Changes

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 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 anesthesia 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> 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 REFjournal | authorlast=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 | doiDOI=10.1542/peds.103.3.686 | pmidpubmedID= 10049981 | pmcpubmedCID= }}</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 bookREFbook |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>

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" />

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" />

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 journalREFjournal |authorlast=Sorakan |first=ST, Finlay JC, .. |last2=Finla |first2=J.C. |last3=Jefferies AL |first3=A.L. |title=Newborn male circumcision |journal=Paediatr Child Health |date=2015 |volume=20 |issue=6 |pages=311–5311–315 |url=http://www.cps.ca/en/documents/position/circumcision |doiDOI= |pmidpubmedID=26435672 |pmcpubmedCID=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" />

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 newsREFnews |authorfirst=Erin |last=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 2016-12-08}}</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.=REFnews |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=-12-05 |accessdate=|sectionphrase=|section=|pages=|column=|language=|agency=|publisher=|id=|quote=|notes=|harvid=|ref=}}</ref>

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" />

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 webREFweb |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>

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 webREFweb |authorlast=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=2013-09-30 September 2013 |accessdate=2013-10-22 October 2013}}[] Tuesday, 1 October 2013</ref>

The medical doctors at Sørland Hospital in [[Kristiansand]], Southern [[Norway]] have all refused to perform circumcisions on boys, citing reasons of conscience.<ref>{{vcite newsREFnews |authorfirst=Solrun F. |last=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=2016-08-30 August 2016}}</ref>

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" />

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 journalREFjournal |last=Mussell |first=R. |authorlink= |date=June 2004-06 |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 |doiDOI=10.1136/jme.2004.008615 |pmcpubmedCID=1733857 |pmidpubmedID=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" />

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 REFweb |authorlast=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 -06 | accessdate= 2013-11-25 November 2013.}}</ref>

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 webREFweb |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=2017-02-23 February 2017}}</ref>

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" />

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 REFjournal |last=Foxauthor |first=Fox M, . |last2=Thomson |first2=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=463–9 463–469 | url=http://jme.bmj.com/content/31/8/463.full | doiDOI=10.1136/jme.2004.009340 | pmidpubmedID=16076971 | pmcpubmedCID=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" />

The American Academy of Pediatrics currently has no official stance on neonatal circumcision.<ref>{{Cite journalREFjournal |last=Circumcision|first=Task Force OnCircumcision |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 |doiDOI=10.1542/peds.2012-1989 |issn=0031-4005 |pmidpubmedID=22926180}}</ref><ref>{{Cite webREFweb |url=https://pediatrics.aappublications.org/content/pediatrics/130/3/e756.full.pdf |title=TECHNICAL REPORT Male Circumcision |last=AAP}}</ref>

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 journalREFjournal |last=Van 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 |doiDOI=10.1136/medethics-2013-101346 |issn=0306-6800 |pmidpubmedID=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 journalREFjournal |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 |doiDOI=10.1542/peds.2012-2896 |pmidpubmedID=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 journalREFjournal |last=Circumcision|first=Task Force OnCircumcision |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 |doiDOI=10.1542/peds.2013-0081 |issn=0031-4005 |pmidpubmedID=23509171}}</ref>

Svoboda argues against non-therapeutic circumcision.<ref name=":05">{{Cite journalREFjournal |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 |doiDOI=10.1001/journalofethics.2017.19.8.msoc2-1708 |pmidpubmedID=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" />

Reis and Reis's article explore the role physicians play in neonatal circumcision.<ref name=":14">{{Cite journalREFjournal |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 |doiDOI=10.1001/journalofethics.2017.19.8.msoc3-1708 |pmidpubmedID=28846522 |issn=2376-6980 |last1last=Reis-Dennis |first1first=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" />

The ''[[Journal of Medical Ethics]]'' published a "symposium on circumcision" in its June 2004 issue.<ref name="symposium">{{vcite journal |REFjournalauthor= | 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:

