of any present disease."<ref name="hutson">{{REFjournal
−
author=Hutson JM | title=Circumcision: a surgeon’s perspective | journal=J Med Ethics | date=2004 | volume=30 | issue=3 | pages=238–40 | url=http://jme.bmj.com/content/30/3/238.full | doi=10.1136/jme.2002.001313 | pmid=15173354 | pmc=1733864 }}</ref>
+
|last=Hutson
 +
|init=JM
 +
|title=Circumcision: a surgeon’s perspective
 +
|journal=Journal of Medical Ethics
 +
|date=2004
 +
|volume=30
 +
|issue=3
 +
|pages=238-240
 +
|url=http://jme.bmj.com/content/30/3/238.full
 +
|DOI=10.1136/jme.2002.001313
 +
|pubmedID=15173354
 +
|pubmedCID=1733864
 +
}}</ref>
 
</blockquote>
 
</blockquote>
  
Line 100: Line 355:
  
 
<blockquote>
 
<blockquote>
−
"If we believe in evidence based medicine, then there can be no debate about male circumcision; it has become a desirable option for the whole world. Paradoxically, this simple procedure is a life saver; it can also bring about major improvements to both male and female reproductive health. Rather than condemning it, we in the developed world have a duty to develop better procedures that are neither physically cruel nor potentially dangerous, so that male circumcision can take its rightful place as the kindest cut of all."<ref name="short">{{vcite journal |
+
"If we believe in evidence based medicine, then there can be no debate about male circumcision; it has become a desirable option for the whole world. Paradoxically, this simple procedure is a life saver; it can also bring about major improvements to both male and female reproductive health. Rather than condemning it, we in the developed world have a duty to develop better procedures that are neither physically cruel nor potentially dangerous, so that male circumcision can take its rightful place as the kindest cut of all."<ref name="short">{{REFjournal
−
author=Short RV | title=Male circumcision: a scientific perspective | journal=J Med Ethics | date=2004 | volume=30 | issue=3 | pages= | url=http://jme.bmj.com/content/30/3/241.1.full | doi=10.1136/jme.2002.002576 | pmid=15173356 | pmc=1733868 }}</ref>
+
|last=Short
 +
|init=RV
 +
|title=Male circumcision: a scientific perspective
 +
|journal=Journal of Medical Ethics
 +
|date=2004
 +
|volume=30
 +
|issue=3
 +
|url=http://jme.bmj.com/content/30/3/241.1.full
 +
|DOI=10.1136/jme.2002.002576
 +
|pubmedID=15173356
 +
|pubmedCID=1733868
 +
}}</ref>
 
</blockquote>
 
</blockquote>
  
−
Viens (2004) 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 that 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."<ref name="viens">{{vcite journal | author=Viens AM | title=Value judgment, harm, and religious liberty | journal=J Med Ethics | date=2004 | volume=30 | issue=3 | pages=241–7 | url=http://jme.bmj.com/content/30/3/241.2.full | doi=10.1136/jme.2003.003921 | pmid=15173355 | pmc=1733861 }}</ref>
+
Viens (2004) 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 that 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."<ref name="viens">{{REFjournal
 +
|last=Viens
 +
|init=AM
 +
|title=Value judgment, harm, and religious liberty
 +
|journal=Journal of Medical Ethics
 +
|date=2004
 +
|volume=30
 +
|issue=3
 +
|pages=241-247
 +
|url=http://jme.bmj.com/content/30/3/241.2.full
 +
|DOI=10.1136/jme.2003.003921
 +
|pubmedID=15173355
 +
|pubmedCID=1733861
 +
}}</ref>
  
−
Hellsten (2004), however, describes arguments in support of circumcision as "rationalisations",  and states 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 concludes, "Rather, with further education and knowledge the cultural smokescreen around the real reasons for the maintenance of the practice can be overcome in all societies no matter what their cultural background.<ref name="hellsten">{{vcite journal | author=Hellsten SK | title=Rationalising circumcision: from tradition to fashion, from public health to individual freedom—critical notes on cultural persistence of the practice of genital mutilation | journal=J Med Ethics | date=2004 | volume=30 | issue= | pages=248–53 | url=http://jme.bmj.com/content/30/3/248.full | doi=10.1136/jme.2004.008888 | pmid=15173357 | pmc=1733870 }}</ref>
+
Hellsten (2004), however, describes arguments in support of circumcision as "rationalisations",  and states 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 concludes, "Rather, with further education and knowledge the cultural smokescreen around the real reasons for the maintenance of the practice can be overcome in all societies no matter what their cultural background.<ref name="hellsten">{{REFjournal
 +
|last=Hellsten
 +
|init=SK
 +
|title=Rationalising circumcision: from tradition to fashion, from public health to individual freedom—critical notes on cultural persistence of the practice of genital mutilation
 +
|journal=Journal of Medical Ethics
 +
|date=2004
 +
|volume=30
 +
|pages=248-253
 +
|url=http://jme.bmj.com/content/30/3/248.full
 +
|DOI=10.1136/jme.2004.008888
 +
|pubmedID=15173357
 +
|pubmedCID=1733870
 +
}}</ref>
  
 
Mussell (2004) examined the process by which the BMA arrived at a position on non-therapeutic circumcision male minors, when the organisation had groups and individuals of different ethnicities, religion, culture, and widely varying viewpoints.
 
Mussell (2004) examined the process by which the BMA arrived at a position on non-therapeutic circumcision male minors, when the organisation had groups and individuals of different ethnicities, religion, culture, and widely varying viewpoints.
Line 112: Line 403:
 
Arguments were put forward that non-therapeutic male circumcision is a net ''benefit'' for some because it helps them to integrate in the community.
 
Arguments were put forward that non-therapeutic male circumcision is a net ''benefit'' for some because it helps them to integrate in the community.
  
−
Arguments were also put forward that non-therapeutic male circumcision is a net ''harm'' because it is seen as a 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. This argument was given emphasis by Britain's incorporation of the [[European Convention on Human Rights]] (1950) into domestic law by the [[Human Rights Act 1998]].
+
Arguments were also put forward that non-therapeutic male circumcision is a net ''harm'' because it is seen as a 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. This argument was given emphasis by Britain's incorporation of the European Convention on Human Rights (1950) into domestic law by the Human Rights Act 1998.
−
 
 
−
The BMA produced a document that set forth legal and ethical concerns but left the final decision on whether or not to perform a non-therapeutic circumcision to the attending physician.<ref name="mussell2">{{vcite journal |
 
−
author=Mussell R | title= The development of professional guidelines on the law and ethics of male circumcision | journal=J Med Ethics | date=2004 | volume=30 | issue=3 | pages=254–8. | url=http://jme.bmj.com/content/30/3/254.full | doi=10.1136/jme.2004.008615 | pmid=15173358 | pmc=1733857 }}</ref>
 
  
−
The last document published by the ''Journal of Medical Ethics'' in its symposium on circumcision was a reprint of the BMA statement: "The law and ethics of male circumcision: guidance for doctors (2003).<ref name="BMA2003">{{vcite journal |
+
The BMA produced a document that set forth legal and ethical concerns but left the final decision on whether or not to perform a non-therapeutic circumcision to the attending physician.<ref name="mussell2">{{REFjournal
−
author=British Medical Association | title=The law and ethics of male circumcision: guidance for doctors | journal=J Med Ethics | date=2004 | volume=30 | issue=3 | pages=259–63 | url=http://jme.bmj.com/content/30/3/259.full | doi=10.1136/jme.2004.008540 | pmid=15173359 | pmc=1733850 }}</ref>
+
|last=Mussell
 +
|init=R
 +
|title=The development of professional guidelines on the law and ethics of male circumcision
 +
|journal=Journal of Medical Ethics
 +
|date=2004
 +
|volume=30
 +
|issue=3
 +
|pages=254-258
 +
|url=http://jme.bmj.com/content/30/3/254.full
 +
|DOI=10.1136/jme.2004.008615
 +
|pubmedID=15173358
 +
|pubmedCID=1733857
 +
}}</ref>
  
