Fox and Thompson make a significant contribution to the body of literature about the ethics of neonatal circumcision. If law is to be ethical, how then shall it fulfil a requirement to protect children from unnecessary surgery involving amputation of parts of the genitals? If laws are enacted to prohibit male circumcision, as have been enacted to prohibit female circumcision, should government carve out...
Fox and Thompson make a significant contribution to the body of literature about the ethics of neonatal circumcision. If law is to be ethical, how then shall it fulfil a requirement to protect children from unnecessary surgery involving amputation of parts of the genitals? If laws are enacted to prohibit male circumcision, as have been enacted to prohibit female circumcision, should government carve out exceptions for millennia old religious practices that involve such surgery?
Perhaps existing laws, against child abuse and endangerment, are sufficient to prohibit and criminalize infant and child circumcision, but if they continue to be interpreted as inapplicable by prosecutors, new laws may be needed.
In the United States, government curtails certain activities of religious groups that pertain to children of adult adherents. This is done variously by judicial decree or legislative enactment. Courts have ordered physicians and hospitals to provide critical medical care, over the
objections of parents, to children of Christian Scientists and Jehovah's Witnesses. In some states where church members practice the handling of deadly snakes to prove their faith, state statutes now prohibit the involvement of children under 18 years of age. In such cases there has been great reluctance to interfere with the religious freedom assured by the Constitution, but government interest in protecting children has prevailed. Since neonatal circumcision sometimes causes death or dismemberment of its subjects, should government have less interest in prohibiting it? Now that research shows that much sensory tissue designed
to communicate sexual sensations is lost to circumcision (p.34, Cold & Taylor), should the law be idle regarding infant male circumcision, and the right of a child to decide as an adult what is to become of his prepuce?
Almost all Muslim males are circumcised sometime during childhood or as youths. Many Jewish infants undergo ritual Jewish circumcision, but in the US a majority of Jewish infants receive hospital circumcisions alongside Gentile infants (p.216, Glick). It is often argued that a prohibition on infant and child circumcision is impermissible as it would interfere with the religious desires of Jews and Muslims to circumcise their infants and children. Could they be excluded from the effects of a
law of otherwise general application? Would such exclusion send a signal that government regards the human rights of Jewish and Muslim children as less important than those of other children?
One US organization proposes a law, applicable to males, and similar to the national prohibition of female circumcision. Progress is very slow for proponents, hindered by a continuing belief that parents of males must be empowered to decide whether or not to circumcise their sons. Does that belief, and its sustenance of inaction on a law pertaining to male circumcision, threaten the laws against female circumcision? What if some parents of girls invoke their right to equal protection of the law in a constitutional attack on the laws against female circumcision? Indeed, why should they not have rights equal to those of parents of male children? Even if there is no equivalency of male circumcision to female circumcision (there is a good case for some equivalency), don't we now
know enough about the adverse effects of male circumcision to decide it should not be performed on non-consenting infants and children?
It is ironic that Fox and Thomson cite Dr Lewis Sayre's work. Sayre's claims of fantastical cures from circumcision are often used to show how strange it is that we have widespread infant circumcision in the English speaking world. What is never mentioned is that Sayre carefully avoided total foreskin amputation, opting instead for removing the tip only of a restrictive prepuce, or for a dorsal slit only, when possible. He appears to have been interested only in immediate, existing pathological phimosis
as a cause of disease. He advocated the retention of almost all of the foreskin to preserve most of its functions. He considered more radical cutting to be "unjustifiable mutilation." He also protested widespread routine, or universal, circumcision (pp.158-60, Glick). Is there a lesson, for today's advocates of indiscriminate circumcision, in his desire to preserve as much of the foreskin? Sayre did not have an anti-sexual agenda
as did many of his contemporaries, and he acknowledged the value of the male prepuce.
Thanks to Fox and Thomson, we are closer to confronting many long neglected questions about this surgery that has never been adopted by 80% of the world's population.
