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The Bioethics of the Circumcision of Male Children



Summary

Human rights. International human rights law has profoundly transformed medical ethics.4 7 11 14 15 20 22 23 40 41 50 52 57 66 67 73 74 78 This page, therefore, indexes human rights instruments in addition to medical ethics documents. The Physician's Oath of the World Medical Association requires doctors to use their medical knowlege in compliance with "the laws of humanity."4 The codes of medical ethics of Australia,22 Canada,23 Norway,40 and the United States42 all require doctors to respect the human rights of patients. The United Kingdom makes respect for the human rights of patients a legal requirement by the Human Rights Act 1998.52 74 Children enjoy certain human rights (including the right to special protection) under general human rights instruments.61 72 They also enjoy additional protections under special instruments related to childhood.62  65 See Attorneys for the Rights of the Child for a table of human rights that are violated by circumcision of male children. The UN Commission on the former Yugoslavia defines circumcision as sexual assault and a human rights violation.69 In Article 24.3 of the Convention on the Rights of the Child65 the phrase, "traditional procedures prejudicial to the health of children," refers to the practice of circumcision. The circumcision of male children, therefore, violates numerous provisions of various international human rights instruments,67 72 75 and must be considered unethical medical practice. Doctors Opposing Circumcision has released a detailed report on human rights and the circumcision of children.79

Cruel and degrading treatment. Cruel and degrading treatment is a violation of human rights.52 56 64 64 76 Circumcision is a cruel and degrading treatment because it degrades the appearance and function of the male sex organ by removing large amounts of healthy functional protective erogenous tissue. Doctors should not participate in cruel or degrading treatment.10 22 Doctors should report incidents of cruel or degrading treatment or torture to their professional association or their supervisor, if possible, or to an international human rights organization.26

Informed consent. Doctors must respect a patient's autonomy.36 Consent must be obtained for a surgical procedure prior to its performance or the procedure is classified as battery.24 Valid consent may only be given by a fully informed person.25 36 49 The person must possess the capacity to make the decision.27 36 Consent must be voluntary and not coerced.28 36 Medical ethics requires doctors provide all material information to patients or their proxy representatives prior to obtaining consent for a surgical procedure.19 25 29 Information must also be provided for alternative treatments, including the choice of no treatment.19 29 36 41 Non-circumcision is a viable and reasonable alternative, so the attending physician must also provide full information regarding non-circumcision.48 When the patient is legally incompetent, a proxy representative must be found to grant permission for investigation and treatment on his/her behalf.19 27 36

Consent for adults Competent adult patients have very broad powers to consent that extend even to excision of functional body parts. Patients must be provided with all material information about circumcision and also about alternatives to circumcision.25 48 Information provided to the patient should include full information on the expected and probable losses of sexual function and sensation associated with male circumcision.37 44 47 55 57

Consent for Children. Children are separate persons from their parents and possess a separate set of legal rights.27 Parent's rights cannot override child's rights.53 54 Children are legally incompetent persons so parents usually grant informed permission for diagnosis and treatment on behalf of children.19 35 48 When parents bring a child to a doctor, it is the child who is the patient and not the parents.18 19 30 The doctor's responsibilities are to his child-patient and to no one else.4 18 19 52 The doctor's responsibility to the child-patient is paramount.42 52 When parents decide about treatment for a child, that decision must be made in the child's best interests.19 30 34 35 38 52 53 Children must be involved in the decision.15 18 19 23 30 52 Non-essential procedures should be delayed until the the child is mature enough to decide.19 52 Moreover, parental power to grant permission for treatment is less extensive than if the parent was granting permission for his or her own treatment.19 52 Parents may only grant permission for diagnosis and treatment of disease.19 35

Consent for child circumcision. The current practice of the medical community is to obtain permission from a parent for circumcision of a child. (In the United Kingdom and British Columbia the permission of both parents is required.)52 53

The medical community has long based this protocol for obtaining consent on the assumption that a parent may legitimately give consent to the non-therapeutic circumcision of a child. There is, however, no basis in law to support this assumption. A male neonatal circumcision is neither a diagnostic procedure nor a treatment of a disease.19 36 Thus non-therapeutic circumcision is, in effect, an act of battery. No parent can grant consent for an act of battery. By this reasoning, "parental consent" for a non-therapeutic, non-diagnostic circumcision operation on a child appears to be invalid. However, a court decision would be necessary to resolve the question.

