Male Circumcision J Med Ethics: First Published As 10.1136/Jme.2002.002576 on 1 June 2004

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device is now off patent, and could be

Male circumcision J Med Ethics: first published as 10.1136/jme.2002.002576 on 1 June 2004. Downloaded from ...... mass produced at very low cost. Even if the rest of the world continues to reject male circumcision, there are a Male circumcision: a scientific billion Muslims for whom it will remain a fact of life. Islamic nations such as perspective Egypt, Sudan, Iraq, Iran, Pakistan, Bangladesh, and Indonesia have specta- R V Short cularly low rates of HIV infection compared with their neighbours, due at least ...... in part to male circumcision. Now would be an opportune time for the Western The health benefits of male circumcision are wide ranging world to profit from this Islamic experi- ence, while offering to help them n this issue, John Hutson has re- prospects, is it ethical to dismiss a improve their surgical procedures. iterated the conventional Western simple prophylactic surgical procedure If we believe in evidence based Imedical view that ‘‘the surgical argu- that can halve male rates of infection? medicine, then there can be no debate ment for circumcision of all neonatal The case for male circumcision has about male circumcision; it has become males at present is very weak’’ and he been further strengthened by a recent a desirable option for the whole world. criticises many of the circumcisions multinational case controlled study in Paradoxically, this simple procedure is a performed in later childhood, without developed and developing countries in life saver; it can also bring about major anaesthesia, as ‘‘physically cruel and Europe, Asia, and South America, which improvements to both male and female potentially dangerous’’ [see page has shown that circumcised men are reproductive health. Rather than con- 238].1 He is also of the opinion that two thirds less likely to have human demning it, we in the developed world ‘‘the diseases which circumcision is able papilloma virus infection of the penis, have a duty to develop better procedures to prevent are uncommon or even rare’’. and their female partners less than half that are neither physically cruel nor But therein he errs, and greatly errs. as likely to develop cervical cancer, potentially dangerous, so that male He cites only two publications dealing when compared with uncircumcised circumcision can take its rightful place with the protective effect of male circum- men and their partners.5 As cervical as the kindest cut of all. cision against HIV infection, and makes cancer is the second commonest cancer J Med Ethics 2004;30:241. no mention of the important recent meta- of women worldwide, these results doi: 10.1136/jme.2002.002576 analysis of Weiss, Quigley, and Hayes2 should surely make the most reluctant Correspondence to: Professor R V Short, which shows conclusively from a large surgeons think again. Department of Obstetrics and Gynaecology, number of studies that male circumcision But nevertheless, Hutson does have a Royal Women’s Hospital, 132 Grattan Street, at least halves the relative risk of HIV infec- point. Male circumcision is not without Carlton, Victoria 3053, Australia; r.short@ tion throughout sub-Saharan Africa.3 its risks. When is it best to perform the unimelb.edu.au Would that we could share Hutson’s operation? Perhaps late in childhood, REFERENCES optimism that ‘‘we are not certain at when the foreskin has separated from present whether AIDS is going to be an the glans penis, and the boy can give 1 Hutson JM. Circumcision: a surgeon’s http://jme.bmj.com/ perspective. J Med Ethics 2004;30:238–40. even more widespread disease in the informed consent to the procedure. 2 Weiss HA, Quigley MA, Hayes RJ. Male future or whether it will be abolished by Such timing would also ensure a more circumcision and risk of HIV infection in sub- some new treatment’’. At the 14th Inter- immediate impact on the transmission Saharan Africa: a systematic review and meta- analysis. AIDS 2002;14:2361–70. national AIDS Conference in Barcelona of HIV. How should the operation be 3 Reynolds SJ, Shepherd ME, Risbud AR, et al. in July 2002 we were informed that performed? The American PlastiBell Male circumcision and risk of HIV-1 and other currently 40 million people are infected device has one of the lowest complica- sexually transmitted infection in India. Lancet 2004;363:1039–40. with HIV, with five million new infection rates, providing a ‘‘no scalpel’’ 4 UNAIDS. Report on the global HIV/AIDS on September 28, 2021 by guest. Protected copyright. tions a year; the AIDS pandemic is only circumcision by means of a ligature tied epidemic. Geneva: UNAIDS, 2002:226. just beginning. There is no cure in sight, around the base of the foreskin when it 5 Castellsague´X, Bosch FX, Munoz N, et al. Male circumcision, penile human papillomavirus and vaccines still remain a distant is stretched over a protective plastic cap infection, and cervical cancer in female partners. hope.4 Faced with such dismal future which covers the glans penis. This New Eng J Med 2002;346:1105–12.