"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 REFjournal | authorlast=Holm |first=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 | doiDOI=10.1136/jme.2004.009001 | pmidpubmedID=15173353 | pmcpubmedCID=1733860}}</ref>

"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 REFjournal |last=Hutsonauthor |first=Hutson JM J.M. | title=Circumcision: a surgeon’s perspective | journal=J Med Ethics | date=2004 | volume=30 | issue=3 | pages=238–40 238–240 | url=http://jme.bmj.com/content/30/3/238.full | doiDOI=10.1136/jme.2002.001313 | pmidpubmedID=15173354 | pmcpubmedCID=1733864 }}</ref>

"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 REFjournal |last=Shortauthor |first=Short RV R.V. | 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 | doiDOI=10.1136/jme.2002.002576 | pmidpubmedID=15173356 | pmcpubmedCID=1733868 }}</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">{{vcite journal REFjournal | authorlast=Viens AM |first=A.M. | title=Value judgment, harm, and religious liberty | journal=J Med Ethics | date=2004 | volume=30 | issue=3 | pages=241–7 241–247 | url=http://jme.bmj.com/content/30/3/241.2.full | doiDOI=10.1136/jme.2003.003921 | pmidpubmedID=15173355 | pmcpubmedCID=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 REFjournal | authorlast=Hellsten SK |first=S.K. | 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 | doiDOI=10.1136/jme.2004.008888 | pmidpubmedID=15173357 | pmcpubmedCID=1733870 }}</ref>

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 REFjournal |last=Mussellauthor |first=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. 254–258 | url=http://jme.bmj.com/content/30/3/254.full | doiDOI=10.1136/jme.2004.008615 | pmidpubmedID=15173358 | pmcpubmedCID=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 REFjournal |authorlast=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=259–63 259–263 | url=http://jme.bmj.com/content/30/3/259.full | doiDOI=10.1136/jme.2004.008540 | pmidpubmedID=15173359 | pmcpubmedCID=1733850 }}</ref>

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= REFjournal | 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 REFjournal | authorlast=Foddy |first=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 | doiDOI=10.1136/medethics-2013-101605 | pmidpubmedID=23781076 | pmc= }}</ref><ref>{{vcite journal REFjournal |last=Earpauthor |first=Earp BD B.D. | title=The ethics of infant male circumcision | journal=J Med Ethics | date=2013 | volume=39 | issue=7 | pages=418–20 418–420 | url=https://www.academia.edu/3430963/The_ethics_of_infant_male_circumcision | doiDOI=10.1136/medethics-2013-101517 | pmidpubmedID=23781078 | pmc= }}</ref>

Povenmire (1988) argues 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" />

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 bookREFbook | last = Somerville | first = Margaret |authorlink=Margaret Somerville | title = The ethical canary: science, society, and the human spirit| url = | accessdate = 2007-02-12 |date=November 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 | chapterurl url= https://www.academia.edu/654017/Altering_baby_boys_bodies_the_ethics_of_infant_male_circumcision| quote =| authorlink = Margaret Somerville | lccn = 2001369341}}</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">{{vcite journal REFjournal | authorlast=Canning DA |first=D.A. | 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 1650–1651 | url= | doiDOI= 10.1016/S0022-5347(05)64535-1 | pmidpubmedID=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 REFjournal |url=http://bioethics.net/journal/pdf/3_2_LT_w01_Benetar.pdf |format=PDF |first=David |last=Benatar |author2last2=Benatar, |first2=Michael |title=How not to argue about circumcision |journal=American Journal of Bioethics |volume=3 |issue=2 |yeardate=2003 |pages=W1–W9 |doiDOI=10.1162/152651603102387820 |pmidpubmedID=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>

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 REFweb |authorlast=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 -12-06 |archiveurlurl=https://web.archive.org/web/20070928050441/https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/malecircum |archivedate=2007-09-28 }}</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" />

