Is it ethical to perform
routine infant male circumcisions?
By M. Paul Vance
Ethical Discussion
Circumcision-the most common surgery performed in the U.S.- is a procedure in search of a disease.
But let us suppose that circumcision causes no "harm" to the male: that it does not lead to death between one in twenty-four thousand and one in five hundred thousand cases; that no penises are inadvertently ablated and that no chromosome XY infants are raised chromosome XX; and that circumcision does not remove erogenous tissue and lead to altered sexual practices.
Let us suppose that adequate pain control techniques are developed (and used) so that during the procedure infants do not rupture their stomachs, vomit, and stop breathing due to overwhelming, intractable pain. Let us suppose that a safe post-operative analgesic is also developed so that the infant does not suffer irritation as urine and feces bathe his raw penis.
Let us also suppose that circumcision prevents masturbation; that circumcision prevents penile cancer, and that circumcision prevents cervical cancer; and that circumcision prevents sexually transmitted diseases; and that circumcision cures meningitis; and that circumcision prevents childhood diseases; and that circumcision prevents urinary tract infections; and that circumcision prevents HIV infections.
Let us suppose all these things.
If we suppose all these things-then, is routine infant circumcision ethical? No.
Medical professionals and parents have fearlessly faced the daunting task of deciding whether an extremely invasive and painful procedure fraught with complications will be medically beneficial to the newborn male at some time in his life. But that is not the issue-the issue is whether an infant male has an "inherent right, inalienable right to his own intact body." (192)
There can be no justification for amputating normal tissue from a normal child.
"I think I could accept a deformity that was an accident of nature, but I can't accept that someone did that to me. I have never been able to accept the fact that when I was a baby someone cut part of my penis off." (193)
"We recognize the inherent right of all human beings to an intact body. Without religious or racial prejudice, we affirm this basic human right. We recognize that the foreskin, clitoris and labia are normal, functional body parts. Parents and/or guardians do not have the right to consent to the surgical removal or modification of their children's normal genitalia. Physicians and other healthcare providers have a responsibility to refuse to remove or mutilate normal body parts. The only persons who may consent to medically unnecessary procedures upon themselves are the individuals who have reached the age of consent (adulthood), and then only after being fully informed about the risks and benefits of the procedure. We categorically state that circumcision has unrecognized victims. In view of the serious physical and psychological consequences that we have witnessed in victims of circumcision, we hereby oppose the performance of a single additional unnecessary foreskin, clitoral, or labial amputation procedure. We oppose any further studies which involve the performance of the circumcision procedure upon unconsenting minors..." (194)
Routine infant circumcision violates principles I, III, IV, and V of the American Medical Association Principles of Medical Ethics:
"A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity." (195)
Physicians are not ethically obligated to provide the care a patient's parents or physician's superior want the physician to perform. The physician's primary ethical loyalties are to his own conscious and to the welfare of his patient.
Numerous studies, cited above, have conclusively shown that circumcision is an extremely painful operation; equally numerous also previously cited studies have conclusively shown that effective intraoperative pain relief is available; and physicians have been repeatedly advised-with little avail-to anesthetize infants while they are being circumcised (196, 197, 198).
Routine infant circumcision does not save lives or reduce suffering and it is not medically indicated. It simply is not compassionate to perform an extremely painful, medically unnecessary operation even with (and that is not the case here) the patient's consent.
The foreskin has several functions: protection of the glans during infancy and throughout life, to facilitate copulation, and to detect sensual stimuli. Removing non-diseased, functioning tissue from an infant at the parent's request violates the infant and does not respect the infant's "human dignity".
Circumcision is a non-therapeutic procedure with definite risks and only potential benefits. Proper penile hygiene accomplishes the same potential benefits-without the pain or loss of function-and is far less intrusive. Circumcising 100,000 infants without anesthesia to prevent one case of penile cancer later in life, or circumcising 195 infants without anesthesia to prevent one case of hospitalizable urinary tract infections is not "competent medical service".
"A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interest of the patient."