 +
The last document published by the ''Journal of Medical Ethics'' in its symposium on circumcision was a reprint of the BMA statement: "The law and ethics of male circumcision: guidance for doctors (2003).<ref name="BMA2003">{{REFjournal
 +
|last=British Medical Association
 +
|title=The law and ethics of male circumcision: guidance for doctors
 +
|journal=Journal of Medical Ethics
 +
|date=2004
 +
|volume=30
 +
|issue=3
 +
|pages=259-263
 +
|url=http://jme.bmj.com/content/30/3/259.full
 +
|DOI=10.1136/jme.2004.008540
 +
|pubmedID=15173359
 +
|pubmedCID=1733850
 +
}}</ref>
 +
-->
 
===Journal of Medical Ethics circumcision issue, July 2013===
 
===Journal of Medical Ethics circumcision issue, July 2013===
−
The ''Journal of Medical Ethics'' devoted the entire July 2013 issue to the controversial issue of non-therapeutic circumcision of male children.<ref>{{vcite journal | author= | title=The issue of male circumcision | journal=J Med Ethics | date=2013 | volume=39 | issue=7 | pages= | url=http://jme.bmj.com/content/39/7.toc | doi= | pmid= | pmc= }}</ref> The numerous articles represent a diverse variety of views.<ref>{{vcite journal | author=Foddy B | title=The concise argument: Medical, religious and social reasons for and against an ancient rite | journal=J Med Ethics | date=2013 | volume=39 | issue=7 | pages=415 | url=http://jme.bmj.com/content/39/7/415.full | doi=10.1136/medethics-2013-101605 | pmid=23781076 | pmc= }}</ref><ref>{{vcite journal |
+
The ''Journal of Medical Ethics'' devoted the entire July 2013 issue to the controversial issue of non-therapeutic circumcision of male children.<ref>{{REFjournal
−
author=Earp BD | title=The ethics of infant male circumcision | journal=J Med Ethics | date=2013 | volume=39 | issue=7 | pages=418–20 | url=https://www.academia.edu/3430963/The_ethics_of_infant_male_circumcision | doi=10.1136/medethics-2013-101517 | pmid=23781078 | pmc= }}</ref>
+
|title=The issue of male circumcision
 +
|journal=Journal of Medical Ethics
 +
|date=2013
 +
|volume=39
 +
|issue=7
 +
|url=http://jme.bmj.com/content/39/7.toc
 +
}}</ref> The numerous articles represent a diverse variety of views.<ref>{{REFjournal
 +
|last=Foddy
 +
|init=B
 +
|title=The concise argument: Medical, religious and social reasons for and against an ancient rite
 +
|journal=Journal of Medical Ethics
 +
|date=2013
 +
|volume=39
 +
|issue=7
 +
|page=415
 +
|url=http://jme.bmj.com/content/39/7/415.full
 +
|DOI=10.1136/medethics-2013-101605
 +
|pubmedID=23781076
 +
}}</ref><ref>{{REFjournal
 +
|last=Earp
 +
|init=BD
 +
|author-link=Brian D. Earp
 +
|title=The ethics of infant male circumcision
 +
|journal=Journal of Medical Ethics
 +
|date=2013
 +
|volume=39
 +
|issue=7
 +
|pages=418-420
 +
|url=https://www.academia.edu/3430963/The_ethics_of_infant_male_circumcision
 +
|DOI=10.1136/medethics-2013-101517
 +
|pubmedID=23781078
 +
}}</ref>
  
−
===Other views===
+
==Other views==
−
Povenmire (1988) argues that parents should not have the power to consent to neonatal non-therapeutic circumcision.<ref name="povenmire" />
+
Povenmire (1988) argued that parents should not have the power to consent to neonatal non-therapeutic circumcision.<ref name="povenmire"/>
  
−
Richards (1996) argues that parents only have power to consent to therapeutic procedures.<ref name="richards" />
+
Richards (1996) argued that parents only have power to consent to therapeutic procedures.<ref name="richards"/>
  
−
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.<ref name = "Somerville">{{vcite book| last = Somerville| first = Margaret| title = The ethical canary: science, society, and the human spirit| url = | accessdate = 2007-02-12|date=November 2000| publisher = [[Viking Press|Viking Penguin Canada]]| location = [[New York, NY]]| isbn = 0-670-89302-1| pages = 202–219| chapter = Altering Baby Boys’ Bodies: The Ethics of Infant Male Circumcision | chapterurl = https://www.academia.edu/654017/Altering_baby_boys_bodies_the_ethics_of_infant_male_circumcision| quote =| authorlink = Margaret Somerville| lccn = 2001369341}}</ref>
+
[[Margaret A. Somerville|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.<ref name="Somerville2000">{{REFbook
 +
|last=Somerville
 +
|first=Margaret A.
 +
|init=M
 +
|author-link=Margaret A. Somerville
 +
|title=The ethical canary: science, society, and the human spirit
 +
|accessdate=2007-02-12
 +
|date=2000-11
 +
|publisher=Viking Press|Viking Penguin Canada
 +
|location=New York, NY
 +
|isbn=0-670-89302-1
 +
|pages=202-219
 +
|chapter=Altering Baby Boys’ Bodies: The Ethics of Infant Male Circumcision
 +
|url=https://www.academia.edu/654017/Altering_baby_boys_bodies_the_ethics_of_infant_male_circumcision
 +
|lccn=2001369341
 +
}}</ref>
  
−
<!-- Somerville argues that because of a lack of credible information about male circumcision in some societies, the ability for the caregiver to grant informed consent on behalf of their child is compromised. This may be especially true of caregivers from a religious or cultural tradition that is particularly biased towards or against circumcising infants.<ref name="somerville">Somerville M. ''The Ethical Canary: Science, Society and the Human Spirit.'' Toronto: Penguin, 2000: pp. 202-19. (ISBN 0-670-89971-2)</ref> -->
+
[[Margaret A. Somerville|Somerville]] argues that because of a lack of credible information about male circumcision in some societies, the ability for the caregiver to grant [[informed consent]] on behalf of their child is compromised. This may be especially true of caregivers from a religious or cultural tradition that is particularly biased towards or against circumcising infants.<ref name="Somerville2000"/>
−
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."<ref name="Canning">{{vcite journal | author=Canning DA | title=Informed consent for neonatal circumcision: an ethical and legal conundrum | journal=J Urol | date=2002 | volume=168 | issue=4 Pt 1 | pages=1650–1 | url= | doi= 10.1016/S0022-5347(05)64535-1 | pmid=12356070 | pmc= }}</ref>
 
  
−
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."<ref>{{vcite journal |url=http://bioethics.net/journal/pdf/3_2_LT_w01_Benetar.pdf |format=PDF |first=David |last=Benatar |author2=Benatar, Michael |title=How not to argue about circumcision |journal=American Journal of Bioethics |volume=3 |issue=2 |year=2003 |pages=W1–W9 |doi=10.1162/152651603102387820 |pmid=14635630 |url-status=dead|archiveurl=https://web.archive.org/web/20070616011136/http://bioethics.net/journal/pdf/3_2_LT_w01_Benetar.pdf |archivedate=2007-06-16 |df= }}</ref>
+
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."<ref name="Canning">{{REFjournal
 +
|last=Canning
 +
|init=DA
 +
|title=Informed consent for neonatal circumcision: an ethical and legal conundrum
 +
|journal=J Urol
 +
|url=http://www.cirp.org/library/legal/canning1/
 +
|date=2002
 +
|volume=168
 +
|issue=4 Pt 1
 +
|pages=1650-1651
 +
|DOI=10.1016/S0022-5347(05)64535-1
 +
|pubmedID=12356070
 +
}}</ref>
  
