Ethics of circumcision

Surrogate consent

Patient autonomy is an important principle of medical ethics. 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.

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

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.

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.

There is an unresolved question whether surrogates may grant effective consent for non-therapeutic child circumcision. 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. 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."

Regardless of these issues, the general practice of the medical community is to receive surrogate informed consent or permission from parents or legal guardians for non-therapeutic circumcision of children.

Medical trade association views

Some medical associations take the position that the parents should determine what is in the best interest of the infant or child. The Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue, the BMA insisting that a non-therapeutic circumcision must not go ahead without the consent of both parents and, if competent, the child himself.

American Academy of Pediatrics view

The American Academy of Pediatrics (1999) states that both parents and physicians have an ethical duty to secure the child's best interest and well-being. They state that in the case of circumcision, where there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, the parents ought to determine what is in the child's best interests, and that it is legitimate for parents to take into account cultural, religious, and ethnic traditions, as well as medical factors. They state that physicians should not coerce parents, but should assist parents in their decision by "explaining the potential benefits and risks and by ensuring that they [the parents] understand that circumcision is an elective procedure." The Academy's Committee on Bioethics approved this policy statement.

Neonatal circumcision is performed with surrogate consent, described as follows by the American Academy of Pediatrics (1999):

"The practice of medicine has long respected an adult's right to self-determination in health care decision-making. This principle has been operationalized through the doctrine of informed consent. The process of informed consent obligates the physician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives for the patient to make an informed choice. For infants and young children who lack the capacity to decide for themselves, a surrogate, generally a parent, must make such choices."

"Physicians counseling families concerning this decision should assist the parents by explaining the potential benefits and risks and by ensuring that they understand that circumcision is an elective procedure. Parents should not be coerced by medical professionals to make this choice."

The Academy (2012) states in part with regard to ethics:

"In cases such as the decision to perform a circumcision in the newborn period (where there is reasonable disagreement about the balance between medical benefits and harms, where there are nonmedical benefits and harms that can result from a decision on whether to perform the procedure, and where the procedure is not essential to the child’s immediate well-being), the parents should determine what is in the best interest of the child. In the pluralistic society of the United States, where parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account their own cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.

"Physicians who counsel families about this decision should assist parents by objectively explaining the potential benefits and risks of circumcising their infant. Because some families may opt to circumcise as part of religious or traditional practice, discussion should also encompass risks and benefits of having a medical professional perform this procedure in a clinical setting versus having it performed by a traditional/religious provider in a nonmedical environment."

Criticism

The American Academy of Pediatrics (AAP) position statement on male circumcision (2012) has attracted significant critical comment.

Van Howe & Svoboda (2013) said:

"These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given."

Frisch et al. (2013) said:

"Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report’s conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia."

American Medical Association view

The American Medical Association (2013) states, "There is strong evidence documenting the health benefits of male circumcision, and it is a low-risk procedure, said Peter W. Carmel, M.D., AMA president. "Today the AMA again made it clear that it will oppose any attempts to intrude into legitimate medical practice and the informed choices of patients."

"The AMA supports the general principles of the 2012 Circumcision Policy Statement of the American Academy of Pediatrics, which reads as follows: "valuation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction"

British Medical Association view

The medical ethics committee of the British Medical Association states:

"In the past, circumcision of boys has been considered to be either medically or socially beneficial or, at least, neutral. The general perception has been that no significant harm was caused to the child and therefore with appropriate consent it could be carried out. The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks. It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child. The responsibility to demonstrate that non-therapeutic circumcision is in a particular child's best interests falls to his parents."

'Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal.

Non-therapeutic circumcision Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes “ritual”) circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths. There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.

Commenting on the development of the 2003 British Medical Association guidance on circumcision, Mussell (2004) states that debate in society is "intensely fraught, with individuals and groups holding conflicting positions." Identifying three positions, "support," "qualified support," and "opposition," he suggests that this controversy "is also reflected within the multicultural, multifaith BMA membership." He identifies this as a difficulty in achieving consensus within the medical ethics committee. Arguments put forward in discussions, according to Mussell, included that circumcision "is a net benefit focused on concepts such as social integration and cultural acceptance", but also that it is "a net harm focused on the breach of children’s rights—the right of the child to be free from physical intrusion and the right of the child to choose in the future."

Canadian Paediatric Society view

The Canadian Paediatric Society (CPS) issued a position statement on September 8, 2015. With regard to ethics, it stated:

Neonatal circumcision is a contentious issue in Canada. The procedure often raises ethical and legal considerations, in part because it has lifelong consequences and is performed on a child who cannot give consent. Infants need a substitute decision maker – usually their parents – to act in their best interests. Yet the authority of substitute decision makers is not absolute. In most jurisdictions, authority is limited only to interventions deemed to be medically necessary. In cases in which medical necessity is not established or a proposed treatment is based on personal preference, interventions should be deferred until the individual concerned is able to make their own choices.

