Journal of Medical Ethics current issue

Medical, religious and social reasons for and against an ancient rite

Foddy, B. — 2013-06-18T02:42:56-07:00

This month's issue of the Journal of Medical Ethics is a special issue devoted entirely to the ethics of infant male circumcision—an elective surgical practice that is currently performed on around a third of the world's male population.1

The last time the Journal ran a symposium on this issue was in 2004, and there has been relatively scant discussion of the practice in the ethical literature since then. Three events that took place in the past year have brought the ethics of infant male circumcision back into the global spotlight.

First, in April of 2012, controversy erupted after it was reported that a baby had died in New York City after contracting Herpes Simplex virus during the Orthodox Jewish variant of circumcision known as metzitzah b'peh, which involves the oral suction of blood from the infant's penis following the circumcision procedure.2

Later that...

Male circumcision and the enhancement debate: harm reduction, not prohibition

Savulescu, J. — 2013-06-18T02:42:56-07:00

Around a third of men worldwide are circumcised. It is probably the most commonly performed surgical procedure. Circumcision is also one of the oldest forms of attempted human enhancement. It is and has been done for religious, social, aesthetic and health reasons.

Circumcision has a variety of benefits and risks, many of which are discussed in this issue. There is some dispute about the magnitude and likelihood of these benefits and risks. Some argue that the risks outweigh the benefits and circumcision should not be performed on children who are not competent to make their own decisions.

If the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure. Around a third of all men would have been harmed. This is an extraordinary public health injury. Presumably, many would be entitled to compensation.

The fact that relatively...

The ethics of infant male circumcision

Earp, B. D. — 2013-06-18T02:42:56-07:00

INTRODUCTION

Is the non-therapeutic circumcision of infant males morally permissible? The most recent major development in this long-simmering debate was the 2012 release of a policy statement and technical report on circumcision by the American Academy of Pediatrics (AAP). In these documents, the US paediatricians’ organisation claimed that the potential health benefits of infant circumcision now outweigh the risks and costs. They went on to suggest that their analysis could be taken to justify the decision of parents to choose circumcision for their incompetent children.1

Circumcision and ‘health benefits’

The AAP's pronouncement unleashed a firestorm of commentary, much of it censorious. In this issue, human rights attorney J Steven Svoboda and Professor of Clinical Paediatrics Robert Van Howe take the AAP to taskⁱ for committing numerous significant errors, both in their analysis of relevant evidence and in basic medical-ethical reasoning.3 In addition, an...

The child's interests and the case for the permissibility of male infant circumcision

Mazor, J. — 2013-06-18T02:42:56-07:00

Circumcision of a male child was recently ruled illegal by a court in Germany on the grounds that it violates the child's rights to bodily integrity and self-determination. This paper begins by challenging the applicability of these rights to the circumcision debate. It argues that, rather than a sweeping appeal to rights, a moral analysis of the practice of circumcision will require a careful examination of the interests of the child. I consider three of these interests in some detail. The first is the interest in avoiding a moderate decrease in expected future sexual pleasure. I argue that even if such a decrease were to occur, it is not wholly unreasonable to think that this might actually be a good thing for the child. Second, I consider the interest in self-determination. I argue that this interest is not as strong as it might appear because the adult's circumcision decision is subject to a variety of biases and a significant lack of information. Finally, I consider the child's interest in avoiding the future costs of adult circumcision. I argue that this interest becomes much stronger in the religious case because the child is quite likely to choose to become circumcised as an adult. The likelihood of the child choosing circumcision in the religious case also reduces the extent to which infant circumcision violates his interest in self-determination. I conclude that male infant circumcision falls within the prerogative of parental decision-making in the secular case and even more clearly so in the religious case. Finally, I distinguish male circumcision from female genital cutting in several important respects and argue that we can coherently hold that male circumcision is permissible without also endorsing all forms of female genital cutting.

Circumcision, sexual dysfunction and the child's best interests: why the anatomical details matter

Lang, D. P. — 2013-06-18T02:42:56-07:00

In his contribution to the Journal of Medical Ethics, Joseph Mazor1 makes a logical case, based on the premises underlying his reasoning, for his article's primary thesis: he concludes that parents have the prerogative to determine the ‘best interests’ of their infant son in a circumcision decision. If the facts of the matter were ultimately no different from what he adduces, one could admit the soundness of his argument. But the paper is flawed by some questionable assumptions and grievous incompleteness.

First, the author insufficiently explores the profound implications of a serious equivocation in the term ‘circumcision’ that is common throughout the literature. He does superficially reference the article on ‘Circumcision’ in The Jewish Encyclopedia, which describes in detail the actual steps involved in brit milah versus brit periah.2 Despite this general allusion, though, he hardly discusses the matter further, as though the...

Evaluations of circumcision should be circumscribed by the evidence

Benatar, D. — 2013-06-18T02:42:56-07:00

One common mistake in discussions about the ethics of infant male circumcisionⁱ is to attempt to answer the question of the practice's permissibility by appealing to general principles and bypassing the empirical evidence about purported benefits and harms of the practice.