Male circumcision argues that it is virtually impossible to ...... justify a policy in which the medical establishment should be able to embark on a ‘‘mass circumcision’’ campaign of Value judgment, harm, and religious 100% of the infant male population (with the exception, of course, where it liberty would be contraindicated by the pre- sence of an anatomical or physiological A M Viens abnormality) [see page 238].1 Indeed, I would be hard pressed to ...... find anyone who could rationally dis- Parents’ freedom to choose infant male circumcision is the correct agree with this contention. However, this is because no one is currently argu- policy ing for the enactment of a policy that stipulates that all healthy male infants ndividuals and groups lobbying to the practice of routinely circumcising should be routinely circumcised (inde- have infant male circumcision pro- infants is unjustified. For instance, in pendent of parental choice). Arguments Ihibited or restricted often argue that this issue of the journal, John Hutson seeking to support a prohibition of

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‘‘routine infant circumcision’’, such as reasonable yet conflicting doctrines and live one’s life on the other hand, are in a the one by Hutson, are arguing against a whom this policy would concern. As different justificatory class. Our process J Med Ethics: first published as 10.1136/jme.2002.002576 on 1 June 2004. Downloaded from straw man—and a pitiful one at that.2 there are reasonable doctrines held by of justifying public policy must bracket Such arguments only serve to miscon- individuals that contain deeply held off reference to substantive conceptions strue the debate and avoid engaging in social, cultural, and religious views of the good in order to ensure that the real and pressing issues concerning concerning the value of having their particular beliefs and values are not the legitimacy of the provision of this son undergo circumcision, current forced onto others. procedure. attempts to advance a policy which In the case of specific policy questions, The questions that should be consid- prohibits the provision of this procedure such as whether it is justified to allow ered, and the ones which I shall be that fail to take these value judgments parents to choose whether or not they interested in discussing here, are what seriously would be unjustified. I argue can circumcise their son, we are not reasons are justifiable for allowing that the proper assessment of the moral seeking to advance a policy that all mem- parents to choose to have their son permissibility of circumcision needs to bers of society will necessarily come to circumcised? After well informed and be made by parents on the basis of an endorse, but to aim to advance a policy careful deliberation should parents have informed deliberation concerning all that no one could reasonably reject. Such the freedom to choose to have their son the potential medical and non-medical a conception recognises that there is a circumcised? These are the most rele- benefits and risks of the procedure. disjunction of reasonable conceptions of vant questions to be considered because the good to be found within society, and views as its task, according to Donald there is a growing collection of citizens, I Ainslie, ‘‘not [as] the [resolution of] medical practitioners, and lawyers who Generally, it is very difficult for indivi- disagreements, but to see what policy are currently lobbying for the practice of duals to view their own conception of can be justified to people despite their infant male circumcision to be out- the good as anything but true. After disagreements’’.5 The important point lawed—for example, there is a bioethi- deliberating and fixing a particular set here is that when bioethicists are con- cist who argues that the criminal law of moral beliefs, it is difficult for an cerned with the construction of bio- should be used to prohibit the procedure individual to view other divergent moral 3 medical policy, in order to advance policy as an instance of aggravated assault. beliefs as anything but false. For if an that will be seen as fair and justifiable to For a number of people, if successful, individual did not think their consid- reasonable people, it cannot be done at such an action would have the notable ered moral judgements about how to the level of conceptions of the good. impact of interfering with their ability live their life were true or best, there When formulating the norms governing (as parents or guardians) to determine would be little reason to hold those biomedical policy, bioethicists must take what is in the best interest of their beliefs, let alone act on them. The as their starting point the fact that a child and/or the freedom to raise their existence and extent of moral diversity plurality of reasonable conceptions of the children under the tenets of a particu- in society present a number of practical good in society will arrive at differ- lar religious doctrine or community. problems, such as disagreements and ent conclusions about what is valuable Although customarily parents are seen even incompatible views about what is or what promotes wellbeing. Moreover, as the best arbiters of decisions affecting valuable. With so many clearly oppos- as value judgments differ among reason- their child’s wellbeing—not because ing, and at times contradictory, concep- able individuals, what one individual parents make the best decisions for their tions of the good within society, there

views as harmful may not be perceived http://jme.bmj.com/ children, but because parents ought to are instances when it is difficult to reach as such by others. In the following be accorded the freedom and autonomy a meaningful consensus on important sections, it will be argued that no per- to make such choices—conceivably it moral issues (especially on highly emo- suasive case has been made in favour of could be the state or medical establish- tive issues). The best we can hope for is limiting the liberty of parents concerning ment who will possess the power to to structure our institutions and prac- their ability to choose whether it is in decide whether parents should be tices (and the norms that govern them) their son’s interest to be circumcised. allowed to make such decisions (at in a way that attempts to take seriously least, with respect to this issue).

the fact that reasonable people will on September 28, 2021 by guest. Protected copyright. This is an important political consid- disagree about what is valuable, good, II eration, but it also has a special salience and right, and how given this fact we (A) Religious liberty and the for bioethics as well. It illustrates the can arrive at fair and justifiable ways to freedom to choose potential extent to which societal and regulate our lives in society.4 Traditional justifications for the per- medical institutions can enact rules and In order for biomedical public policy missibility of religious infant male cir- policies that can constrain or restrict a to be seen as fair and sustainable, what cumcision have been predicated on person’s ability to act in certain ways. is needed is an understanding of the arguments for religious liberty.6 The Thus, of particular importance will be proper type of justification required law generally provides parents with the how, and to what extent, are these when we collaborate on reasonable freedom and discretionary authority, in institutional norms in medicine (that terms with members of society who the course of raising their children, to have so much power over our lives) hold different moral commitments. decide what is in the interest of