Richard Russell, JD
Moreno Valley, California
References
Cold, C.J., and Taylor, J.R. "The prepuce," British Journal of
Urology, Volume 83, Supplement 1, January 1999.
Glick, Leonard B. Marked in Your Flesh: Circumcision from Ancient
Judea to Modern America. Oxford and New York: Oxford University Press,
2005.
[Dr Glick is a Professor of Anthropology, a Medical Doctor, a Jewish American, and a dedicated opponent of infant and child circumcision. His new book is a carefully researched and well documented work of great interest to anyone who wants to know how Jewish circumcision became
hospital circumcision for most Jews in the USA, and became a routine medical procedure for most male infants born in the US.]
We at Doctors Opposing Circumcision (DOC) are gratified by the publication of this paper by Fox and Thompson.1 They confirm the position previously taken by the Norwegian Council for Medical Ethics that male non-therapeutic circumcision violates important principles of medical ethics.2 Their findings also are co...
We at Doctors Opposing Circumcision (DOC) are gratified by the publication of this paper by Fox and Thompson.1 They confirm the position previously taken by the Norwegian Council for Medical Ethics that male non-therapeutic circumcision violates important principles of medical ethics.2 Their findings also are consistent with Articles 1, 2, and 20 of the European Convention on Human Rights and Bioethics.3
DOC concurs with their criticism of the British Medical Association (BMA) statement. As previously reported, we think it is deficient in that it fails to recognize 1) the probable unlawfulness of the circumcision of male children, 2) the lack of medical value, 3) the complications, risks, and other disadvantages, 4) the functional value of the prepuce, 5) the inherent violations of human rights, and 6) the clearly unethical nature of child circumcision.4
Lawfulness
We also believe that non-therapeutic circumcision of children is already unlawful, because the mutilative nature of circumcision makes it a violation of existing child protection laws. For example, a man from Clark County, Washington, USA currently is in gaol for three years for child assault because he attempted to perform a religiously motivated non-therapeutic circumcision on his son.5Without medical justification, may a parent do by proxy consent what he cannot legally do himself?
We think that, in England and Wales, the circumcision of children is a misdemeanour under the Children and Young Persons Act (1933). The continued performance of non-therapeutic circumcision on children in Britain and elsewhere depends on the failure of public prosecutors to enforce existing law.
Where do we go from here?
Doctors have a clear duty to decline all inefficacious or unethical operations on minors. DOC has prepared a guidance on conscientious objection to the performance of non-therapeutic circumcision on children that provides justification and authority for refusing to perform a non-therapeutic circumcision on a child.6 We recommend that all doctors who may be asked to perform a non-therapeutic circumcision of a child download a copy from our website so they may be acquainted with their ethical rights and duties.
Certainly, the Medical Ethics Committee of the BMA has more work to do. A revision to the 2003 statement already is needed because of its original inadequacies.
The General Medical Council needs to grasp this nettle firmly. It is time to cast out its temporizing 1997 policy. A new guidance for doctors that is consistent with the UN Convention on the Rights of the Child (1989) and Articles 1,2, and 20 of the European Convention on Human Rights and Bioethics (1997) is needed.
In a case involving caning, the European Court of Human Rights ruled:
Children and other vulnerable individuals, in particular, are entitled to State protection, in the form of effective deterrence, against such serious breaches of personal integrity.7
We believe that this should apply at least as forcefully to cases of bodily mutilation as to cases of caning. Action by Parliament may be necessary to provide effective deterrence.
Medical societies world-wide have an ethical duty to inform their members of the unethical status of non-therapeutic circumcision of children. Medical Licencing Boards have a duty to issue regulations regarding the non-therapeutic circumcision of children to ensure that medical practice in their jurisdiction complies with the highest standards of medical ethics.
These actions will usher in a new era in which doctors respect the legal right of children to genital integrity.