Joseph Mazor1 avoids the mistake of appealing only to general principles. He correctly argues that it is not sufficient to invoke a child's right to bodily integrity or to self-determinationⁱⁱ. Moreover, he does not appeal to parents’ rights to religious or cultural freedom in order to make his case for the permissibility of parents having their sons circumcised for religious or cultural reasons.

However, in invoking empirical considerations, he is insufficiently careful. For example, he includes, on the negative side of the circumcision ledger, a reduction in sexual pleasure, yet it is not clear that even his own reasoning warrants this. The...

What philosophers can contribute in the face of fundamental empirical disagreement: a response to Benatar and Lang

Mazor, J. — 2013-06-18T02:42:56-07:00

I wish to first thank the two respondents for seriously engaging with my arguments. Their responses suggest that they are both individuals of good conscience who are deeply committed to the quest for truth and to human welfare.

Their responses also highlight the deep empirical disagreements that lie at the heart of the circumcision debate. Given such empirical disagreements, what can philosophers contribute? I wish to reply to my critics in a way that highlights four types of contributions that philosophers can make.

First, philosophers can provide conceptual clarity. For example, I argue in my paper that appeals to the rights of bodily integrity and self-determination (understood as trumps) in the context of the circumcision debate entails a misunderstanding of the nature of these rights. This supports the position of both of my respondents that the empirical details are morally relevant in this debate.

David Lang criticises...

Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision

Svoboda, J. S., Van Howe, R. S. — 2013-06-18T02:42:56-07:00

The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits ‘justify access to this procedure for families who choose it,’ claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. 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.

The AAP Task Force on Neonatal Circumcision: a call for respectful dialogue

2013-06-18T02:42:56-07:00

The American Academy of Pediatrics (AAP) Task Force on Circumcision published its policy statement and technical report on newborn circumcision in September 2012.1 2 Since that time, some individuals and groups have voiced objections to the work of the Task Force, while others have conveyed their support. The AAP task force is pleased that the policy statement and technical reports on circumcision have stimulated debate on this topic and welcomes respectful discussion and dialogue about the scientific and ethical issues that surround neonatal circumcision. We believe this is a complex issue that does not lend itself to simplistic solutions. The Task Force encourages those of all viewpoints to contribute to a vibrant, thoughtful and respectful evidence-based dialogue. We appreciate that the free exchange of competing ideas is a necessary component of scientific discovery. We also recognise that all clinical decisions carry ethical dimensions and...

After Cologne: male circumcision and the law. Parental right, religious liberty or criminal assault?

Merkel, R., Putzke, H. — 2013-06-18T02:42:56-07:00

Non-therapeutic circumcision violates boys’ right to bodily integrity as well as to self-determination. There is neither any verifiable medical advantage connected with the intervention nor is it painless nor without significant risks. Possible negative consequences for the psychosexual development of circumcised boys (due to substantial loss of highly erogenous tissue) have not yet been sufficiently explored, but appear to ensue in a significant number of cases. According to standard legal criteria, these considerations would normally entail that the operation be deemed an ‘impermissible risk’—neither justifiable on grounds of parental rights nor of religious liberty: as with any other freedom right, these end where another person's body begins. Nevertheless, after a resounding decision by a Cologne district court that non-therapeutic circumcision constitutes bodily assault, the German legislature responded by enacting a new statute expressly designed to permit male circumcision even outside of medical settings. We first criticise the normative foundations upon which such a legal concession seems to rest, and then analyse two major flaws in the new German law which we consider emblematic of the difficulty that any legal attempt to protect medically irrelevant genital cutting is bound to face.

Religious circumcision, invasive rites, neutrality and equality: bearing the burdens and consequences of belief

Johnson, M. T. — 2013-06-18T02:42:56-07:00

The decision of the German regional court in Cologne on 26 June 2012 to prohibit the circumcision of minors is important insofar as it recognises the qualitative similarities between the practice and other prohibited invasive rites, such as female genital cutting. However, recognition of similarity poses serious questions with regard to liberal public policy, specifically with regard to the exceptionalist treatment demanded by certain circumcising groups. In this paper, I seek to advance egalitarian means of dealing with invasive rites which take seriously cultural diversity, minimise harm and place responsibility for the burdens and consequences of beliefs upon those who promote practices.

Ancient rites and new laws: how should we regulate religious circumcision of minors?

Davis, D. S. — 2013-06-18T02:42:56-07:00

The ancient practice of metzitzah b'peh, direct oral suction, is still practiced by ultra-Orthodox Jews as part of the religious rite of male newborn circumcision. Between 2000 and 2011, 11 children have died in New York and New Jersey, following infection by herpes simplex virus, presumably from infected practitioners. The City responded by requiring signed parental consent before oral suction, with parents being warned of the dangers of the practice. This essay argues that informed consent is not an appropriate response to this problem. An outright ban would a better response to a practice that is dangerous to children, but might prove unconstitutional under New York State law.