−
The Committee on Medical Ethics of the British Medical Association (2003) published a paper to guide doctors on the law and ethics of circumcision. It 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. It states that a physician has a right to refuse to perform a non-therapeutic circumcision.<ref name="BMAGuide" /> The College of Physicians and Surgeons of British Columbia took a similar position.<ref name="cpsbc">{{vcite web |author=College of Physicians & Surgeons of British Columbia |home= |title=Circumcision (Infant Male) |url=https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/malecircum |url-status=dead|date=2007 |accessdate=6 December 2013 |archiveurl=https://web.archive.org/web/20070928050441/https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/malecircum |archivedate=2007-09-28 }}</ref>
+
The Committee on Medical Ethics of the [[British Medical Association]] (2003) published a paper to guide doctors on the law and ethics of circumcision. It 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. It states that a physician has a right to refuse to perform a non-therapeutic circumcision.<ref name="bma2006"/> The College of Physicians and Surgeons of British Columbia took a similar position.<ref name="cpsbc">{{REFweb
 +
|last=College of Physicians & Surgeons of British Columbia
 +
|title=Circumcision (Infant Male)
 +
|date=2007
 +
|accessdate=2013-12-06
 +
|url=https://web.archive.org/web/20070928050441/https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/malecircum
 +
}}</ref>
  
−
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".<ref name="fox-thomson" />
+
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".<ref name="fox-thomson">{{REFjournal
 +
|last=Fox
 +
|init=M
 +
|last2=Thomson
 +
|init2=M
 +
|title=A covenant with the status quo? Male circumcision and the new BMA guidance to doctors
 +
|journal=Journal of Medical Ethics
 +
|date=2005
 +
|volume=31
 +
|issue=8
 +
|pages=463-469
 +
|url=http://jme.bmj.com/content/31/8/463.full
 +
|DOI=10.1136/jme.2004.009340
 +
|pubmedID=16076971
 +
|pubmedCID=1734197
 +
}}</ref>
  
−
[[Brian Morris (biologist)|Morris]] ''et al''. (2014) argued that "...failure to circumcise a baby boy may be unethical because it diminishes his right to good health."<ref>{{cite journal|last1=Morris|first1=BJ|last2=Bailis|first2=SA|last3=Wiswell|first3=TE|title=Circumcision rates in the United States: rising or falling? What effect might the new affirmative pediatric policy statement have?|journal=Mayo Clinic Proceedings|date=May 2014|volume=89|issue=5|pages=677–86|doi=10.1016/j.mayocp.2014.01.001|pmid=24702735}}</ref>
+
The Belgian Federal Consultative Committee for Bioethics (''[[:fr:Comité consultatif de Bioéthique de Belgique|Comité Consultatif de Bioéthique de Belgique]]'') (2017), after a three-year study, has ruled that circumcision of male children for non-therapeutic purposes is unethical in Belgium.<ref> {{REFweb
 +
|last=Comité Consultif de Bioéthique de Belgique
 +
|website=SPF Santé Publique
 +
|title=Opinion no. 70 of 8 May 2017on  the  ethical  aspects  of  nonmedical circumcision
 +
|url=https://www.health.belgium.be/sites/default/files/uploads/fields/fpshealth_theme_file/opinion_70_web.pdf
 +
|date=2017-05-08
 +
|accessdate=2019-11-03
 +
}}</ref><ref name="bulletin2017">{{REFnews
 +
|title=Ethics committee rules against infant circumcision
 +
|url=http://www.xpats.com/ethics-committee-rules-against-infant-circumcision
 +
|work=The Bulletin
 +
|date=2017
 +
|quote=As circumcision is irreversible and therefore a radical operation, we find the physical integrity of the child takes precedence over the belief system of the parents.
 +
}}</ref> The process is irreversible, has no medical justification in most cases, and is performed on minors unable to give their own permission, according to the committee. Paul Schotsmans of the {{UNI|University of Leuven|UCLouvain}}, on behalf of the committee, noted "the child’s right to physical integrity, which is protected by the Convention on the Rights of the Child, and in particular its protection from physical injury."<ref name="bulletin2017"/> The Belgian minister of health replied that the Federal Institute for Health Insurance cannot check and know whether in (individual cases) a circumcision is medically justified or not and that she will continue to reimburse circumcision of minors as the safety of the child is her primary concern and she wants to avoid botched circumcisions by non-medical circumcisers.
  
−
The Belgian Federal Consultative Committee for Bioethics (''[[:fr:Comité consultatif de Bioéthique de Belgique|Comité Consultatif de Bioéthique de Belgique]]'') (2017), after a three-year study, has ruled that circumcision of male children for non-therapeutic purposes is unethical in [[Belgium]].<ref>Statement in French: {{vcite web | author=Comité Consultif de Bioéthique de Belgique | home= SPF Santé Publique | title=Avis °70 du 8 mai 2017 relatif aux aspects éthiques de la circoncision non médicale | url=https://www.health.belgium.be/sites/default/files/uploads/fields/fpshealth_theme_file/avis_70_circoncision.pdf | date= 8 May 2017 | accessdate=27 September 2017 }}</ref><ref name="bulletin2017">{{vcite news | author= | title=Ethics committee rules against infant circumcision | url=http://www.xpats.com/ethics-committee-rules-against-infant-circumcision | work=The Bulletin | date=2017 | quote=As circumcision is irreversible and therefore a radical operation, we find the physical integrity of the child takes precedence over the belief system of the parents. }}</ref> The process is irreversible, has no medical justification in most cases, and is performed on minors unable to give their own permission, according to the committee. Paul Schotsmans of the [[KU Leuven|University of Leuven]], on behalf of the committee, noted "the child’s right to physical integrity, which is protected by the [[Convention on the Rights of the Child|International Treaty on the Rights of the Child]], and in particular its protection from physical injury."<ref name="bulletin2017" /> The Belgian minister of health replied that the federal institute for health insurance cannot check and know whether in (individual cases) a circumcision is medically justified or not and that she will continue to reimburse circumcision of minors as the safety of the child is her primary concern and she wants to avoid botched circumcisions by non-medical circumcisers.<ref>{{Cite web|url=https://www.standaard.be/cnt/dmf20170920_03084394|title=De Block blijft besnijdenis terugbetalen|last=Vergauwen|first=Eveline|website=De Standaard|language=nl-BE|access-date=2019-06-14}}</ref>
+
==Surrogate consent==
 +
Patient autonomy is an important principle of medical ethics.<ref>{{REFbook
 +
|last=Beauchamp
 +
|first=Tom L.
 +
  |init=TL
 +
|last2=Childress
 +
|first2=James F.
 +
|init2=JF
 +
|title=Principles of Biomedical Ethics
 +
|publisher=New York: {{UNI|Oxford University|Oxon}} Press
 +
  |date=2001
 +
}}</ref> Consent for a non-therapeutic operation offends the principle of autonomy, when granted by a surrogate.
  
−
==HIV in southern and eastern Africa==
+
Since children, and especially infants, are legally incompetent to grant [[informed consent]] for medical or surgical treatment, that consent must be granted by a surrogate — someone designated to act on behalf of the child-patient, if treatment is to occur.<ref name="conundrum">{{REFjournal
−
{{Main|Circumcision and HIV}}
+
|last=Svoboda
 +
|first=J. Steven
 +
|init=JS
 +
|author-link=J. Steven Svoboda
 +
|last2=Van Howe
 +
|first2=Robert S.
 +
|init2=RS
 +
|author2-link=Robert S. Van Howe
 +
|last3=Dwyer
 +
|first3=James G.
 +
|init3=JG
 +
|author3-link=James G. Dwyer
 +
|title=Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum
 +
|url=https://scholarship.law.wm.edu/cgi/viewcontent.cgi?article=1166&context=facpubs
 +
|pages=60-133
 +
|journal=J Contemp Health Law & Policy
 +
|volume=17
 +
|date=2000
 +
}}</ref>
  