their justified—especially in the face of rea- What needs to be recognised is that children (within reason, of course). In sonable disagreement in society about the operation of an agent’s moral con- the case of religious circumcision, a what is valuable, good, right, and so on. ception of the good in their personal day parent’s decision to have their son We will want to ensure that the justifi- to day ethical deliberations should be circumcised is justified on the basis of cation proffered for limiting individual markedly different from the use of their religious views (for example, the freedom and choice is exceedingly public reason to arrive at public policy practice is justified by appealing to a robust and fair. in which all citizens with reasonable canonical text). Although some parents I shall argue that in order for policy conceptions of the good could uphold as may choose not to have their son concerning the prohibition of circumci- fair and justifiable. The reasoning and circumcised or other parents may sion to be acceptable it would have to be justification involved with questions of choose to have their son circumcised demonstrated that such a policy could the public on the one hand, and that of for non-religious reasons, what is seen be justified to those individuals with the personal concerning how one should as important (in terms of justification of

www.jmedethics.com SYMPOSIUM ON CIRCUMCISION 243 the decision) is that it will be agent Although I do not have the space to However, it is when circumcision is relative—that is, justifiable reasons to present the arguments here, it would performed for what is termed ‘‘non- J Med Ethics: first published as 10.1136/jme.2002.002576 on 1 June 2004. Downloaded from circumcise or not circumcise their son seem that to be successful anticircumci- therapeutic’’ reasons that will concern will be based on the parents’ conception sion proponents would have to argue in me in this paper.10 of the good, and not that of the physi- cases where the right to religious liberty I cannot hope to present and evaluate cian, bioethicist, or neighbour. Although of the parent and the child are in all of the medical evidence concerning these agent relative reasons may be per- conflict with each other, the child’s the potential benefits and risks asso- missible or non-permissible, in order for right should supercede the parent’s ciated with circumcision.11 It is clear them to be considered justified reasons right, on the grounds that the child that there are potential advantages for or against the procedure, they need to may not end up remaining a member of and disadvantages associated with the have their basis in the parents’ values. the religious community he is to be procedure; some people believe the What anticircumcision proponents brought up in.7 It seems to me that such medical evidence shows that the proce- maintain is that parents are unjustified an argument would revolve around dure is beneficial, whereas others in believing their child would also whether the practice the parents seeks believe that it shows that the procedure maintain their religious values. It is to justify through their right to religious is unnecessary or confers negligible argued that because we do not know if liberty in the face of their child’s claim results (if any). The only position I do a child will decide to become a follower would be whether the practice is reason- not believe the evidence supports is that of their parents’ religion, it would be able or not. Surely, what is most salient the procedure is unequivocally harmful. better if circumcision decisions were is not whether a parent has the freedom When the issue is termed in reference delayed until adulthood, so that if an to use their religious doctrine as a source to whether a policy of ‘‘routine infant individual wants to remain a member of of value concerning parental decisions, circumcision’’ would be justifiable, the the religious community and his uncir- but whether the decisions which stem question becomes is there enough med- cumcised status was a barrier to reli- from the doctrine are reasonable. ical evidence that demonstrates that the gious marriage or burial, he could David Meeler has recently argued benefits of undergoing circumcision are consent to the procedure as an adult. that an appropriate balance is to be so favourable that all healthy male The problem is that such decisions are found when a follower’s rights and infants should undergo the procedure not seen to be able to be delayed until liberties as a citizen are reasonably res- (or, at least, that the procedure should this time—the religious significance of pected by their religion (for example, in be recommended to all patients as a the procedure is to be done in child- this case, whether an infant’s rights and routine procedure). Most medical asso- hood. An individual’s understanding of liberties are respected by a religious view ciations, such as the American Academy a good life (which will include raising which mandates male circumcision).8 of Pediatrics,12 the British Medical their children in a loving, caring manner Although it will not be seen as unrea- Association,13 the Canadian Pediatrics and making decisions that promote sonable for followers of particular Society,14 and the Royal Australasian their welfare) will unavoidably be religions to have certain freedoms or College of Physicians,15 among others, linked and supported by their religious behaviours restricted or constrained maintain that although there are poten- views. When it comes to an individual’s (compared with other citizens who do tial medical benefits associated with the right to practice their religion, this not subscribe to the religion) the ques- procedure, on balance these benefits do seems inextricably linked with how an tion remains of how we are to determine not overwhelmingly support a policy of individual wants to raise their child. when such restrictions become unrea- universal recommendation. http://jme.bmj.com/ Anticircumcision proponents argue sonable. In order for anticircumcision However, this is a different question that in as much as it is important for proponents to successfully maintain of whether infant male circumcision is a parents to be accorded religious liberty that the freedom of parents to choose justifiable procedure—that is, whether (that is, the freedom to appeal to whether they ought to have their son the provision of this procedure can be religious principles to guide their moral circumcised is not a protected incidence allowed. Most medical associations choices), concomitantly, it is just as of religious liberty (or even parental maintain that it is in fact justifiable— important for the child to be accorded autonomy, in general), they would have no medical body has advocated a policy on September 28, 2021 by guest. Protected copyright. religious liberty (the freedom to choose to show that the religious values to that calls for the prohibition of circum- whether he wants to join his parent’s which they appeal to justify their decision cision. Although they recognise that 9 religion, another religion, or no religion is unreasonable. Many anticircumci- existing medical evidence does not at all). It is maintained that people are sion proponents claim that what makes support that the procedure that can be not born with a particular set of these religious values unreasonable universally recommended, they do not religious beliefs and it is not a child’s stems from the fact that they ignore believe the medical evidence shows that choice to be brought up under certain the harm that results from circumcision. the procedure is so detrimental that it