[[Brian J. 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 journalREFjournal |last1last=Morris |first=B.J. |first1authorlink=BJBrian J. Morris |last2=Bailis |first2=SAS.A. |last3=Wiswell |first3=TET.E. |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 2014-05 |volume=89 |issue=5 |pages=677–86677–686 |doiDOI=10.1016/j.mayocp.2014.01.001 |pmidpubmedID=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>Statement in French: {{vcite web REFweb | authorlast=Comité Consultif de Bioéthique de Belgique | homewebsite= 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 -05-08 | accessdate=2017-09-27 September 2017 }}</ref><ref name="bulletin2017">{{vcite news | author= 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 [[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 webREFweb |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>

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 REFjournal |last=Rennie |first=Stuart |authorlink= |author2first2=Adamson S . |last2=Muula |author3first3=Daniel |last3=Westreich |date=June 2007 -06 |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 |pmidpubmedID=17526688 |url=http://jme.bmj.com/cgi/content/full/33/6/357 |accessdate= |pmcpubmedCID=2598273 |quote= |doiDOI=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>{{REFbook |last=Boyle, |first=G.J. ( |year=2013). |chapter=Critique of African RCTs into Male Circumcision and HIV Sexual Transmission. In |editor=G.C. Denniston ''et al. (Eds.), '' |title=Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements. |location=Dordrecht, The Netherlands: |publisher=Springer Science+Business Media. doi: |DOI=10.1007/978-94-007-6407-1_15 {{ISBN |isbn=978-94-007-6406-4}}</ref>

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 [[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 journalREFjournal |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 |doiDOI=10.1038/nature.2011.9520 |yeardate=2011}}</ref>

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 REFweb | url=https://www.nhs.uk/news/lifestyle-and-exercise/circumcision-and-stis/ | title=Circumcision and STIs | date=2009-03-26}}</ref>

Patient [[autonomy]] is an important principle of [[medical ethics]].<ref>{{vcite book REFbook |last=Beauchampauthor |first=Beauchamp, Tom L., and |last2=Childress, |first2=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.

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 |first=J. Steven |last=Svoboda, |first2=Robert S. |last2=Van Howe, |first3=James C. |last3=Dwyer, |title=Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. |pages=17 |journal=J Contemp Health Law & Policy |volume=61 ( |date=2000).}}</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">{{vcite journal REFjournal |authorlast=Committee on Bioethics | title=Informed consent, parental permission, and assent in pediatric practice | journal=Pediatrics | date=1995 | volume=95 | issue=2 | pages=314–7 314–317 | url=http://pediatrics.aappublications.org/content/95/2/314.full.pdf | doi= | pmidpubmedID=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" />

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 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" />

There is an unresolved question whether surrogates may grant effective consent for non-therapeutic child circumcision.<ref name="povenmire">{{cite journal REFjournal |last=Povenmire |first=R. |authorlink= |yeardate= |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 |pmidpubmedID=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 REFjournal |last=Richards |first=D. |authorlink= |date=May 1996 -05 |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 REFjournal | authorlast=Sorakan ST, |first=S.T. |last2=Finlay JC, |first2=J.C. |last3=Jefferies AL |first3=A.L. | title=Newborn male circumcision | journal=Paediatr Child Health | date=2015 | volume=20 | issue=6 | pages=311–5 311–315 | url=http://www.cps.ca/en/documents/position/circumcision | doi= | pmidpubmedID= 26435672 | pmcpubmedCID= 4578472}}</ref>

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" />

* {{cite journal REFjournal |last=Freeman |first=M.D. |authorlink= |date=January 1999 -01 |title=A child's right to circumcision |journal=BJU Int |volume=83 |issue=Suppl. 1 |pages=74–78 |pmidpubmedID=10349417 |quote= |doiDOI=10.1046/j.1464-410x.1999.0830s1074.x}}* {{cite journal REFjournal | authorlast= Goodman |first=J . | title=Jewish circumcision: an alternative perspective | journal=BJU Int | date=1999 | volume=83 Suppl. 1 | issue= | pages=22–27 | doiDOI=10.1046/j.1464-410x.1999.0830s1022.x | pmidpubmedID=10349411 | pmc= }}