−
Rennie et al. (2007) remark that the results of three randomised controlled trials in sub-Saharan Africa, showing reduced risk of HIV among circumcised men, "alter the terms of the debate over the ethics of male circumcision."<ref name="rennie">{{vcite journal |last=Rennie |first=Stuart |authorlink= |author2=Adamson S Muula |author3=Daniel Westreich |date=June 2007 |title=Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low-income countries |journal=Journal of Medical Ethics |volume=33 |issue=6 |pages=357–361 |pmid=17526688 |url=http://jme.bmj.com/cgi/content/full/33/6/357 |accessdate= |pmc=2598273|quote= |doi=10.1136/jme.2006.019901}}</ref> However, the methodology of the African RCTs has been severely criticised, thereby invalidating claims that circumcision reduces the sexual transmission of HIV.<ref>Boyle, G.J. (2013). Critique of African RCTs into Male Circumcision and HIV Sexual Transmission. In G.C. Denniston et al. (Eds.), ''Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements. Dordrecht, The Netherlands: Springer Science+Business Media. doi: 10.1007/978-94-007-6407-1_15 {{ISBN|978-94-007-6406-4}}</ref>
+
A surrogate's powers to grant consent are more circumscribed than the powers granted to a competent individual acting on his own behalf.<ref name="conundrum" /><ref name="bioethics">{{REFjournal
 +
|last=Committee on Bioethics
 +
  |title=Informed consent, parental permission, and assent in pediatric practice
 +
|journal=Pediatrics
 +
|date=1995
 +
|volume=95
 +
|issue=2
 +
|pages=314-317
 +
|url=http://pediatrics.aappublications.org/content/95/2/314.full.pdf
 +
  |pubmedID=7838658
 +
}} Reaffirmed May 2011.</ref> A surrogate may only act in the best interests of the patient.<ref name="conundrum"/> A surrogate may not put a child at risk for religious reasons.<ref name="conundrum"/> A surrogate may grant consent for a medical procedure that has ''no'' [[medical indication]] ''only'' if it is the child's best interests.<ref name="conundrum"/>
  
−
Supporters of circumcision argue that using circumcision and other available means to halt the spread of HIV is in the common good (but overlook the fact that HIV is transmitted in the seminal fluid). 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."<ref name="rennie" /> However, there clearly remains a risk of transmitting or acquiring HIV while engaging in unprotected sex and other high risk behaviors (circumcised or not).
+
The attending physician must provide the surrogate with all material information concerning the proposed benefits, risks, advantages, and drawbacks of the proposed treatment or procedure.<ref name="conundrum"/><ref name="bioethics"/>
  
−
The [[World Health Organization]] (2007) 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."<ref>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</ref> However, since babies and children are not sexually active, sexually-transmitted HIV infection is not a relevant concern. 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. If the adult chooses to remain celibate or if a couple remain monogamous, or if HIV is eliminated by the time the child is an adult, the sexual reduction surgery would not have been needed. Moreover, they argue that circumcising a child purportedly to partially protect him from HIV infection in adulthood may be seen as granting permission to engage in dangerous sexual practices. Obviously baby boys do not need such protection and can choose for themselves as consenting adults if they want a circumcision.<ref name="Somerville" /> This stance, however, does not take into account the fact that adult men may already have contracted HIV before getting circumcised.<ref>{{Cite journal|last=Harmon|first=Katherine|title=Can male circumcision stem the AIDS epidemic in Africa?|url=http://www.nature.com/news/can-male-circumcision-stem-the-aids-epidemic-in-africa-1.9520|journal=Nature News|language=en|doi=10.1038/nature.2011.9520|year=2011}}</ref>
+
The Committee on Bioethics of the AAP (1995) states that parents may only grant surrogate informed permission for diagnosis and treatment with the assent of the child whenever appropriate.<ref name="bioethics"/>
  
−
The UK National Health Service ([[NHS]]) has stated that the African studies have "important implications for the control of sexually transmitted infections in Africa", but that in the United Kingdom practising safe sex including [[condom]] use is the best way to prevent sexually-transmitted disease when having sex.<ref>{{Cite web | url=https://www.nhs.uk/news/lifestyle-and-exercise/circumcision-and-stis/ | title=Circumcision and STIs| date=2009-03-26}}</ref>
+
There was an unresolved question whether surrogates may grant effective consent for non-therapeutic child circumcision.<ref name="povenmire">{{REFjournal
 +
|last=Povenmire
 +
|init=R
 +
|authorlink=
 +
|date=
 +
|note=1998–1999
 +
|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
 +
|pubmedID=16526136
 +
|url=http://www.cirp.org/library/legal/povenmire/
 +
|accessdate=2013-11-25
 +
}}</ref>
  
−
==Surrogate consent==
+
<ref name="conundrum"/>  Richards (1996) argues that parents may only consent to medical care, so are not empowered to grant consent for non-therapeutic circumcision of a child because it is not medical care.<ref name="richards">{{REFjournal
−
Patient [[autonomy]] is an important principle of [[medical ethics]].<ref>{{vcite book |
+
|last=Richards
−
author=Beauchamp, Tom L., and Childress, James F. | chapter= | title= Principles of Biomedical Ethics | publisher=New York: Oxford University Press | date=2001 | isbn= | pages= }}</ref> Some believe that consent for a non-therapeutic operation offends the principle of autonomy, when granted by a surrogate.
+
|init=D
 +
|authorlink=
 +
|date=1996-05
 +
|title=Male Circumcision: Medical or Ritual?
 +
|journal=Journal of Law and Medicine
 +
|volume=3
 +
|issue=4
 +
|pages=371-376
 +
|url=http://www.cirp.org/library/legal/richards/
 +
|accessdate=2008-04-11
 +
}}</ref> The Canadian Paediatric Society (2015) recommends that circumcisions done in the absence of a [[medical indication]] or for personal reasons "should be deferred until the individual concerned is able to make their own choices."<ref name="CPS2015" />
 +
 
 +
Regardless of these issues, the unethical general practice of the medical community in the United States is to receive surrogate informed consent or permission from parents or legal guardians for non-therapeutic circumcision of children.<ref name="povenmire"/><ref name="conundrum" />
 +
 
 +
== The emerging consensus on surrogate consent for non-therapeutic newborn, infant, and child circumcision ==
 +
The power of parents and other surrogates to grant consent is dependent upon the existence of a physical or medical condition in a minor child that requires diagnostic and/or treatment.<ref name="richards"/> <ref name="aap1995">{{REFjournal
 +
|last=Committee on Bioethics
 +
|etal=no
 +
|title=Informed consent, parental permission, and assent in pediatric practice
 +
|trans-title=
 +
|language=
 +
|journal=Pediatrics
 +
|location=
 +
|date=1995-02
 +
|volume=95
 +
|issue=2
 +
|article=
 +
|page=
 +
|pages=314-7
 +
|url=http://www.cirp.org/library/ethics/AAP/
 +
|archived=
 +
|quote=
 +
|pubmedID=7838658
 +
|pubmedCID=
 +
|DOI=
 +
|accessdate=2023-05-26
 +
}}</ref>  The right to grant surrogate consent cannot exist in the absence of such a condition. The AAP Committee on Bioethics (2016) now states: "A parent’s authority is not absolute but constrained by respect for the child."<ref name="aviva2016">{{REFjournal 
 +
|last=Committee on Bioethics
 +
|etal-no
 +
|title=Informed Consent in Decision-Making in Pediatric Practice
 +
|trans-title=
 +
|language=
 +
|journal=Pediatrics
 +
|location=
 +
|date=2016-08
 +
|volume=138
 +
|issue=2
 +
|article=
 +
|page=e20161484.
 +
|pages=
 +
|url=https://publications.aap.org/pediatrics/article/138/2/e20161484/52512/Informed-Consent-in-Decision-Making-in-Pediatric?autologincheck=redirected
 +
|archived=
 +
|quote=
 +
|pubmedID=27456514
 +
|pubmedCID=
 +
|DOI=
 +
|doi=10.1542/peds.2016-1484
 +
|accessdate=2023-05-27
 +
}}</ref> This may mean that the AAP now recognizes the child as a person with legal rights of his/her own.
  