religious traditions or customs. A valid In the next section, I briefly examine the should be prohibited or outlawed. point; however it would be untenable argument for the prohibition of parents Although medical evidence concern- in practice not to make decisions for being able to make a choice concerning ing the procedure is of vast importance, children because they may have chosen circumcision, based on the putative I maintain that to view this issue as one differently. Infants and children cannot harm of the procedure. solely concerning medical benefit and make decisions for themselves, and risk is to draw too narrow a view. The parents have a duty to make decisions (B) Circumcision as a putative harm question of the justifiability of circumci- on behalf of their child concerning their Almost all individuals would agree that sion should not be made exclusively wellbeing, such as religious upbringing, there are some instances when it is along a therapeutic/non-therapeutic dis- choice of schooling, immunisation, liv- permissible for male circumcision to be tinction because such a view fails to take ing environment, dietary requirements, performed. In cases of what is termed seriously all of the potential non-med- insurance and investments for the child, ‘‘therapeutic circumcision’’ (that is, ical benefits (and risks) associated and so on. Parents need to have the cases where reasons for the procedure with this procedure. In addition to the freedom to make decisions for their are to remedy an anatomical or patho- empirical evidence that supports judg- children based on what they view as logical condition), most people would ments made by parents concerning best, on the balance of benefits and risks. view such an intervention as justifiable. the medical benefits or risks of the

www.jmedethics.com 244 SYMPOSIUM ON CIRCUMCISION procedure, there are other judgements experienced with the procedure—this is extremely limited and presents con- which inform parents’ decisions that not only includes the proven expertise of tradictory results.21 In one of the papers J Med Ethics: first published as 10.1136/jme.2002.002576 on 1 June 2004. Downloaded from have their basis in other factors (such as the operator, but attention to proper that is often cited by anticircumcision social, cultural, religious). operating conditions and adequate proponents, the claim that circumcision Reasonable conceptions of the ‘‘good’’ aftercare. It is reasonable for parents removes an important component of the will differ in how they attribute value to who choose to have their son circum- sensory mechanism of the penis is based the body, the prudential value of pro- cised to expect that these conditions will on finding of an extremely small sample phylactic health measures, the moral be in place.17 size (n = 22) of cadavers.22 Not only is a significance of belonging to a commu- The most obvious source of harm that pathological study not ideal for conclu- nity, among many other considerations. might be observed from circumcision is sions concerning the physical sensation We recognise that people will disagree from complications of the procedure. and enjoyment of sex in the living, we over the value of the procedure (where The complication rate for the procedure have no findings that show that sensa- the value derived may be from a is very low; studies show that the tion transmission pathways of the penis consideration of potential medical and incidence of clinically significant com- differ substantially between circumcised non-medical benefits), and the question plications is 0.9% to 1.5%.18 Particularly and uncircumcised men. As it presently concerning a parent’s choice is made as it is the standard of care to provide stands, there is no convincing evidence with respect to the value or disvalue it optimal operative and postoperative that shows that sexual function of would bring to their son. What needs to pain relief and good aftercare, it will circumcised individuals is worsened or be recognised is that the worth of be difficult to convince people that this damaged as a result of a properly circumcision is determined by a value procedure is harmful on this basis. performed circumcision. judgment made by parents. The argu- Another prominent argument against When it comes to an adequate assessment that the procedure is morally circumcision is based on the position ment of the potential harms of a impermissible—that is, regardless of that subsequent effects of procedure medical procedure or cultural practice, your reasonable concept of the good, are harmful. Recently, there have been it is essential that we have reliable the provision of circumcision should not studies documenting that circumcision empirical evidence on which to con- be allowed—is in the wrong justificatory results in damage to the penis.19 struct the debate. In addition, it is also class. It is advocating a substantive Margaret Somerville observes: ‘‘… good essential that we realise that medical moral position, instead of using public ethics depend on good facts, and good evidence is not the only data that count reason to arrive at a fair and justifiable law depends on good ethics. The medical in the debate—non-medical benefits policy. It is maintaining that the proce- facts about infant male circumcision and risks must also be recognised as dure has no value or has a level of have changed as a result of medical valid and relevant factors available for disvalue to such an extent that we must research. We now know that infant male rational criticism and consideration. Let remove a parent’s ability to evaluate its circumcision is harmful in itself and has me be clear: the reporting of potential merits or distractions. This, I maintain, harmful consequences. Circumcision negative effects to parents when making is a mistake. It is wrong to believe that removes healthy, functioning, erogenous the decision of whether or not it is in one can only value circumcision for tissue that serves important protective, their son’s interest to be circumcised is medical reasons and that circumcision sensory and sexual purposes.’’20 very important. However, when it comes cannot contribute to some children’s I would contend that we do not know to the question of whether these pur- wellbeing. Although there is much more in any robust or determinate sense that ported effects constitute a harm suffi- http://jme.bmj.com/ that could be discussed concerning the infant male circumcision is harmful in cient to justify prohibiting the practice objectivity and subjectivity of welfare itself, nor can we say the same with of circumcision, I do not see the case 23 (especially how non-medical benefits respect to its purported harmful conse- being adequately made. contribute to wellbeing), I cannot dis- quences. Part of this difficulty in deter- cuss further this aspect of the issue here. mining what is a harmful consequence (C) Circumcision and the law The argument that circumcision results stems from the fact that different people Another prominent argument advanced in a serious harm seems to me to be a will view what is harmful differently.