Further, it is not clear how medically unnecessary non-therapeutic circumcision can be in the best interest of any particular child. A court ruling in the United Kingdom held that a circumcision was not in the best interest of a particular child.52

The rules of the General Medical Council of the United Kingdom require that non-therapeutic or controversial surgery be done only with the consent of a court.36

Inappropriate procedures. Children have a right to be protected from unnecessary procedures.15 Parental wishes are not the determining factor.19 35 52 53 Doctors have no obligation to perform inappropriate procedures upon patients.34 46 52 53 Doctors should refuse to perform unnecessary non-therapeutic circumcisions.34 46

Putting the patient's needs first and above all other considerations. Most codes of medical ethics require the attending physician to put the patient's needs first. The patient's health must be the doctor's "first consideration."4 The doctor owes the patient "complete loyalty."5 Pediatric health care providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses.19 The doctor's responsibilities to his or her patient exist independent of parental desires or proxy consent.19 The doctor must "consider first the well-being of the patient."23 "A physician shall, while caring for a patient, regard responsibility to the patient as paramount."42 When parents present a child for circumcision, the doctor's responsibilities are to that child and not to the parents.19 He must put the child's needs above the desires of the parents. Circumcision may be carried out only if it is in the "best interests" of the child.52 53 The doctor has the independent responsibility of making a determination whether or not circumcision is in the best interests of a child.52 53 The burden of proof that non-therapeutic circumcision is in the child's best interests is on the parents desiring the circumcision.52 When a non-therapeutic circumcision is carried out simply at parental request, the doctor may unethically be placing parental desires above the needs of the child.35 The doctor may also unethically consider the receipt of a fee, and may place that consideration above the child's needs, although a doctor must not exploit his patient for profit or financial reasons.11 22 (The primary beneficiary of circumcision is the medical community. Doctors get an estimated US$200 million+ in fees for the 1,100,000+ circumcisions performed annually in the United States, while hospitals get an estimated US$500 million+ due to longer hospital stays for both mother and baby when a circumcision is performed.)

Opinions of bioethicists. Non-therapeutic circumcision of male children, although still common in the United States, and to a much lesser degree in Australia and Canada, now is viewed by ethicists as an unethical procedure.16 31 39 43 45 49 54 56 In addition, international organizations have adopted resolutions affirming the right of the child to bodily integrity.14 70

Pain relief. Circumcision is an inherently painful procedure. Contemporary medical ethics requires that anesthesia/analgesia be provided for painful procedures on children.12 17 52 53 Provision of pain relief, however, cannot make an unethical procedure ethical.

Proposed standards. Hodges and associates45 propose the following requirements for ethical prophylactic medical interventions on children:

  1. Clinically verifiable disease, deformity, or injury are present or are highly likely to be present in the future.
  2. The proposed intervention must be the least invasive and most conservative treatment option.
  3. Despite any harm that may be foreseen, there must be a reasonable expectation that the procedure will result in a net benefit to the patient while having at most a minimal negative impact on the patient's health.
  4. The patient is competent to consent to the procedure and provides fully informed consent. Where a patient cannot provide informed consent, the procedure must be required by medical urgency, thereby excusing a lack of consent. Since reasonable and competent adults would normally refuse to give consent to medically unnecessary interventions (especially those that alter normal appearance and/or function), it must be assumed that children would also refuse if they had the capacity to understand their situation, formulate their wishes, and express them.
  5. The intervention is part of standard practice, and its imposition is sanctioned by society for valid, urgent, and potentially calamitous health reasons that justify failure to obtain individual consent.
  6. There is also a reasonable expectation that without the intervention the individual will be at high risk of developing the disease. A high risk for an untreated individual is not defined as a higher risk than a treated individual but an absolute vulnerability to disease-that is, an individual's chance of ever being diagnosed with the disease is close to 1 in 1. To put this in perspective, an American woman's chance of being diagnosed with breast cancer is 1 in 8 (12.6%), yet this figure is not said to justify prophylactic intervention-that is, routine neonatal mastectomy.

Non-therapeutic circumcision of male or female children would not satisfy these criteria.45

Proportionality. One bioethics authority defines proportionality as follows:

The well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology. Therapeutic procedures that are likely to cause harm or undesirable side-effects can be justified only by a proportionate benefit to the patient.51

Circumcision of male infants fails the test of proportionality because the non-existent therapeutic benefit is overbalanced by the certainty of permanent injury to the penis, to loss of protective, immunological, mechanical, sensory, erogenous, and sexual functions, as well as the risk to health and life inherent in every circumcision.