The U.S. has realized that routine female circumcision is "genital mutilation"-that it violates the female's privacy and harms the female physically and psychologically for life.
Routine circumcision began in the U.S in the 1870's to prevent children (boys and girls) from masturbating and as a punishment for masturbation, and to prevent/cure a variety of psychological disorders in males and females of all ages. All the original reasons for instituting routine infant circumcision have been disproved; not a single "new reason" for routine male circumcision is accepted outside the U.S. and Canada. Does the U.S. and Canada know something the rest of the world doesn't know?
No.
It is time for the U.S. to realize that routine male circumcision-although currently legal-is unethical. Routine male circumcision mutilates the genitals, violates the male's privacy, and physically and psychologically harms the male for life. Let it be said here-as is true for most of the females who have been mutilated in Africa, the Middle East, and the U.S.-that most U.S. male victims do not realize they are victims.
Physicians break no law or principle by refusing to circumcise infants. By agreeing to circumcise however, physicians serve the interests of everyone except the person he is ethically obligated to serve: the infant. Circumcision removes normal functioning tissue, inflicts great pain, and induces long-lasting behavioral changes. Circumcising physicians are not performing a procedure "in the best interest of the patient".
"A physician shall respect the rights of patients..."
Like it or not, an infant is a person.
All patients, including infants, have the right to privacy and bodily integrity-physicians have the duty to refrain from violating these rights without sufficient justification.
A parent's desire is not sufficient justification for a physician to violate an infant's rights.
"Physicians shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues, and the public...."
As covered previously, circumcision is an extremely painful procedure that permanently removes functioning tissue. Complication rates of circumcision exceed benefit rates; extra hospitalization times for circumcision exceed urinary tract infection hospitalization times; deaths to circumcision approximate deaths to penile cancer. Recommending-even tacitly-circumcision as a beneficial procedure is a failure on the part of the physician to "study, apply.... (and) make relevant information available to patients". Physicians have an ethical obligation to "apply...scientific knowledge" by dissuading parents from seeking to circumcise their infant boys and girls
Physicians who circumcise also violate the medico-ethical principles of autonomy and non-malifience.
Autonomy. For individuals without decision-making capacity, it is at times necessary to violate their present autonomy so as to preserve their future autonomy. (For example, treating an unconscious individual).However, circumcision is non-therapeutic: the infant does not need the operation. Thus, by circumcising the infant, the physician violates the patients autonomy by forever negating the patient's right to decide whether or not he will be circumcised.
Non-malifience. As healers, physicians are bound to practice beneficence and non-malifience. Beneficence commands the physicians to attempt to heal, treat, or alleviate suffering in his patient; non-malifience directs the physician to avoid unnecessarily harming his patient. Circumcising physicians refrain from practicing beneficence and do malifience. Prior to circumcision, the infant is not diseased, does not require treatment, and is not suffering. Here then, the physician can indirectly practice beneficence by recommending to the parents not to have their son circumcised. However, if the physician agrees to circumcise the infant, he inflicts extreme pain on an infant: he inflicts a wound that serves no purpose other than being a result of fulfilling-not the infant's-but other peoples wishes. The only term that can describe such an act is malifience.
Evil is unspectacular and always human, and shares our bed and eats at our own table. W.H. Auden
192. Milos, Marilyn, National Organization of Circumcision Information Resource Centers (NOCIRC),
http://www.nocirc.org/
193. Denniston, G.C. (1989) "First, do no harm." The Truth Seeker (3):37
194. Excerpt, Declaration of the First International Symposium on Circumcision
http://www.nocirc.org/declare.html
195. American Medical Association Code of Medical Ethics Council on the Ethical and Judical Affairs 1996-1997 Edition,
196. 1996 Position Statement: Routine Circumcision of Normal Male Infants and Boys. Australian College of Paediatrics.
197. Lannon, Carol M., (1999). "American Academy of Pediatrics Task Force on Circumcision, Circumcision Policy Statement." Pediatrics 103(3).
198. 1996 Position Statement: Canadian Paediatric Society (CPS) Canadian Medical Association Journal 154(6): 769-780