by anticircumcision proponents in on September 28, 2021 by guest. Protected copyright. more crucial issue. In what follows, I Whether something is a harm will often favour of prohibiting the procedure briefly examine three ways in which it is depend (although not always) on one’s stems from legal (rather than moral or purported that circumcision is harmful: conception of the good, the overall value medical) considerations. It has been (1) complications from the procedure, attached to the action/event, how one argued that everything from criminal (2) subsequent effects of procedure, and conducts a cost benefit analysis (for statutes to human rights legislation (3) a set back to one’s rights. example an individual may make a trade could justify prohibiting infant male There are two suppositions to my off in favour of some other benefit), circumcision, as the procedure could argument. Firstly, it will be taken for among other considerations. The concept represent a violation or set back to one’s granted in this paper that the permissi- of harm is a difficult and complex issue rights. For instance, Margaret Somer- bility of circumcision will presuppose that I do not have the space to explore ville has argued that provisions in the that practitioners are using optimal pain here, however, it seems that in order for criminal code (of Canada) already cover control measures. The medical evidence anticircumcision proponents to be suc- the type of harm purported to be clearly demonstrates that pain control cessful in their argument, they would associated with infant male circumci- measures are effective in substantially have to show that circumcision causally sion as an instance of assault, specifi- reducing or eliminating the pain of the results in a majority of the population cally aggravated assault. Where assault procedure.16 As with any other medical who have been circumcised to loose their is defined as anything more than de procedure, I would contend that practi- ability to protect their penises, be sexu- minimis contact with another person tioners not using optimal pain control to ally stimulated, and so on. without their consent, and aggravated alleviate discomfort or pain are falling To my knowledge there is no con- assault as touch that results in breaking below a standard of good clinical care. clusive epidemiological and/or sociolo- the full thickness of the skin, circumci- Secondly, it will also be taken for gical evidence that supports the claim sion could fall under the definition granted that the practitioners will also that circumcision constitutes such sub- of aggravated assault.24 According to be adequately trained and sufficiently stantive harm(s); the evidence available Somerville, surgery avoids being classed

www.jmedethics.com SYMPOSIUM ON CIRCUMCISION 245 as aggravated assault in two cases: (1) liberty rights must be superceded by These arguments fail to take as their the surgery, performed by a competent other competing rights. This, of course, starting point the fact that a plurality of J Med Ethics: first published as 10.1136/jme.2002.002576 on 1 June 2004. Downloaded from physician, is therapeutic and conducted assumes that the human rights provi- reasonable individuals will arrive at with the informed consent of the patient sions of the United Nations actually apply different conclusions concerning the (or surrogate decision maker) and (2) to the case of circumcision, and that value of circumcision. Anticircumcision the surgery, performed by a competent infants actually possess all of the human proponents who are seeking to have the physician, is non-therapeutic, con- rights outlined in these charters. procedure prohibited do not appear ducted with the informed consent of In addition to substantive legal ques- interested in advancing a policy that the adult patient, and is not contrary to tions about conferring human rights to could be seen as fair and justifiable to public policy. Somerville believes that children, there are also important philo- members of society who hold opposing infant male circumcision does not fit sophical and jurisprudential implications moral commitments on this issue. In into either category of justified surgical concerning the question of assigning light of a diversity of moral views con- intervention because the requirement human rights to children, especially cerning the worth of circumcision, a for informed consent cannot be fulfilled infants. Although we would no doubt number of anticircumcision proponents by a child and because non-therapeutic agree that we have weighty moral and have abandoned the route of public circumcision constitutes more than a de legal obligations towards infants, it is moral deliberation and are seeking legal minimis (a trifle) intervention.25 still controversial whether it is the case remedies to enforce their moral view. To Others have argued that infant male that they have all the same legal rights as me, this seems to be the wrong way to circumcision is a harm because it human beings with agency. Depending construct biomedical public policy. violates a child’s human rights. Appeal- on how one justifies a human rights ing to documents such as the United account, for instance whether one uses a (D) Circumcision and health care Nations’ International Covenant on Civil personhood or needs based account, the policy and Political Rights, Universal Declaration of existence conditions of human rights What needs to be realised is that the Human Rights, and the Convention on the and what kinds of harms will violate achievement of fair and sustainable 27 Rights of the Child, various claims have these rights will be different. Rights public policy cannot be done at the level been made that circumcision violates a make important normative claims on of conceptions of the good, but must be child’s right or freedom with respect to: individuals, organisations, and govern- secured using politically liberal values expression, thought, religion, torture, ments. Although the normative authority shared by reasonable members of self determination, dignity, respect, iden- of these rights makes them tempting society. Allowing parents to make deci- tity, bodily integrity, discrimination, and regulatory avenues to be pursued by sions concerning what procedures are in non-interference, among other things. anticircumcision proponents, we must their child’s interest are justified not Some of these arguments are quite weak be cautious in our thinking concerning because parental autonomy is a value and specious; others quite challenging the structure, substance, and reach of that everyone should uphold but and test our considered judgments con- human rights claims.28 because it is an instance of, as Ainslie cerning what rights we ought to accord I am inclined to believe that allowing a has maintained, ‘‘the terms for our to children and what acts violate those parent to choose whether or not to have living together in a society despite our rights. Space limitations prevent me their son circumcised does not violate his different moral commitments … For from fully evaluating the substance human rights but, as I said, this would this is the only way to allow each of us and potential success of using human require further argumentation that I to subscribe to our own moral doctrines http://jme.bmj.com/ rights arguments to prohibit circumci- cannot provide here. However, I do think and yet still live together’’.29 sion. However, in this interesting and this move towards using legal remedies The discussion concerning whether unsettled area of inquiry, I want to such as human rights legislation to pro- parents should be free to choose briefly advance a few problematic fea- hibit circumcision signals a significant whether their son will be circumcised tures of taking this route. motivation of anticircumcision propo- also has an interesting corollary in Although anticircumcision proponents nents. Medical evidence has not justified healthcare systems where there are will often recognise the importance of the prohibiting the provision of circumcision. parallel public and private structures. on September 28, 2021 by guest. Protected copyright. religious liberty of parents (as a human Moral arguments have not been