Royal Australasian College of Physicians view

The Royal Australasian College of Physicians (2004) comments that "The difficulty with a procedure which is not medically indicated is whether it may still be in the child’s “best interests” (that is, in the case of circumcision, decreasing the risk of UTI [urinary tract infection] and penile cancer, and ensuring acceptance within a religio-cultural group) on the one hand or whether it may constitute an assault upon the child and be a violation of human rights on the other. Arguments to justify the "best interests" case are based upon data to suggest a decreased risk of medical conditions later in life, none of which, with the possible exception of UTIs in boys, requires a decision in the neonatal period, and this could be seen to be an argument to defer a decision until the individual can express his own preferences. [...] One issue, which is agreed, is that before parents make a decision about circumcision they should have access to unbiased and clear information on the medical risks and benefits of the procedure." Views differ on whether limits should be placed on caregivers having a child circumcised.

Royal Dutch Medical Association view

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 states that "there is no convincing evidence that circumcision is useful or circumcision of male minors is necessary for prevention or health", that "circumcision of male minors entails the risk of medical or psychological complications", that "circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present", that "circumcision of male minors conflicts with the child’s right to autonomy and physical integrity", that circumcision of male minors should be restricted "as much as possible," and that "it is reasonable to put off circumcision until the age at which ... the boy himself can decide about the intervention, or can opt for any available alternatives."

JME symposium on circumcision, June 2004

The Journal of Medical Ethics published a "symposium on circumcision" in its June 2004 issue. 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."

Hutson (2004) states:

"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."

Short (2004) disputes Hutson's claims and argues that male circumcision has future prophylactic benefits that make it worthwhile. He concludes:

"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."

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."

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.

Mussell (2004) examined the process by which the BMA arrived at a position on non-therapeutic circumcision male minors, when the organisation had groups and individuals of different ethnicities, religion, culture, and widely varying viewpoints.

Arguments were put forward that non-therapeutic male circumcision is a net benefit for some because it helps them to integrate in the community.

Arguments were also put forward that non-therapeutic male circumcision is a net harm because it is seen as a breach of children’s rights—the right of the child to be free from physical intrusion and the right of the child to choose in the future. This argument was given emphasis by Britain's incorporation of the European Convention on Human Rights (1950) into domestic law by the Human Rights Act 1998.

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.

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).

Criticism and revision of BMA statement

The BMA statement of 2003 took the position that non-therapeutic circumcision of children is lawful in the United Kingdom. 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. The BMA accepted this criticism and revised its statement to incorporate certain changes based on the critique by Fox & Thomson. The revised statement (2006) 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.

Journal of Medical Ethics circumcision issue, July 2013

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

Other views

Richards (1996) argues that parents only have power to consent to therapeutic procedures. Povenmire (1988) argues that parents should not have the power to consent to neonatal non-therapeutic circumcision.

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.

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."

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."

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. The College of Physicians and Surgeons of British Columbia took a similar position.

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".

Morris et al. (2014) argued that "...failure to circumcise a baby boy may be unethical because it diminishes his right to good health."

Nordic view

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 to, "Let boys decide for themselves whether they want to be circumcised." They further declared that "Circumcision without a medical indication on a person unable to provide informed consent conflicts with basic principles of medical ethics."

The Nordic Association of Clinical Sexologists supports the position of the Nordic Association of Ombudsmen:

"As clinical sexologists, we are concerned about the human rights aspects associated with the practice of non-therapeutic circumcision of young boys. To cut off the penile foreskin in a boy with normal, healthy, genitalia deprives him of his right to grow up and make his own informed decision. Unless there are compelling medical reasons to operate before a boy reaches an age and a level of maturity at which he is capable of providing informed consent, the decision to alter the appearance, sensitivity and functionality of the penis should be left to its owner, thus upholding his fundamental rights to protection and bodily integrity."

Circumcision to reduce the risk of HIV infection

Rennie et al. (2007) remark that the results of three randomised controlled trials, showing reduced risk of HIV among circumcised men, "alter the terms of the debate over the ethics of male circumcision."

Supporters of circumcision argue that using circumcision and other available means to halt the spread of HIV is in the common good. They argue that the reduced risk of catching HIV and other alleged benefits of circumcision make it worthwhile. 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." The percentage is approximately 50% lower of contracted HIV in circumcised males as opposed to uncircumcised males. However, there remains a risk of HIV while engaging in unprotected sex and other high risk behaviors.

The World Health Organization (2007) describes the efficacy of circumcision as "proven beyond reasonable doubt", but 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."

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. They argue that a child's sexual behaviour as an adult is very difficult to predict, as is the future of HIV and treatment or prevention of AIDS. If the child chooses to remain celibate or if a couple remain monogamous, or if HIV is eliminated by the time the child is an adult, the surgery would not have been needed. Moreover, they argue that circumcising a child strictly to protect him from HIV infection may be seen as permission, or even entitlement to engage in dangerous sexual practices. Others would argue that baby boys do not immediately need such protection and can choose for themselves, at a later stage, if they want a circumcision.