I was wondering whether Professor Short had ever seen a sexually active neonate; I certainly have not. Most commentators who criticise circumcision from an ethical point of view take issue with the fact that the newborn baby has no option to refuse. However, Professor Short seems
to be saying that circumcision has value in preventing HIV transmission - in which case the procedure does not have to be perf...
I was wondering whether Professor Short had ever seen a sexually active neonate; I certainly have not. Most commentators who criticise circumcision from an ethical point of view take issue with the fact that the newborn baby has no option to refuse. However, Professor Short seems
to be saying that circumcision has value in preventing HIV transmission - in which case the procedure does not have to be performed at birth. Why not delay the operation until the age of, say, twelve, when the patient at least retains the right to refuse the procedure and hold onto an essentially normal part of his anatomy?
There is no precedent for widespread and indiscriminate removal of a normal part of human anatomy for the prevention of future disease, when the operation could be performed later - and for good reason: it is not ethically acceptable.
What are the lessons arising from the complex case of Terri Schiavo
for bioethics[1] and bioethicists and for the management of end-of-life
conflict?[2] The most important lesson is that battles cannot be lead in
order to the procedure of law to anticipate the dead of a human being.
Rather, we must act humanly to see that every person dies naturally with
all the possible care until the end.
What are the lessons arising from the complex case of Terri Schiavo
for bioethics[1] and bioethicists and for the management of end-of-life
conflict?[2] The most important lesson is that battles cannot be lead in
order to the procedure of law to anticipate the dead of a human being.
Rather, we must act humanly to see that every person dies naturally with
all the possible care until the end.
The demanded virtue in the issue of
end-of-life should not be the courage of the ‘warriors’ that fights for
justice, that is often unilateral, but the demanded virtues are prudence
and mercy towards the sick persons above all in end of life for the good
of everyone and of all the community. We need these virtues with the aim
of ‘the good’: the justice is constructed and founded on ‘the good’. And
‘the good’ is not in the principles, neither ethics nor law principles,
because principles are vices[2], but into the aims of a balanced
consciousness of our limits that we well know to discern also the our end-of-life with prudence and mercy.
References
1. Koch T, The challenge of Terri Schiavo: lessons for bioethics, J
Med Ethics 2005;31:376-378.
2. Bloche MG, Managing Conflict at the End of Life, N Engl J Med.
2005 Jun 9; 352:2371-2373.
All will agree with Nick Bostrom that healthy life beyond eighty can
be most valuable, even life, which is not so healthy. I would certainly
like to become a feisty octogenarian. But how is that relevant to saying
that we should be satisfied with eighty good years as individuals, and
that it would be bad for us collectively, if life expectancy increased
considerably beyond eighty?
All will agree with Nick Bostrom that healthy life beyond eighty can
be most valuable, even life, which is not so healthy. I would certainly
like to become a feisty octogenarian. But how is that relevant to saying
that we should be satisfied with eighty good years as individuals, and
that it would be bad for us collectively, if life expectancy increased
considerably beyond eighty?
He is a little hard on Dr Goodman, whose basic point was never
answered. Life expectancy in eight countries of southern Africa is less
than forty years, and we must take a little of the responsibility for
that. Would we not increase injustice in the world, if we succeeded in
prolonging our lives into a second century, before seeing their lot
improved?
I conclude by again congratulating Nick Bostrom on his thought
provoking article, and promise not to reply to a third spirited defence of
it. The author gets the last word.
Commenting on my Fable, Allen B. Shaw raises two main points. The one
concerning inequality was already raised by Neville W Goodman (7 June
2005), so I refer the reader to the various replies that people made to
Goodman’s comment. Shaw’s other point concerns the alleged worthlessness
of healthy life beyond 80:
“Do we want or need more than eighty good years to complete our
personal biograp...