able to Governmental involvement or con- right), it is claimed that this right should justify removing the decision from par- straints on certain religious practices, not extend to cases where this religious ents concerning this procedure. However, such as circumcision, continue to practice is harmful or violates one of the the move towards employing the law as occur.30 Recently in a number of jur- child’s human rights (that is, practices a means of prohibiting the procedure isdictions in Canada (and earlier in performed under the auspices of religious appears a convenient way to enforce a other countries such as England), the liberty are justifiable to extent that particular value judgment in a way that provision of infant circumcisions had to actions taken do not violate the basic appears to remove the moralism inherent be removed from the schedule of cov- rights and liberties of citizens).26 Both in its source. Arguments which seek to ered procedures available as part of the claims are far from being evident. In the prohibit circumcision are predicated on public healthcare service. A number of case of harm, in order for a prohibition particular conceptions of the good that private insurance carriers and health against religious circumcision to consti- inform their notion of value, what could plans in the United States have also tute a reasonable sanction against a reli- contribute to a child’s welfare, what decided not to reimburse the cost of the gious doctrine, we would be required to factors inform their cost benefit analysis, procedure. The reason for these deci- settle the issue concerning the putative and so on. Anticircumcision proponents sions was based partly on the lack of harmful effects of circumcision. On the are taking what they believe to be a non- medical indications for the procedure; balance of evidence, we have no reason to negotiable moral truth—that circumci- however it also saved governments and believe that circumcision is a harm that sion is unequivocally harmful and must insurers a large amount of money by merits state intervention to prohibit its be prohibited, whether citizens recog- having parents pay for the procedure practice. In the case of parents’ rights nise this harm or not—that is not open themselves. There were a number of verses children’s rights, it is not clear that to compromise or abandonment, and individuals and groups (religious and these rights are actually in conflict, and if attempting to institutionalise this judg- non-religious) who expressed dissatis- they are, it is not clear whether religious ment in society. faction with these policy decisions. It

www.jmedethics.com 246 SYMPOSIUM ON CIRCUMCISION would be, in my mind, dubious to argue medical practitioners and state licensed This freedom, however, does not that such a policy would infringe on an professionals, what kind of weight come without responsibilities. Both J Med Ethics: first published as 10.1136/jme.2002.002576 on 1 June 2004. Downloaded from individual or group’s religious liberty; should be accorded to the very likely medical practitioners and parents have however it does point to potential possibility that individuals would con- important responsibilities concerning implications concerning access to continue to seek such a procedure regard- the decision to circumcise. Parents need troversial medical services (especially, less of what the law permits? Given that to take measures to educate themselves for instance, in places where healthcare the practice of male circumcision is such about all of the potential benefits and services are scarce or inadequate). an important aspect of Muslim and risks of the procedure. Medical prac- Constraints on the practice of circumci- Jewish religious observance (and the titioners must be ready to provide sion have been noted in the provision of practice would continue to have impor- adequate, accurate, and unbiased infor- private healthcare services as well.31 tant social value for other members of mation to parents about all of the It is also worth noting that there have society as well), to what extent would potential benefits and risks of the 35 been precedents of medical profes- the state and medical establishment procedure. sionals attempting to reach compro- have to take seriously the ramifications In summary, the case against allow- mises concerning circumcision, in an of individuals obtaining the procedure ing parents to choose whether circumci- attempt to accommodate certain reli- for their children elsewhere in society? sion is or is not in their son’s interest gious/cultural practices. In the West Any policy that would seek to make has not been conclusively made. In our Midlands of England, there are some circumcision prohibited (or using the pluralistic society, there will be marked health districts which have provided existing criminal law to affect the same diversity between reasonable concep- religious circumcisions (covered by pub- outcome) would quite likely result in tions of the good concerning what lic health system) in order to ensure the practice being driven underground interventions are valuable or promote that they are carried out by skilled with predictably dire results. As it has a child’s welfare. Even in contexts practitioners with full anaesthetic to been seen with other medical proce- when such interventions are medical in minimise pain and complications.32 In dures that have been outlawed by the nature, the potential benefits or risks the city of Seattle in the United States, state—for example, the most vivid case associated with the child’s welfare concerns will often involve medical, social, the Harborview Medical Center (know- in recent history is abortion—unquali- and cultural factors. As it presently ing that if requests to have their fied or lesser qualified practitioners will stands, there is an absence of sufficient daughters ‘‘circumcised’’ were not ful- step in to fill the gap in the market. evidence or persuasive argumentation to filled, mothers would seek out the Such a state of affairs would put boys in warrant changing the current policy— procedure in a non-medical environ- much greater risk of harm. I do not that parents should have the freedom to ment) agreed to offer a compromise for suggest that this reason would justify 33 make an informed and well deliberated the procedure. They offered to provide the continued provision of the proce- choice concerning whether the proce- a procedure in which the labia or clitoris dure itself; however, the potential harm dure is in their son’s interest. would not be touched, but a small resulting from botched underground incision in the clitoral prepuce would medical procedures would have to be J Med Ethics 2004;30:241–247. be made to draw some blood. Although taken into account when evaluating the doi: 10.1136/jme.2003.003921 this compromise would have satisfied overall benefits and costs associated Correspondence to: A M Viens, Department of some members of the community, with a policy prohibiting circumcision. Philosophy, St Anne’s College, Oxford 34 opponents of female genital cutting University, Oxford, UK; adrian.viens@ http://jme.bmj.com/ prevented its provision. It does not seem philosophy.ox.ac.uk unreasonable or unattainable to work III This commentary was peer reviewed by an towards compromises in society that Medical professionals, especially those external referee. respect the multitude of different moral engaged in setting policy such as commitments in a way that does not bioethicists, must take as their starting REFERENCES violate our considered judgments about point the fact that reasonable people what justice demands. Although the will disagree about what is valuable and 1 Hutson JM. Circumcision: a surgeon’s

