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Male circumcision and the enhancement debate: harm reduction, not prohibition
  1. Julian Savulescu
  1. Correspondence to Professor Julian Savulescu, Faculty of Philosophy, The Oxford Uehiro Centre for Practical Ethics, Oxford OX1 1PT, UK; julian.savulescu{at}philosophy.ox.ac.uk

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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 few people think that the situation is as bad as this indicates that most people implicitly believe that circumcision is not generally a significant harm, if a harm at all. (This is an example of the kind of argument called modus tollens. If p, then q. Not-q, therefore not-p.)

One might thus conclude either that:

  1. It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.

Or

  • 2. If circumcision is against the interests of an infant or young child, it is only mildly so.

In general, people should make their own decisions about body modification and human enhancement when this is possible. Such an approach speaks in favour of waiting until a child becomes an adult to make his or her own decision about circumcision. And procedures which are not clearly in a child's interests should not be performed on that child. However, religious and other social exclusion may make delay in circumcision psychologically harmful.

It would be a mistake to ban circumcision given its importance to many people. A dangerous ‘black market’ would be created. As with other forms of potentially risky bodily modification or enhancement, the best policy is one of harm reduction, not prohibition. Non-medical circumcision should be discouraged, but not prohibited (for further discussion see ‘Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgements of What Is Best for Their Patients’1 and ‘Liberal Rationalism and Medical Decision-Making’2).

Many of the risks of circumcision, such penile injury, herpetic infection and pain, are almost entirely avoidable with modern surgery. What seems ethically clear is that male circumcision in developed countries should only be performed by a properly qualified paediatric surgeon in a hospital setting, with appropriate analgesia. Where religion requires that circumcision be conducted by a religious official, that official should be surgically trained or participate in the surgical procedure in a way that does not compromise the interests of the infants.

Religions can be flexible. Religious practices have been adapted in other cases. Circumcision is a challenge to modern religion to embrace modern medicine and surgery to protect the child.

There is one objection to circumcision which is common in folk debate but which should be dismissed. Some people would object that the removal of the foreskin is ‘not natural’ and just because of this it should not be performed on a child. This kind of naturalistic objection dominates discussion of bodily modification and enhancement in general.

Medicine, of course, is not natural. Vaccination is not natural. Pain relief is not natural. In both these cases, some religious fundamentalists objected on the grounds that vaccination and pain relief in labour thwarted God's will. Thankfully, such arguments are no longer popular today. We have embraced many non-natural medical interventions which are not aimed at treating diseases, such as contraception, abortion and cosmetic surgery. The first two enhance reproductive freedom. Indeed, elective Caesarean section is not natural but is an increasingly attractive option for some women who believe that an elective Caeasarean will maximise the outcome of pregnancy for their baby and themselves.

Imagine a child was undergoing an abdominal surgical procedure for some pain. The surgeon inspects the appendix and it is normal. However, the surgeon decides to remove the healthy appendix anyway to prevent future appendicitis and because surgery was already in progress. Whether such a decision was right does not turn on whether natural bodily integrity is important to preserve, or whether there is some right to an appendix, but on the risks and benefits of removing a healthy appendix in this situation.

Circumcision is not natural. Whether any particular circumcision is in the interests of a child depends on the alternatives, and on the way it is performed and the situation in which it is performed. It is clear that the routine circumcision of male infants that is and was practiced in many parts of the developed world is no longer justified or necessary. However, the best practice should be for doctors to engage parents in a dialogue about the risks and benefits of circumcision, perhaps attempting to discourage it. But if parents are adamant, frequently for religious reasons, then the procedure should be performed by a surgical professional in a hospital environment where the risks are minimised.

In cases of controversial enhancement or bodily modifications, the best social policy is one of harm reduction, not prohibition.

Another objection stereotypical of the enhancement debate occurs in the male circumcision debate. Some claim that circumcision reduces sexual function, though others deny this. Thus, some objectors claim that the foreskin is necessary for optimal sexual functioning.

Let us assume that circumcision does reduce sexual sensitivity (though the evidence on this appears conflicting). It does not follow that the male foreskin is necessary for satisfactory sexual functioning. The possibility that circumcision is an enhancement implies that we, at some point, may be able to do better than nature, for example, by making the penis less likely to contract disease or more sensitive to stimulation. It is also possible that at some point in the future artificial foreskins may become available that mimic the natural variety in promoting sexual pleasure.

There are already attempts to replicate nature—there are artificial foreskins (eg, the SenSlip). It is only a matter of time before these are better than what nature provided. The results of nature are not the result of design (even religious fundamentalists agree with this in the case of the foreskin), but of blind evolutionary processes which enable survival and reproduction in a particular evolutionary niche. It is possible, in principle, to do better than the foreskin.

Finally, if the foreskin enhances sexual functioning, there might be opportunity for further compromise. Circumcisions can be comparatively ‘tight’ or ‘loose’. Loose circumcisions preserve some of the rolling action in the prepuce that acts as a natural lubricant. One form of harm minimisation that could respect religious liberties while reducing loss in sexual function would be to try to ensure all circumcisions are loosei.

Dialogue and compromise may be preferable to extremist positions such as zero-tolerance prohibition and laissez-faire.

Postscript: possible interventions

Michael Glass posted a very constructive response to a blog I wrote on this topic which engendered lively debate. He suggests useful practical interventions. I reproduce them here in his own words as I cannot express them better than he has: First, the forced circumcision of men has been documented in many contexts, including Ambon, Indonesia in 2001, South Africa, Kenya and other places.3–6 I believe that the best way to stop forced circumcision is to treat it as a sexual assault, and brand the assailants as sexual offenders. This is a powerful way of stigmatising the aggressors. Secondly, circumcision is very risky if it is done by incompetent surgeons, or if it is done in unhygienic surroundings or by unqualified people. Despite this, there appear to be no laws that would prohibit unqualified people from circumcising others. Take the case of Omunnakwe Amechi in London. He successfully argued that there were no formal rules governing circumcision and it was not regulated by the General Medical Council or anyone else.7 It is outrageous that someone can walk in off the street and circumcise people without any qualifications. Thirdly, not all parents agree on circumcision. Take this recommendation that circumcision “should not be performed in the face of parental disagreement.”8 This should be enacted into law. Fourthly, there should be firm rules to ensure that every baby to be circumcised must be medically examined by an independent doctor and a circumcision must not go ahead unless the doctor has given written advice that the child was strong enough to withstand the surgery and is free of any contra-indications like haemophilia or a genital anomaly that would make the procedure inadvisable. Fifthly, if a circumciser does the job badly, he or she should be prohibited from doing circumcisions. See the cases of Drs Aladdin Mattar (1997)9 and Suman Sood (2006)10 in Australia,11 a New Zealand case12 a recent British case.13 These and other rules won't stop circumcisions from being performed but will help to minimise the harm that is done.14

For a full discussion, see ‘Male Circumcision and the Enhancement Debate: Harm reduction Not Prohibition’ and related comments in the blog Practical Ethics in the News.15

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • i Thanks to Bennett Foddy for this point.

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