Commenting on my Fable, Allen B. Shaw raises two main points. The one
concerning inequality was already raised by Neville W Goodman (7 June
2005), so I refer the reader to the various replies that people made to
Goodman’s comment. Shaw’s other point concerns the alleged worthlessness
of healthy life beyond 80:
“Do we want or need more than eighty good years to complete our
personal biographies?”
But many lives are not finished at 80. Even today when we still lack
effective means of controlling the aging process, there are those who
continue to enjoy life, create, learn and contribute beyond 80. If they
could remain physically and mentally healthy and vigorous, there is no
reason whatever to think that they could not continue to lead worthwhile
lives for many, many more decades.
Not every book needs the same number of pages, and this may hold for
our “personal biographies” too. The more basic question is: Who should
decide when your life’s book is complete? At what point are you better off
dead than alive? This decision, I hope we can agree, should be made by the
author of your life – i.e. by you yourself.
Great novels should not end because the author runs out of paper and
ink; they should end because she judges that she has said what she wanted
to say and the work is complete.
The analogy between a person’s life and a book is illuminating from
another direction as well. The Library of Congress holds 18 million
volumes. Each year, approximately twice that number of human lives are
destroyed as a consequence of aging. If the knowledge and experience of a
human mind corresponded to a single book, aging in effect be burns down
the Library of Congress twice a year, erasing all the information
contained therein. Of course, a human mind contains much more knowledge
and experience than a book. More importantly, a human mind can feel,
think, desire, and love.
It’s time we cease pretending that the annual destruction of the
health and life of millions of human beings is somehow a fine thing. It
will take us decades before we can fix aging, but we will get there sooner
if we stop making excuses for the status quo.
Nick Bostrom provides a thought provoking and amusing parable about the defeat of senescence by basic research.[1] The parable form, however, tends to beg the important questions its moral raises. Would the application of what we already know be a better approach? Are there more
important moral priorities? Is the human lifespan already long enough?
Nick Bostrom provides a thought provoking and amusing parable about the defeat of senescence by basic research.[1] The parable form, however, tends to beg the important questions its moral raises. Would the application of what we already know be a better approach? Are there more
important moral priorities? Is the human lifespan already long enough?
Life expectancy has already greatly increased in the last century, and may continue to do so. If we want to keep our telomeres longer for longer, we should tackle obesity and tobacco. Our problem lies in the ten years of declining health we endure before reaching the end of a perfectly
satisfactory lifespan. It also lies in the unhappiness and loneliness of lives it would be unkind to prolong.
The real moral problem is that the poor do not live as long as the rich, not that the latter die too soon. And when we turn to that large part of the world, in which the human lifespan is little more than half of what we enjoy in the U K, then it becomes immoral to try to prolong our own lives. The inequality in the world would increase. We would live longer, while children die for lack of clean water, adequate food or basic medical care. Surely we should direct effort to finding and supplying drugs for their diseases, before worrying about our own telomeres.
The article implies that what is good for the individual is good for the community. This is not always so. I might enjoy an extra twenty years of life, but that does not mean we would be happier if everyone had the extra years. I should be happy if the Inland Revenue exempted me from taxation, but not if it exempted everyone.
Would it be good, if we all lived longer? There is a pensions crisis, because we are doing so. What are our choices? We can be poor in old age. Or we can be poorer during our maturity, because we have to save more and
pay more tax. Or we can work longer, which is fine for philosophers, but not so great for the many, who yearn to retire.
World populaton increases. It will become unsustainable. There are not enough fish in the sea. The Chinese will want as many cars as we have, so pollution and global warming will increase. We will run out of space.
Compulsory limitation of family size is unpalatable and probably unenforceable. We may yet set up colonies on other worlds, as he says, but that will not solve overpopulation on earth.
Few want to die, but neither do we desire the curse of immortality. Do we want or need more than eighty good years to complete our personal biographies? That gives enough time for golf, gardening, and grandchildren.