perspective. J Med Ethics 2004;30:238–40. on September 28, 2021 by guest. Protected copyright. harm that clitorectomies and infibula- what is harmful. They have an obliga- 2 I believe that the term ‘‘routine infant tion cause is not permissible, this does tion to construct institutional norms circumcision’’ is a misnomer. It denotes a position not mean we do not have an obligation and policies that do not presuppose or that nobody really holds, namely that as a matter of routine, all healthy boys should be circumcised. to find ways of accommodating differ- enforce a particular moral or political Opposition to a policy of ‘‘routine infant ent cultural practices. As in the case doctrine. There is a need to differentiate circumcision’’ does not have to indicate of the compromise offered by the between rituals and practices that are in opposition to a parent’s right to choose for their son to undergo the procedure, nor the provision Harborview Clinic, we should endeavour fact grievously harmful and those which of the procedure in general. to take measures that aim to respect the relate to the enhancement of a child’s 3 Somerville MA. The ethical canary: science, value judgments and cultural practices religious and cultural identity. I do not society and the human spirit. Toronto: Penguin, 2000:202–19. of others in a way that reduces the believe it has been shown that a 4 This political conception is most vividly argued mortality and morbidity that would compelling interest would be served by for by Rawls J, Political liberalism. New York: result from individuals seeking female using the law to prohibit a parent Columbia University Press,1996. 5 Ainslie DC. Bioethics and the problem of genital cutting elsewhere. Such an from justifying their decision whether pluralism. Soc Philos Policy 2002;19:1–28 (see attitude of tolerance does not seek to or not to circumcise their son based on p14). provide a moral defence of the particular appeals to their evaluative judgments. 6 By religious liberty in the context of bioethics, I mean the legitimacy and extent to which practice, but can be judgmental towards Circumcision is a significant feature of individuals and/or groups should be able to use particular practices in a way that the Jewish and Muslim faiths and any religious principles and beliefs to make decisions respects the values of other cultures policy or legislative action seeking to concerning the desirability or exemption of medical procedures and treatments. while reducing the potential for harm. prohibit its provision will be opposed by 7 However, there would have to be a difficult cost/ Finally, there is one last pertinent both religious communities (and those benefit analysis made concerning the cost of issue that needs to be raised. If the who believe that this practice should be being circumcised and not becoming an adherent of your parent’s religion versus not being provision of circumcision were actually justifiably protected as an instance of circumcised and being brought up in the faith prohibited from being preformed by religious liberty). community where it is prescribed. It would require

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a complex argument on both sides; however, I am Pediatrics 1989;83:1011–15; Fredman, RM. political status of children: new essays. Oxford: inclined to believe that it would be difficult to Neonatal circumcision: a general practitioner Oxford University Press, 2002;19–30; Sumner J Med Ethics: first published as 10.1136/jme.2002.002576 on 1 June 2004. Downloaded from successfully argue that, on balance, it would be survey. Med J Aust 1969;1:117–20. Such figures LW. The moral foundations of rights. Oxford: more detrimental to have the parent’s right to will vary depending on what is classified as a Oxford University Press, 1987:10–11 and 202–5. religious freedom trump their child’s right rather complication. 28 Sumner puts the point nicely: ‘‘like the arms race than vice versa in this particular case. 19 Cold CJ, Taylor JR. The prepuce. BJU Int the escalation of rights rhetoric is out of control. In 8 Meeler D. Reasonable sanctions for reasonable 1999;83(Suppl 1):34–44. liberal democracies of the West … public issues doctrines. J Soc Phil 2000;31:153–9. 20 Somerville 2000. are now routinely phrased in language of rights’’. 9 This is a different question from whether a 21 Fink KS, Carson CC, DeVellis RF. Adult (1987:1). religious doctrine is unreasonable. The question of circumcision outcomes study: effect on erectile 29 Ainslie 2002:17. whether the religious mandate for circumcision is function, penile sensitivity, sexual activity and 30 For instance, in October 2001, a new law in unreasonable and justifiably prohibited—for satisfaction. J Urol 2002;167:2113–16; Collins S, Sweden stipulates that a licensed doctor can only instance it violates a person’s rights and/or Upshaw J, Rutchik S, et al. Effects of circumcision perform circumcisions or a person certified by the liberties as citizens—is examined in II (C). on male sexual function: debunking a myth? J National Board of Health (in the case of 10 Moreover, although I am primarily concerned Urol 2002;167:2111–12; Laumann EO, Masi, circumcisions performed by mohels, there were with ‘‘non-therapeutic’’ infant male circumcisions CM, Zuckerman, EW. Circumcision in the United additional requirements that they be required as religious rites of passage, I am States. Prevalence, prophylactic effects, and accompanied by a physician or nurse for inclined to believe that what I have to say can also sexual practice. JAMA 1997;277:1052–7. anaesthesia). The Jewish community objected to apply to parents who decide to have their son 22 Taylor JR, Lockwood AP, Taylor AJ. The prepuce: the law claiming it interferes with their religious circumcised on value judgments of a non-religious specialized mucosa of the penis and its loss to traditions. Department of State, United States nature. circumcision. Br J Urol 1996;77:291–5. Government. ‘‘Sweden’’ in The International 11 For detailed examinations of some of this 23 There is indeed anecdotal evidence and case Religious Freedom Report 2002. (http:// literature, see Niku SD, et al. Neonatal studies of a very small fraction of men circumcised www.state.gov/g/drl/rls/irf/2002/13983.htm). circumcision. Urol Clin North Am 1995;22:57– as infants (and an even smaller number of men I am inclined to believe that most members of the 65; Benatar M, Benatar D. Between prophylaxis circumcised as adults) who report regretting religious community would agree that although it and child abuse: the ethics of neonatal male having undergone the procedure. To my is an interference with religious tradition, it is a circumcision. Am J Bioeth 2003;3:35–48. That is knowledge, there is no strong medical or reasonable constraint on the practice. not to say that I will not be relying on medical epidemiological evidence concerning, for 31 At the Rainbow Flag Health Service Sperm Bank evidence in this paper, only that I will not be using instance, the comparative differences in sensation in Alameda, California, the clinic has a policy not it to advance a substantive position concerning or body image between circumcised or to offer its services to individuals who would want the overall benefits or risks of circumcision. uncircumcised men that would support a finding to have their son circumcised (http:// 12 American Academy of Pediatrics (Task Force on that men who were circumcised were substantially www.gayspermbank.com/philosophy.htm). Circumcision). Circumcision policy statement. harmed. However, the use of anecdotal evidence Although