−
Since children, and especially infants, are legally incompetent to grant [[informed consent]] for medical or surgical treatment, that consent must be granted by a surrogate — someone designated to act on behalf of the child-patient, if treatment is to occur.<ref name="conundrum">J. Steven Svoboda, Robert S. Van Howe, James C. Dwyer, Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. 17 J Contemp Health Law & Policy 61 (2000).</ref>
+
Boys are born with a healthy [[foreskin]] that is free of disease. There are no medical indications for a neonatal [[circumcision]]. The [[medical trade association| medical trade associations]] and other promoters have put forward various alleged benefits from neonatal circumcision for decades to develop business for their physican-members.
  
−
A surrogate's powers to grant consent are more circumscribed than the powers granted to a competent individual acting on his own behalf.<ref name="conundrum" /><ref name="bioethics">{{vcite journal |
+
The validity of surrogate consent for non-therapeutic circumcision of boys has been questioned for decades.<ref name="povenmire"/> <ref name="richards" /> <ref name="hill2003">{{REFjournal
−
author=Committee on Bioethics | title=Informed consent, parental permission, and assent in pediatric practice | journal=Pediatrics | date=1995 | volume=95 | issue=2 | pages=314–7 | url=http://pediatrics.aappublications.org/content/95/2/314.full.pdf | doi= | pmid=7838658 | pmc= }} Reaffirmed May 2011.</ref> A surrogate may only act in the best interests of the patient.<ref name="conundrum" /> A surrogate may not put a child at risk for religious reasons.<ref name="conundrum" /> A surrogate may grant consent for a medical procedure that has ''no'' medical indication ''only'' if it is the child's best interests.<ref name="conundrum" />
+
|last=Hill
 +
|first=
 +
|init=G
 +
|author-link=George Hill
 +
|title=Can anyone authorize the nontherapeutic permanent alteration of a child's body?
 +
|journal=The American Journal of Bioethics
 +
|date=2003
 +
|volume=3
 +
|issue=2
 +
|pages=16-8
 +
|url=https://www.researchgate.net/profile/George-Hill-3/publication/371599857_Can_Anyone_Authorize_the_Nontherapeutic_Permanent_Alteration_of_a_Child's_Body/links/648b8819c41fb852dd0949be/Can-Anyone-Authorize-the-Nontherapeutic-Permanent-Alteration-of-a-Childs-Body.pdf
 +
|quote=
 +
|pubmedID=14635628
 +
|pubmedCID=
 +
|DOI=10.1162/152651603766436342
 +
|format=PDF
 +
  |accessdate=2023-07-11
 +
}}</ref>
  
−
The attending physician must provide the surrogate with all material information concerning the proposed benefits, risks, advantages, and drawbacks of the proposed treatment or procedure.<ref name="conundrum" /><ref name="bioethics" />
+
Bioethicists Myers & Earp (2020) exhaustively reviewed the evidence for and against the alleged health benefits to a healthy person claimed for non-therapeutic circumcision of a neonate, infant or child. They balanced this against the [[pain]], [[trauma]], and loss of body tissue and function. They concluded the claimed health benefits are insufficient to support surrogate consent for non-therapeutic circumcision. Given this, only the subject can grant consent for a non-therapeutic circumcision, after he reaches the right age for circumcision, which does not occurs until a male reaches the age of consent in his jurisdiction which may vary from 16 to 18 years of age. The present practice in the [[United States]] and elsewhere of parental consent for non-therapeutic circumcision is entirely unethical.<ref name="myers2020">{{REFjournal
 +
|last=Myers
 +
|first=
 +
|init=A
 +
|author-link=Alex Myers
 +
|last2=Earp
 +
|first2=
 +
|init2=BD
 +
|author2-link=Brian D. Earp
 +
|etal=no
 +
|title=What is the best age to circumcise? A medical and ethical analysis
 +
|trans-title=
 +
|language=
 +
|journal= Bioethics
 +
|location=
 +
|date=2020
 +
|volume=34
 +
|issue=7
 +
|pages=645-63
 +
|url=https://www.researchgate.net/profile/Brian-Earp-2/publication/337720859_What_Is_the_Best_Age_to_Circumcise_A_Medical_and_Ethical_Analysis/links/5f815f61a6fdccfd7b555395/What-Is-the-Best-Age-to-Circumcise-A-Medical-and-Ethical-Analysis.pdf
 +
|archived=
 +
|quote=Based on a careful consideration of the relevant evidence, arguments and counterarguments, we conclude that medically unnecessary penile circumcision-like other medically unnecessary genital procedures, such as 'cosmetic' labiaplasty-should not be performed on individuals who are too young (or otherwise unable) to provide meaningful consent to the procedure.
 +
|pubmedID=32068898
 +
|pubmedCID=
 +
|DOI=
 +
|doi=10.1111/bioe.12714
 +
|format=PDF
 +
|accessdate=2020-05-27
 +
}}</ref>
  
−
The Committee on Bioethics of the AAP (1995) states that parents may only grant surrogate informed permission for diagnosis and treatment with the assent of the child whenever appropriate.<ref name="bioethics" />
+
Moreover, non-therapeutic circumcision of boys may also be unlawful,<ref name="Adler">{{REFjournal
 +
|last=Adler
 +
|first=Peter W.
 +
|init=PW
 +
|author-link=Peter W. Adler
 +
|url=http://rjolpi.richmond.edu/archive/Adler_Formatted.pdf
 +
|title=Is Circumcision Legal?
 +
|volume=16
 +
|issue=3
 +
|journal=Richmond J. L. & Pub. Int.
 +
|page=439
 +
|date=2013
 +
}}</ref> if a court should accept Adler's arguments.
  
−
There is an unresolved question whether surrogates may grant effective consent for non-therapeutic child circumcision.<ref name="povenmire">{{cite journal |last=Povenmire |first=R. |authorlink= |year=1998–1999 |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=2013-11-25 |quote= }}</ref><ref name="conundrum" /><ref name="Adler">Peter W. Adler. [http://rjolpi.richmond.edu/archive/Adler_Formatted.pdf Is Circumcision Legal?] 16(3) Richmond J. L. & Pub. Int. 439 (2013).</ref> Richards (1996) argues that parents may only consent to medical care, so are not empowered to grant consent for non-therapeutic circumcision of a child because it is not medical care.<ref name="richards">{{cite journal |last=Richards |first=D. |authorlink= |date=May 1996 |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= }}</ref> The Canadian Paediatric Society (2015) recommends that circumcisions done in the absence of a medical indication or for personal reasons "should be deferred until the individual concerned is able to make their own choices."<ref name="CPS2015">{{vcite journal | author=Sorakan ST, Finlay JC, Jefferies AL | title=Newborn male circumcision | journal=Paediatr Child Health | date=2015 | volume=20 | issue=6 | pages=311–5 | url=http://www.cps.ca/en/documents/position/circumcision | doi= | pmid= 26435672 | pmc= 4578472}}</ref>
+
== Observations ==
  
−
Regardless of these issues, the general practice of the medical community in the United States is to receive surrogate informed consent or permission from parents or legal guardians for non-therapeutic circumcision of children.<ref name="BMA2006" /><ref name="povenmire" />
+
The non-therapeutic circumcision industry in the United States produces more than $2 billion annually.<ref name="bollinger2012">{{REFweb
 +
|url=https://www.academia.edu/6442587/High_Cost_of_Circumcision_3.6_Billion_Annually
 +
|title=High Cost of Circumcision: $3.6 Billion Annually
 +
|last=Bollinger
 +
|first=Dan
 +
|author-link=Dan Bollinger
 +
|publisher=Academia
 +
|website=https://www.academia.edu
 +
|date=2012
 +
|accessdate=2021-11-12
 +
|format=
 +
|quote=As the saying goes, follow the money. Now you know why neither the [[American Academy of Pediatrics]], American Medical Association, [[American Academy of Family Physicians]], or the [[American Congress of Obstetricians and Gynecologists| American College of Obstetricians and Gynecologists]] haven’t condemned this unnecessary surgery, and why their physician members are quick to recommend the procedure to expectant parents.
 +
}}</ref> [[Third-party payment]] is a major support to the performance of this medically-unnecessary surgery. If parents could not grant consent for non-therapeutic circumcision, then no one could grant consent for the non-therapeutic circumcision of a child, so the $2 billion annual business would collapse. The American [[Medical trade association| medical trade associations]], more than those of other nations, have been unwilling to recognize the child's right to [[physical integrity]], to security of the person, and the right to personal autonomy.
  