References
1. Bostrom N. The fable of the dragon tyrant. J Med Ethics
2005;31:273-7
Deborah Kirklin seems to suggest that those of us who argue that a
woman should have the right to make the decision about the outcome of her
pregnancy should avoid commenting on fetal development. Whether a fetus
can ‘smile’, she claims, is irrelevant to our case for women’s abortion
rights, and we should not use ‘biological discourse’. I find this
proposition very odd.
Deborah Kirklin seems to suggest that those of us who argue that a
woman should have the right to make the decision about the outcome of her
pregnancy should avoid commenting on fetal development. Whether a fetus
can ‘smile’, she claims, is irrelevant to our case for women’s abortion
rights, and we should not use ‘biological discourse’. I find this
proposition very odd.
Images of the fetus moving its facial muscles have been uncritically
received in recent debate as evidence that it can ‘smile’. Very few people
have attempted to contest the idea that the now-famous 4-D images of the
fetus tell us just how emotionally complex the fetus is. (In the same way,
few have generated arguments against the claim a fetus feels pain because
it moves away from the point of a needle). In our culture, in other words,
biological development, and the ability to feel and experience, are all
the time conflated, without many arguing about the difference between the
two. There is clearly a great deal of confusion about how to define
personhood, and there is also evidently a strong trend towards finding
this quality present in the fetus. As a result, there is a great deal of
discomfort about late abortion.
Maybe what I have argued on these issues so far is not well enough
explained. But it would be a lazy, ineffective supporter of choice, very
much lacking in intellectual rigour, that chose to ignore them and simply
kept repeating the mantra, ‘abortion is a woman’s right’. It would also be
one destined to become increasingly irrelevant to the abortion debate.
Making the case for abortion – especially late in pregnancy -
requires those who support abortion rights to have something to say about
fetal development (using ‘biological discourse’ as Kirklin describes it).
I can guarantee that if we do not, there will certainly be more ‘bio-
technically based challenges’ to the case for women’s choice in the
future.
Dr Ellie Lee, lecturer in social policy, University of Kent, and Co-
ordinator, Pro Choice Forum.
In reply to Mr. Goodman's comment to "The Fable of the Dragon-Tyrant"
by Dr. Bostrom, and in particular to the statement "The idea that we
should actively and purposely aim to prevent death is absurd. It is also,
going with the principal of distributive justice, simply immoral while 80%
of the world does not have clean drinking water":
The idea is not absurd given the actual possibility, acknow...
In reply to Mr. Goodman's comment to "The Fable of the Dragon-Tyrant"
by Dr. Bostrom, and in particular to the statement "The idea that we
should actively and purposely aim to prevent death is absurd. It is also,
going with the principal of distributive justice, simply immoral while 80%
of the world does not have clean drinking water":
The idea is not absurd given the actual possibility, acknowledged by
many experts, that medical technology may prevent ageing and death in a
few decades. It is an engineering problem - perhaps solvable in even less
time, perhaps only in much more time. Following the scientific method, let
research and experiment decide.
I wholeheartedly agree on the paramount importance of providing clean
drinking water to everyone on the planet. This, and other similar
unacceptable gaps between haves and have nots, are urgent problems that
need urgent solutions. But I don't see how this can support your labelling
advanced and visionary medical research as "immoral". One does not exclude
the other.
Neville Goodman comments that there is "no sensible ethical argument
that we should not try to keep people as healthy as possible for as long
as possible". With this I strongly agree. Yet he goes on to assert that
"the idea that we should actively and purposely aim to prevent death is
absurd". There is a tension between these two claims inasmuch as dying has
been shown to be associated with serious neg...
Neville Goodman comments that there is "no sensible ethical argument
that we should not try to keep people as healthy as possible for as long
as possible". With this I strongly agree. Yet he goes on to assert that
"the idea that we should actively and purposely aim to prevent death is
absurd". There is a tension between these two claims inasmuch as dying has
been shown to be associated with serious negative long-term effects on
health.