there is no positive obligation on Pediatrics 1999;103:686–93. would not seem to bolster the anticircumcision medical practitioners to perform circumcisions, it 13 British Medical Association. The law and ethics of position, as a vast majority of circumcised men is worth considering the extent to which limits to male circumcision: guidance for doctors (March appear satisfied with their status or do not feel such a procedure actually, if at all, impinges on 2003). harmed or damaged for undergoing the religious liberty. This, however, is a separate, yet 14 Canadian Paediatric Society (Fetus and Newborn procedure. It would be beneficial to have more related, consideration concerning the ability of Committee). Neonatal circumcision revisited. evidence concerning the comparative sexual parents to access this procedure in a hospital or CMAJ 1996;154:769–80. This statement was functioning between circumcised and clinical setting, and not the ability of parents to reaffirmed in March 2002. In this report, the uncircumcised men, although the inherent practice the rite of circumcision (for example, as a committee only considered medical evidence: subjectivity of such reporting would make it religious ceremony in the home or place of ‘‘religious and personal values were not included difficult to assess the effects of the comparative worship). in the assessment’’. states. It would nonetheless be helpful to have 32 Rickwood AMK, Kenny SE, Donnell SC. Towards 15 Royal Australasian College of Physicians more evidence in this area to inform the current evidence based circumcision in English boys: (Paediatrics and Child Health Division). Position debate. survey of trends in practice. BMJ statement on circumcision, Sydney: Royal 24 Somerville 2000. Somerville’s position on 2000;321:792–3. Australasian College of Physicians, 2002. This religious circumcision is more permissive 33 Celia W. Dugger. Tug of taboos: African genital statement was developed as a unified position of compared to non-religious circumcision. She rite vs. US law. New York Times (12 December six medical societies in Australia and New believes ‘‘only those who believe they have a 1996), p 9; Coleman DL. The Seattle compromise: Zealand: the Royal Australian College of fundamental, absolute religious obligation to multicultural sensitivity and americanization. http://jme.bmj.com/ Physicians, the Australian Association of carry out infant male circumcision should be Duke Law Journal 1998;47:717–83. Paediatric Surgeons, the New Zealand Society of exempt from a prohibition on it’’. However, if 34 I use the term female genital cutting, instead of Paediatric Surgeons, the Urological Society of circumcision is the harm she makes it out to be, ‘‘female circumcision’’ in order to make clear the Australasia, the Royal Australasian College of this exemption seems arbitrary and tenuous. As marked difference between this procedure and Surgeons, and the Paediatric Society of New much as it seems that circumcision should be male circumcision. The removal of the male Zealand. protected as an instance of religious liberty, why foreskin is in no way similar or equivalent 16 In addition to the use of a dorsal penile nerve should we privilege religious value judgments (morphologically or symbolically) to the removal block or subcutaneous ring block, the use of other over other non-religious value judgments? And of the clitoris and/or labia. interventions to minimise operative and what would stop others from going further and 35 Studies have shown that parents are often postoperative pain, such as sucrose pacifier, saying that no value judgments (religious or unhappy with the information they receive from on September 28, 2021 by guest. Protected copyright. buffered lidocaine, small needles, otherwise) could justify a parent’s decision to physicians about circumcision. See Adler R, acetaminophen, swaddling, environmental circumcise their son? Ottaway S, Gould S. Circumcision: we have modification, topical anaesthetic (for example, 25 The question of how far a parent’s ability to heard from the experts; now let’s hear from the EMLA) are all useful measures should be consent (on behalf of their children) extends is an parents. Pediatrics 2001;107:e20. This study employed. See Geyer J, Ellsbury D, Kleiber C, et important one. For instance, it has been demonstrated that satisfaction with a parent’s al. An evidence-based multidisciplinary protocol maintained that a parent can only have the legal decision concerning circumcision was highly for neonatal circumcision pain management. power to consent to a procedure that removes correlated with the discussion and information J Obstet Gynecol Neonatal Nurs 2002;31:403– tissue when it is necessary for the diagnosis or provided by the medical profession. However, 10; Litman RS. Anesthesia and analgesia for treatment of disease (and only when that there are other studies which show that many newborn circumcision. Obstet Gynecol Surv. procedure is foreseen to present with negligible parents make their decision whether or not to 2001;56:114–17; Kraft NL. A pictorial and video risk and minimal burden). See Nuffield Council on circumcise their son prior to discussions with guide to circumcision without pain. Adv Neonatal Bioethics. Human tissue: ethical and legal issues. physicians, and physician discussions appear to Care 2003;3:50–62; Taddio A, Pollock N, London: Nuffield Council on Bioethics, 1995. have little impact on a parent’s decision. See Gilbert-MacLeod C, et al. Combined analgesia However, this seems to be too limited. For Tiemstra JD. Factors affecting the circumcision and local anesthesia to minimize pain during instance, it has been seen as permissible for older decision. J Am Board Fam Pract circumcision. Arch Pediatr Adolesc Med siblings (who are minors) to donate bone marrow 1999;12:16–20; Brown MS, Brown CA. 2000;154:620–3. to a younger sibling—a procedure which confers Circumcision decision: prominence of social 17 I am primarily concerned with circumcisions that no medical benefit for the donor and puts them concerns. Pediatrics 1987;80:215–19; take place in a medical environment (for example, under considerable risk of harm of death. Bean GO, Egelhoff C. Neonatal circumcision: a clinic or hospital). However, I still believe that 26 For instance, the American Academy of when is the decision made? J Fam Pract there is an obligation to obtain a skilled Pediatrics’ Committee on Bioethics have 1984;18:883–7. Nevertheless, although practitioner and proper pain control measures for maintained that ‘‘the constitutional guarantees of physician discussion may ultimately have little circumcisions performed in a non-medical freedom of religion do not sanction harming affect in changing a parent’s mind (for example, if setting. another person in the practice of one’s religion’’. a parent does not believe a circumcision is in her 18 Gee WF, Ansell JS. Neonatal circumcision: a ten- Compare with: Committee on Bioethics. American son’s interest, then having a physician present its year overview: with comparison of the Gomco Academy of Pediatrics. Religious objections to potential benefits will not tend to change their clamp and Plastibell device. Pediatrics medical care. Pediatrics 1997;99:279–81. decision) we have good reason to require that 1976;58:824–7, 824; Wiswell TE, Geschke DW. 27 For an excellent examination of these issues, see parents are presented with all potential benefits Risks from circumcision during the first month of Griffin J. Do children have rights? In: David and risks for the purposes of ensuring fully life compared with those for uncircumcised boys. Archard, Colin Mcleod, eds. The moral and informed consent.