 
{{SEEALSO}}
 
{{SEEALSO}}
 +
* [[Brian D. Earp]]
 +
* [[Brussels Collaboration on Bodily Integrity]]
 +
* [[Human rights]]
  
−
==References==
+
{{LINKS}}
−
* {{cite journal |last=Freeman |first=M.D. |authorlink= |date=January 1999 |title=A child's right to circumcision |journal=BJU Int |volume=83 |issue=Suppl. 1 |pages=74–78 |pmid=10349417  |quote=  |doi=10.1046/j.1464-410x.1999.0830s1074.x}}
+
* {{REFjournal
−
* {{cite journal | author= Goodman J | title=Jewish circumcision: an alternative perspective | journal=BJU Int | date=1999 | volume=83 Suppl. 1 | issue= | pages=22–27 | doi=10.1046/j.1464-410x.1999.0830s1022.x | pmid=10349411 | pmc= }}
+
|last=Goodman
 +
|init=J
 +
|author-link=Jenny Goodman
 +
|url=https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1464-410x.1999.0830s1022.x
 +
|title=Jewish circumcision: an alternative perspective
 +
|journal=BJU Int
 +
|date=1999
 +
|volume=83 Suppl. 1
 +
|pages=22-27
 +
  |DOI=10.1046/j.1464-410x.1999.0830s1022.x
 +
|pubmedID=10349411
 +
|accessdate=2023-05-27
 +
}}</ref></ref>
  
−
==Notes==
 
−
{{Reflist}}
 
  
−
{{Circumcision series}}
+
{{REF}}
  
−
==External links==
+
[[Category:Medical ethics]]
 +
[[Category:Human rights]]

Latest revision as of 12:59, 1 September 2024

Construction Site

This article is work in progress and not yet part of the free encyclopedia IntactiWiki.

 

Male circumcision is the surgical removal of the foreskin (prepuce) from the human penis.[1] The foreskin has protective, immunological, sensory, and sexual functions. The ethics of non-therapeutic child circumcision being imposed on unconsenting minors (babies and children) has been a source of ongoing controversy.[2][3][4]

Some medical trade associations formerly took the position that the parents should determine what is in the best interest of the newborn, infant, or child.[5] however the AAP has now abandoned all previous position statements on male circumcision.

Others say that circumcision is an infringement of the child's autonomy and should be delayed until he is capable of making the decision himself.[6] A circumcision operation may be performed at any age, so an intact boy may elect to have a circumcision whenever he wishes.

Medical trade association views

Australia and New Zealand

Flag of Australia (converted).svg

The Royal Australasian College of Physicians (2010) released a statement indicating that neonatal male circumcision "generally considered an ethical procedure", provided that 1) the child's decision makers, typically the parents, are acting in best interest of child and have been given full knowledge and 2) the procedure is performed by a competent provider, with sufficient analgesia, and does not unnecessarily harm the child or have substantial risks.[7] They argue that parents should be allowed to be the primary decision-makers because providers may not understand the full psychosocial benefits of circumcision.[7] Additionally, this procedure does not present substantial harm compared to its potential benefits, so parents should be allowed full decision-making capacity as long as they are educated properly.[7]

This statement also recognizes that waiting until the boy is of sufficient age to make his own decision would better respect his autonomy, but points out that this may interfere with a child's religious inclusion that circumcision was meant to confer.[7] With neonatal male circumcision, they acknowledge that the child may later on disagree with the parents' decision [7] but using the same reasoning, an uncircumcised child may also disagree with his parents' decision not to have him circumcised in infancy,[7] but he can have a circumcision at any age.

Canada

Flag of Canada (Pantone).svg

The Canadian Paediatric Society (CPS) issued a position statement on September 8, 2015, which highlighted the ethical issue surrounding the child's inability to give consent.[8] Since children require a substituted decision maker acting in their best interests, they recommend deferring non-medically indicated procedures, such as circumcision, until children can make their own decisions. Yet the CPS also self-servingly states that parents of male newborns must receive unbiased information about neonatal circumcision, so that they can weigh specific risks and benefits of circumcision in the context of their own familial, religious and cultural beliefs![8]

Denmark

Flag of Denmark.svg

The Danish Medical Association (Lægeforeningen) has released a statement (2016) regarding the circumcision of boys under the age of eighteen years. The organization says that the decision to circumcise should be "an informed personal choice" that men should make for themselves in adulthood.[9] According to Dr. Lise Møller, the chairwoman of the Doctors’ Association's Ethics Board, allowing the individual to make this decision himself when he is of age respects his right of self-determination.[10]

Netherlands

Flag of the Netherlands.svg

The Royal Dutch Medical Association (Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst) (KNMG) and several Dutch specialist medical societies published a statement of position regarding circumcision of male children on 27 May 2010. The KNMG argues against circumcising male minors due to lack of evidence the procedure is useful or necessary, its associated risks, and violate the child's autonomy.[6] They recommend deferring circumcision until the child is old enough to decide for himself.[6] The Royal Dutch Medical Association questions why the ethics regarding male genital alterations should be viewed any differently from female genital alterations, when there are mild forms of female genital alterations (like pricking the clitoral hood without removing any tissue or removing the clitoral hood altogether). They have expressed opposition to both male circumcision and all forms of female circumcision, however they do not advocate a prohibition of male circumcision and prefer that circumcisions be done by doctors instead of illegal, underground circumcisers .[6]

Scandinavia

In 2013 children's ombudsmen from Sweden, Norway, Finland, Denmark, and Iceland, along with the Chair of the Danish Children's Council and the children's spokesperson for Greenland, passed a resolution that emphasized the decision to be circumcised should belong to the individual, who should be able to give informed consent.[11]

The Nordic Association of Clinical Sexologists supports the position of the Nordic Association of Ombudsmen who reason that circumcision violates the individual's human rights by denying the male child his ability to make the decision for himself.[12]

The medical doctors at Sørland Hospital in Kristiansand, Southern Norway have all refused to perform circumcisions on boys, citing reasons of conscience.[13]

United Kingdom

Flag of the United Kingdom (3-5).svg

2019 revision of BMA guidance

The British Medical Association, being cognizant of the Re B and G (children) (No 2) EWFC 3 (2015) and Re L and B (CHILDREN) (2016) family court decisions, issued a new guidance to its member physicians in 2019. The new guidance urges its member physicians to take an extremely cautious approach to parental requests for the performance of non-therapeutic circumcision on minor boys and to ascertain that the requested non-therapeutic circumcision is in the boy's best interests.[14]

Lempert et al. (2022) criticized the 2019 BMA guidance for "serious weaknesses". They listed:

  1. the absence of an explicit stance on the underlying ethical status of NPC, coupled with an implicit permissive stance,
  2. an incoherent and impracticable analysis of the child’s best interests,
  3. unbalanced guidance regarding cultural issues,
  4. unbalanced guidance regarding scientific issues,
  5. unjustified differential treatment of children of the same sex,
  6. unjustified differential treatment of children of different sexes,
  7. problems with child safeguarding, and
  8. problems with regulation and training,
  9. an unjustified presumption of lawfulness of NPC of minors, and
  10. failure adequately to address recent case law.[15]

United States

Flag of the United States.svg

American Academy of Pediatrics

The American Academy of Pediatrics currently has no official stance on neonatal circumcision. The previous statement expired in 2017 and has not been reaffirmed.[16][17]

Criticism

The expired American Academy of Pediatrics (AAP) position statement on male circumcision (2012) attracted significant critical comment during its brief life, including from the AAP itself.