Goodman also claims that working to defeat aging is "simply immoral
while 80% of the world does not have clean drinking water". I submit that
both the lack of clean drinking water and the lack of means to remain
healthy as we grow older are huge problems that we need to solve. But it
does not follow from the urgency of providing clean drinking water that it
is immoral to work on defeating aging, any more than it follows from this
that it is immoral to work on cures for cancer or diabetes. We can, and
should, vigorously pursue both objectives.
The sheer scale of the human misery, disease, loss of capacity, and
untimely death that is caused by age-related decay of our bodies boggles
the mind. The amount of death and suffering that is caused by the
consequences of human senescence (circa 100,000 deaths every day) is much
greater than the amount caused by the lack of clean drinking water,
although both are unfathomable. We have a strong moral obligation to work
to put an end to both as soon as possible. The first step is to recognize
that this obligation exists.
Dear Editor,
Fox and Thompson make a significant contribution to the body of literature about the ethics of neonatal circumcision. If law is to be ethical, how then shall it fulfil a requirement to protect children from unnecessary surgery involving amputation of parts of the genitals? If laws are enacted to prohibit male circumcision, as have been enacted to prohibit female circumcision, should government carve out...
Dear Editor,
I was wondering whether Professor Short had ever seen a sexually active neonate; I certainly have not. Most commentators who criticise circumcision from an ethical point of view take issue with the fact that the newborn baby has no option to refuse. However, Professor Short seems to be saying that circumcision has value in preventing HIV transmission - in which case the procedure does not have to be perf...
Dear Editor,
What are the lessons arising from the complex case of Terri Schiavo for bioethics[1] and bioethicists and for the management of end-of-life conflict?[2] The most important lesson is that battles cannot be lead in order to the procedure of law to anticipate the dead of a human being. Rather, we must act humanly to see that every person dies naturally with all the possible care until the end.
...
Dear Editors,
All will agree with Nick Bostrom that healthy life beyond eighty can be most valuable, even life, which is not so healthy. I would certainly like to become a feisty octogenarian. But how is that relevant to saying that we should be satisfied with eighty good years as individuals, and that it would be bad for us collectively, if life expectancy increased considerably beyond eighty?
He is...
Dear Editor,
Commenting on my Fable, Allen B. Shaw raises two main points. The one concerning inequality was already raised by Neville W Goodman (7 June 2005), so I refer the reader to the various replies that people made to Goodman’s comment. Shaw’s other point concerns the alleged worthlessness of healthy life beyond 80:
“Do we want or need more than eighty good years to complete our personal biograp...
Dear Editor,
Nick Bostrom provides a thought provoking and amusing parable about the defeat of senescence by basic research.[1] The parable form, however, tends to beg the important questions its moral raises. Would the application of what we already know be a better approach? Are there more important moral priorities? Is the human lifespan already long enough?
Life expectancy has already greatly increase...
Dear Editor,
Deborah Kirklin seems to suggest that those of us who argue that a woman should have the right to make the decision about the outcome of her pregnancy should avoid commenting on fetal development. Whether a fetus can ‘smile’, she claims, is irrelevant to our case for women’s abortion rights, and we should not use ‘biological discourse’. I find this proposition very odd.
Images of the fetus m...
Dear Editor,
In reply to Mr. Goodman's comment to "The Fable of the Dragon-Tyrant" by Dr. Bostrom, and in particular to the statement "The idea that we should actively and purposely aim to prevent death is absurd. It is also, going with the principal of distributive justice, simply immoral while 80% of the world does not have clean drinking water":
The idea is not absurd given the actual possibility, acknow...
Dear Editor,
Neville Goodman comments that there is "no sensible ethical argument that we should not try to keep people as healthy as possible for as long as possible". With this I strongly agree. Yet he goes on to assert that "the idea that we should actively and purposely aim to prevent death is absurd". There is a tension between these two claims inasmuch as dying has been shown to be associated with serious neg...
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