Circumcision: What should be done?

Ben-Yami, H. — 2013-06-18T02:42:56-07:00

I explain why I think that considerations regarding the opposing rights involved in the practice of circumcision—rights of the individual to bodily integrity and rights of the community to practice its religion—would not help us decide on the desirable policy towards this controversial practice. I then suggest a few measures that are not in conflict with either religious or community rights but that can both reduce the harm that circumcision as currently practiced involves and bring about a change in attitude towards the practice, thus further reducing its frequency. These measures are the compulsory administration of anaesthetics; the banning of the metzitzah b'peh; and having an upper age limit of a few months on non-therapeutic circumcision of minors. I conclude with general considerations on why the steps taken towards the reform of circumcision should be moderate.

The child's right to an open future: is the principle applicable to non-therapeutic circumcision?

Darby, R. J. L. — 2013-06-18T02:42:56-07:00

The principle of the child's right to an open future was first proposed by the legal philosopher Joel Feinberg and developed further by bioethicist Dena Davis. The principle holds that children possess a unique class of rights called rights in trust—rights that they cannot yet exercise, but which they will be able to exercise when they reach maturity. Parents should not, therefore, take actions that permanently foreclose on or pre-empt the future options of their children, but leave them the greatest possible scope for exercising personal life choices in adulthood. Davis particularly applies the principle to genetic counselling, arguing that parents should not take deliberate steps to create physically abnormal children, and to religion, arguing that while parents are entitled to bring their children up in accordance with their own values, they are not entitled to inflict physical or mental harm, neither by omission nor commission. In this paper, I aim to elucidate the open future principle, and consider whether it is applicable to non-therapeutic circumcision of boys, whether performed for cultural/religious or for prophylactic/health reasons. I argue that the principle is highly applicable to non-therapeutic circumcision, and conclude that non-therapeutic circumcision would be a violation of the child's right to an open future, and thus objectionable from both an ethical and a human rights perspective.

Circumcision of male infants as a human rights violation

Svoboda, J. S. — 2013-06-18T02:42:56-07:00

Every infant has a right to bodily integrity. Removing healthy tissue from an infant is only permissible if there is an immediate medical indication. In the case of infant male circumcision there is no evidence of an immediate need to perform the procedure. As a German court recently held, any benefit to circumcision can be obtained by delaying the procedure until the male is old enough to give his own fully informed consent. With the option of delaying circumcision providing all of the purported benefits, circumcising an infant is an unnecessary violation of his bodily integrity as well as an ethically invalid form of medical violence. Parental proxy ‘consent’ for newborn circumcision is invalid. Male circumcision also violates four core human rights documents—the Universal Declaration of Human Rights, the Convention on the Rights of the Child, the International Covenant on Civil and Political Rights, and the Convention Against Torture. Social norm theory predicts that once the circumcision rate falls below a critical value, the social norms that currently distort our perception of the practice will dissolve and rates will quickly fall.

Infant circumcision: the last stand for the dead dogma of parental (sovereignal) rights

Van Howe, R. S. — 2013-06-18T02:42:56-07:00

J S Mill used the term ‘dead dogma’ to describe a belief that has gone unquestioned for so long and to such a degree that people have little idea why they accept it or why they continue to believe it. When wives and children were considered chattel, it made sense for the head of a household to have a ‘sovereignal right’ to do as he wished with his property. Now that women and children are considered to have the full complement of human rights and slavery has been abolished, it is no longer acceptable for someone to have a ‘right’ to completely control the life of another human being. Revealingly, parental rights tend to be invoked only when parents want to do something that is arguably not in their child's best interest. Infant male circumcision is a case in point. Instead of parental rights, I claim that parents have an obligation to protect their children's rights as well as to preserve the future options of those children so far as possible. In this essay, it is argued that the notion that parents have a right to make decisions concerning their children's bodies and minds—irrespective of the child's best interests—is a dead dogma. The ramifications of this argument for the circumcision debate are then spelled out and discussed.

Ethics briefings

Davies, M., Brannan, S., Chrispin, E., English, V., Mussell, R., Sheather, J. C. — 2013-06-18T02:42:56-07:00

Disclosure of information and donor conception

Ever so often in the UK, there is a flurry of activity around the information requirements of donor-conceived individuals. In April 2013, it was the launch of a report from the Nuffield Council on Bioethics that brought the issue back to public consciousness.1

Since 1991, information about treatment with donor gametes or embryos has been collected by the Human Fertilisation and Embryology Authority (HFEA). Since then, over 35 000 donor-conceived individuals have been born through treatment in licensed clinics. Medical information and information about donors’ appearance are collected by clinics, and donors are encouraged to put together a ‘pen portrait’ giving information about themselves for any resulting children. One focus of the new report is on improving the quality and quantity of information available about donors.

Traditionally, gamete and embryo donations were practised on an anonymous basis, so that those born...