In a dissenting paper, Frisch et al. (2013) point out "Circumcision fails to meet the criteria to serve as a preventive measure for UTI [...] As a preventive measure for penile cancer, circumcision also fails to meet the criteria for preventive medicine [...] circumcision for HIV protection in Western countries fails to meet the criteria for preventive medicine [...] Circumcision fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children."

Frisch et al. conclude that "The AAP report lacks a serious discussion of the central ethical dilemma with, on one side, parents’ right to act in the best interest of the child on the basis of cultural, religious, and health-related beliefs and wishes and, on the other side, infant boys’ basic right to physical integrity in the absence of compelling reasons for surgery. Physical integrity is one of the most fundamental and inalienable rights a child has. Physicians and their professional organizations have a professional duty to protect this right, irrespective of the gender of the child."

Van Howe & Svoboda (2013) criticize the AAP statement because it failed to include important points, in accurately analyzed and interpret current medical literature, and made unsupported conclusions.[18]

Frisch et al. (2013) pointed out the difference of the AAP's statements in comparison to other Western countries, such as Canada, Australia, and various European countries.[19] They attribute this to cultural bias since non-therapeutic male circumcision is prevalent in the United States. They also criticized the strength of the health benefits the statement had claimed, such as protection from HIV and other STIs.[19] The American Academy of Pediatrics responded that because about half of American males are circumcised and half are not, there may be a more tolerant view concerning circumcision in the US, but that if there is any cultural “bias” among the AAP task force who wrote the Circumcision Policy statement, it is much less important than the bias Frisch et al. may hold because of clear prejudices against the practice that can be found in Europe. The AAP elaborately explained why they reached conclusions regarding the health benefits of circumcision that are different from the ones reached by some of their European counterparts.[20]

American Medical Association Journal of Ethics

In August 2017, the American Medical Association Journal of Ethics featured two separate articles challenging the morality of performing non-therapeutic infant circumcision.

Svoboda argues against non-therapeutic circumcision.[21] He states that this decision should be considered in the context of benefit vs risk of harm, rather than simply risk-benefit due to the non-therapeutic nature of the procedure.[21] He states that benefits do not outweigh the risks, and also claims that foreskin removal should be considered a sexual harm.[21] He also goes on to conclude that non-therapeutic circumcision largely violates the physician's duty to respect a patient's autonomy since many procedures take place before a patient is able to freely give consent himself.[21]

Reis and Reis's article explore the role physicians play in neonatal circumcision.[22] They state that if physicians outline all the currently known risks and benefits of the procedure to the parents and believes the procedure is indeed medically indicated, they cannot be held accountable for any harm from the procedure.[22] However, they still advise against physicians recommending unnecessary, irreversible surgeries, which is a category circumcision falls in frequently.[22]

Journal of Medical Ethics

Journal of Medical Ethics circumcision issue, July 2013

The Journal of Medical Ethics devoted the entire July 2013 issue to the controversial issue of non-therapeutic circumcision of male children.[23] The numerous articles represent a diverse variety of views.[24][25]

Other views

Povenmire (1988) argued that parents should not have the power to consent to neonatal non-therapeutic circumcision.[26]

Richards (1996) argued that parents only have power to consent to therapeutic procedures.[27]

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.[28]

Somerville argues that because of a lack of credible information about male circumcision in some societies, the ability for the caregiver to grant informed consent on behalf of their child is compromised. This may be especially true of caregivers from a religious or cultural tradition that is particularly biased towards or against circumcising infants.[28]

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."[29]

The Committee on Medical Ethics of the British Medical Association (2003) published a paper to guide doctors on the law and ethics of circumcision. It 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. It states that a physician has a right to refuse to perform a non-therapeutic circumcision.[4] The College of Physicians and Surgeons of British Columbia took a similar position.[30]

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".[31]

The Belgian Federal Consultative Committee for Bioethics (Comité Consultatif de Bioéthique de Belgique) (2017), after a three-year study, has ruled that circumcision of male children for non-therapeutic purposes is unethical in Belgium.[32][33] The process is irreversible, has no medical justification in most cases, and is performed on minors unable to give their own permission, according to the committee. Paul Schotsmans of the University of Leuven, on behalf of the committee, noted "the child’s right to physical integrity, which is protected by the Convention on the Rights of the Child, and in particular its protection from physical injury."[33] The Belgian minister of health replied that the Federal Institute for Health Insurance cannot check and know whether in (individual cases) a circumcision is medically justified or not and that she will continue to reimburse circumcision of minors as the safety of the child is her primary concern and she wants to avoid botched circumcisions by non-medical circumcisers.

Surrogate consent

Patient autonomy is an important principle of medical ethics.[34] Consent for a non-therapeutic operation offends the principle of autonomy, when granted by a surrogate.

Since children, and especially infants, are legally incompetent to grant informed consent for medical or surgical treatment, that consent must be granted by a surrogate — someone designated to act on behalf of the child-patient, if treatment is to occur.[35]

A surrogate's powers to grant consent are more circumscribed than the powers granted to a competent individual acting on his own behalf.[35][36] A surrogate may only act in the best interests of the patient.[35] A surrogate may not put a child at risk for religious reasons.[35] A surrogate may grant consent for a medical procedure that has no medical indication only if it is the child's best interests.[35]

The attending physician must provide the surrogate with all material information concerning the proposed benefits, risks, advantages, and drawbacks of the proposed treatment or procedure.[35][36]

The Committee on Bioethics of the AAP (1995) states that parents may only grant surrogate informed permission for diagnosis and treatment with the assent of the child whenever appropriate.[36]

There was an unresolved question whether surrogates may grant effective consent for non-therapeutic child circumcision.[26]

[35] Richards (1996) argues that parents may only consent to medical care, so are not empowered to grant consent for non-therapeutic circumcision of a child because it is not medical care.[27] The Canadian Paediatric Society (2015) recommends that circumcisions done in the absence of a medical indication or for personal reasons "should be deferred until the individual concerned is able to make their own choices."[8]

Regardless of these issues, the unethical general practice of the medical community in the United States is to receive surrogate informed consent or permission from parents or legal guardians for non-therapeutic circumcision of children.[26][35]

The emerging consensus on surrogate consent for non-therapeutic newborn, infant, and child circumcision

The power of parents and other surrogates to grant consent is dependent upon the existence of a physical or medical condition in a minor child that requires diagnostic and/or treatment.[27] [37] The right to grant surrogate consent cannot exist in the absence of such a condition. The AAP Committee on Bioethics (2016) now states: "A parent’s authority is not absolute but constrained by respect for the child."[38] This may mean that the AAP now recognizes the child as a person with legal rights of his/her own.

Boys are born with a healthy foreskin that is free of disease. There are no medical indications for a neonatal circumcision. The medical trade associations and other promoters have put forward various alleged benefits from neonatal circumcision for decades to develop business for their physican-members.

The validity of surrogate consent for non-therapeutic circumcision of boys has been questioned for decades.[26] [27] [39]

Bioethicists Myers & Earp (2020) exhaustively reviewed the evidence for and against the alleged health benefits to a healthy person claimed for non-therapeutic circumcision of a neonate, infant or child. They balanced this against the pain, trauma, and loss of body tissue and function. They concluded the claimed health benefits are insufficient to support surrogate consent for non-therapeutic circumcision. Given this, only the subject can grant consent for a non-therapeutic circumcision, after he reaches the right age for circumcision, which does not occurs until a male reaches the age of consent in his jurisdiction which may vary from 16 to 18 years of age. The present practice in the United States and elsewhere of parental consent for non-therapeutic circumcision is entirely unethical.[40]

Moreover, non-therapeutic circumcision of boys may also be unlawful,[41] if a court should accept Adler's arguments.

Observations

The non-therapeutic circumcision industry in the United States produces more than $2 billion annually.[42] Third-party payment is a major support to the performance of this medically-unnecessary surgery. If parents could not grant consent for non-therapeutic circumcision, then no one could grant consent for the non-therapeutic circumcision of a child, so the $2 billion annual business would collapse. The American medical trade associations, more than those of other nations, have been unwilling to recognize the child's right to physical integrity, to security of the person, and the right to personal autonomy.

