SYMPOSIUM ON CIRCUMCISION 241 device is now off patent, and could be Male circumcision J Med Ethics: first published as 10.1136/jme.2003.003921 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 com- pared 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 infec- tion rates, providing a ‘‘no scalpel’’ 4 UNAIDS. Report on the global HIV/AIDS on September 30, 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 www.jmedethics.com 242 SYMPOSIUM ON CIRCUMCISION ‘‘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.2003.003921 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.