See also

External links


References

  1. ↑ REFbook Sawyer S: Pediatric Physical Examination & Health Assessment. Jones & Bartlett Publishers. Pp. 555-556. ISBN 978-1-4496-7600-1.
  2. ↑ REFjournal Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of Healthy Boys: Criminal Assault?. J Law Med. February 2000; 7: 301-310. Retrieved 29 May 2024.
  3. ↑ REFweb (September 2004). Policy Statement On Circumcision Icons-mini-file pdf.svg, Royal Australasian College of Physicians. Retrieved 28 February 2007.
  4. ↑ a b Committee on Medical Ethics. The law and ethics of male circumcision: Guidance for doctors. London: British Medical Association 2006.
  5. ↑ REFjournal Task force on circumcision. Circumcision policy statement. Pediatrics. 1999; 103(3): 686-693. PMID. DOI.,
  6. ↑ a b c d Non-Therapeutic Circumcision of Male Minors. Utrecht: Royal Dutch Medical Association, 2010.
  7. ↑ a b c d e f Circumcision of Male Infants. Royal Australasian College of Physicians. September 2010.
  8. ↑ a b c REFjournal Sorakan ST, Finla JC, Jefferies AL. Newborn male circumcision. Paediatr Child Health. 2015; 20(6): 311-315. PMID. PMC.
  9. ↑ REFnews McCann, Erin (8 December 2016)."Danish Doctors’ Group Wants to End Circumcision for Boys".
  10. ↑ REFnews (5 December 2016)."Danish doctors come out against circumcision". Retrieved 2 November 2019.
  11. ↑ REFweb Nordic Association of Children's Ombudsmen (30 September 2013). Let the boys decide for themselves. Retrieved 3 November 2019.[] Tuesday, 1 October 2013
  12. ↑ Statement on Non-Therapeutic Circumcision of Boys.. Nordic Association of Clinical Sexologists, Helsinki, 10 October 2013.
  13. ↑ REFnews Faull, Solrun F. (30 August 2016)."Hospital doctors in Southern Norway will not circumcise boys".
  14. ↑ REFdocument Anonymous: Non-therapeutic male circumcision (NTMC) of children – practical guidance for doctors PDF, British Medical Association. (2019). Retrieved 29 June 2021.
  15. ↑ REFjournal Lempert A, Chegwidden J, Steinfeld R, Earp BD. Non-therapeutic penile circumcision of minors: Current controversies in UK law and medical ethics.. Clinical Ethics. May 2022; Retrieved 20 May 2022.
  16. ↑ REFjournal Task Force On Circumcision. Circumcision Policy Statement. Pediatrics. 1 September 2012; 130(3): 585-586. PMID. DOI.
  17. ↑ REFweb AAP. TECHNICAL REPORT Male Circumcision.
  18. ↑ REFjournal Van Howe RS, Svoboda JS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. Journal of Medical Ethics. 1 July 2013; 39(7): 434-441. PMID. DOI.
  19. ↑ a b REFjournal Frisch M, Aigrain Y, Barauskas V, Bjarnason R, Boddy SA, Czauderna P, de Gier RPE, de Jong TPVM, Fasching G. Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision. Pediatrics. 1 April 2013; 131(4): 796-800. PMID. DOI.
  20. ↑ REFjournal Task Force On Circumcision. Cultural Bias and Circumcision: The AAP Task Force on Circumcision Responds. Pediatrics. 1 April 2013; 131(4): 801-804. PMID. DOI.
  21. ↑ a b c d REFjournal Nontherapeutic Circumcision of Minors as an Ethically Problematic Form of Iatrogenic Injury. AMA Journal of Ethics. 1 August 2017; 19(8): 815-824. PMID. DOI.
  22. ↑ a b c REFjournal Reis-Dennis, S., Reis, E.. Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries?. AMA Journal of Ethics. 1 August 2017; 19(8): 825-833. PMID. DOI.
  23. ↑ REFjournal The issue of male circumcision. Journal of Medical Ethics. 2013; 39(7)
  24. ↑ REFjournal Foddy B. The concise argument: Medical, religious and social reasons for and against an ancient rite. Journal of Medical Ethics. 2013; 39(7): 415. PMID. DOI.
  25. ↑ REFjournal Earp BD. The ethics of infant male circumcision. Journal of Medical Ethics. 2013; 39(7): 418-420. PMID. DOI.
  26. ↑ a b c d REFjournal Povenmire R. 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. Retrieved 25 November 2013.
  27. ↑ a b c d REFjournal Richards D. Male Circumcision: Medical or Ritual?. Journal of Law and Medicine. May 1996; 3(4): 371-376. Retrieved 11 April 2008.
  28. ↑ a b REFbook Somerville M: Altering Baby Boys’ Bodies: The Ethics of Infant Male Circumcision, in: The ethical canary: science, society, and the human spirit. New York, NY: Viking Press. Pp. 202-219. ISBN 0-670-89302-1. Retrieved 12 February 2007.
  29. ↑ REFjournal Canning DA. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Urol. 2002; 168(4 Pt 1): 1650-1651. PMID. DOI.
  30. ↑ REFweb College of Physicians & Surgeons of British Columbia (2007). Circumcision (Infant Male). Retrieved 6 December 2013.
  31. ↑ REFjournal Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. Journal of Medical Ethics. 2005; 31(8): 463-469. PMID. PMC. DOI.
  32. ↑ REFweb Comité Consultif de Bioéthique de Belgique (8 May 2017). Opinion no. 70 of 8 May 2017on the ethical aspects of nonmedical circumcision, SPF Santé Publique. Retrieved 3 November 2019.
  33. ↑ a b REFnews (2017)."Ethics committee rules against infant circumcision".
    Quote: As circumcision is irreversible and therefore a radical operation, we find the physical integrity of the child takes precedence over the belief system of the parents.
  34. ↑ REFbook Beauchamp TL, Childress JF: Principles of Biomedical Ethics. New York: Oxford University Press.
  35. ↑ a b c d e f g h REFjournal Svoboda JS, Van Howe RS, Dwyer JG. Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. J Contemp Health Law & Policy. 2000; 17: 60-133.
  36. ↑ a b c REFjournal Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995; 95(2): 314-317. PMID. Reaffirmed May 2011.
  37. ↑ REFjournal Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. February 1995; 95(2): 314-7. PMID. Retrieved 26 May 2023.
  38. ↑ REFjournal Committee on Bioethics. Informed Consent in Decision-Making in Pediatric Practice. Pediatrics. August 2016; 138(2): e20161484.. PMID. DOI. Retrieved 27 May 2023.
  39. ↑ REFjournal Hill G. Can anyone authorize the nontherapeutic permanent alteration of a child's body? PDF. The American Journal of Bioethics. 2003; 3(2): 16-8. PMID. DOI. Retrieved 11 July 2023.
  40. ↑ REFjournal Myers A, Earp BD. What is the best age to circumcise? A medical and ethical analysis PDF. Bioethics. 2020; 34(7): 645-63. PMID. DOI. Retrieved 27 May 2020.
    Quote: Based on a careful consideration of the relevant evidence, arguments and counterarguments, we conclude that medically unnecessary penile circumcision-like other medically unnecessary genital procedures, such as 'cosmetic' labiaplasty-should not be performed on individuals who are too young (or otherwise unable) to provide meaningful consent to the procedure.
  41. ↑ REFjournal Adler PW. Is Circumcision Legal?. Richmond J. L. & Pub. Int.. 2013; 16(3): 439.
  42. ↑ REFweb Bollinger, Dan (2012). High Cost of Circumcision: $3.6 Billion Annually, https://www.academia.edu, Academia. Retrieved 12 November 2021.
    Quote: As the saying goes, follow the money. Now you know why neither the American Academy of Pediatrics, American Medical Association, American Academy of Family Physicians, or the American College of Obstetricians and Gynecologists haven’t condemned this unnecessary surgery, and why their physician members are quick to recommend the procedure to expectant parents.
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