Recent developments. A group of doctors who oppose the practice of circumcision argue that the present Circumcision Policy Statement of the American Academy of Pediatrics compromises medical ethics in order to support the continued practice of male neonatal circumcision.50 The matter of male circumcision is pending before the United Nations Human Rights Commission.75

Ethical Principles. The four recognized principles that guide medical ethics are:

Non-therapeutic circumcision of children by medical personnel must be measured against these four principles. Circumcision fails all four principles because:

  1. Non-therapeutic circumcision of male children fails the test of beneficence because it lacks a proven documented benefit.45 46 53
  2. Non-therapeutic circumcision of male children fails the test of non-maleficence because it inflicts bodily injury and pain to the patient by surgically excising healthy functional tissue.31 53 56
  3. Non-therapeutic circumcision of male children fails the test of justice because it violates the patient's legal right to bodily integrity.31 54
  4. Non-therapeutic circumcision of male children fails the test of autonomy because consent must be given by a proxy.31 42

Europe. The European Convention on Human Rights and Biomedicine (1997) is an instrument of international law.73 Twenty-one European nations now have become "states-party" to this treaty.77 It has been in effect since 1 December 1999. The circumcision of male children appears to violate Articles 1, 2, and 20 of this convention.73 The Charter of Fundamental Rights of the European Union (2000) recognizes rights to freedom from cruel and degrading treatment, to right to respect for his or her physical and mental integrity, and the right to the security of the person.76 Children shall have the right to such protection and care as is necessary for their well-being.76 Circumcision of infants and children is incompatible wth this provision.

United Nations Educational, Scientific, and Cultural Organization (UNESCO). UNESCO has had an active bioethics programme since 1993. UNESCO claims to have 36 bioethics experts on staff. UNESCO seeks "to define and promote a common ethical standard-setting framework that States can use in formulating and putting into practice their own policies in the field of bioethics." The UNESCO General Conference adopted the Universal Declaration on Bioethics and Human Rights on 19 October 2005.

Article 8 provides:

In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected. 78

Children are vulnerable individuals so doctors have a duty under the Declaration to respect their personal integrity. Non-therapeutic circumcision of infants and children is offensive to this provision.



Council of Europe. On 27 June 2013, the Committee on Social Affairs, Health and Sustainable Development of the Parliamentary Assembly of the Council of Europe issued a committee report on the need for protection of the physical integrity of children, which was published on 6 September 2013.80 The Parliamentary Assembly of the Council of Europe, meeting at Strasbourg on 1 October 2013, adopted a resolution concerning the protection of the physical integrity of children81 and then a recommendation82 to the parliaments of the European nations regarding the human rights violations inherent in the circumcision of male children.

Library Holdings

Holdings are indexed in chronological order

Medical Ethics

  1. Hippocrates. Oath of Hippocrates (circa 400 B.C.). In: Harvard Classics. Boston: P. F. Collier & Son, 1910.
  2. Anonymous. Clitoridectomy and Medical Ethics. Medical Times and Gazette (London) 1867:(1):391-2.
  3. War Crimes Tribunal. Nuremberg Code (1947)
  4. World Medical Association. Declaration of Geneva: A physician's oath (1948).
  5. World Medical Association. Declaration of London: International Code of Medical Ethics (1949).
  6. World Medical Association. Declaration of Helsinki (1964).
  7. World Medical Assembly. Declaration of Tokyo: Guidelines for Medical Doctors concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in relation to Detention and Imprisonment. (1975)
  8. Council on Ethical and Judicial Affairs. Principles of Medical Ethics. Chicago: American Medical Association (1980)
  9. Paediatric Services Committee. Newborn Circumcision of Males. New South Wales Health Department. (1982)
  10. UN Principles of Medical Ethics (1982)
  11. Australian College of Paediatrics. Policy Statement on Circumcision. Parkville, Vic. (1983).
  12. Fletcher AB. Pain in the Neonate (Editorial) N Engl J Med 1987; 317(21):1347-48.
  13. Committee on Bioethics. American Academy of Pediatrics. Religious Exemptions from Child Abuse Statutes (1988) (Protection of child from parent's religious requirements.) Pediatrics 1988:
  14. Declaration of the First International Symposium on Circumcision. Adopted by the First International Symposium on Circumcision, Anaheim, California, March 3, 1989.
  15. Alderson P. European Charter of Children's Rights 1993;October:13-15.
  16. Kluge E. Female circumcision: When medical ethics confronts cultural values. Can Med Assoc J 1993:148(2);288-9.
  17. Walco GA, Cassidy RC, Schechter NL. The ethics of pain control in infants and children. N Engl J Med 1994; 331 (8): 541-544.
  18. Shield JPH, Baum JD. Children's consent to treatment. BMJ 1994;308:1182-83.
  19. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-317.
  20. Warren J, Smith FD, Dalton JD, et al. Circumcision of children. BMJ 1996; 312: 377.
  21. Denniston GC. Circumcision and the code of ethics. Humane Health Care International 1996;12(2):78-80.
  22. Australian Medical Association. Code of Ethics. (2004)
  23. Canadian Medical Association. Code of Ethics. Can Med Assoc J 1996;155:1176A-1176B.
  24. Etchells E, Sharpe G, Walsh P, et al. Bioethics for Clinicians: 1. Consent Can Med Assoc J 1996;155:177-80.
  25. Etchells E, Sharpe G, Burgess MM, et al. Bioethics for Clinicians: 2. Disclosure. Can Med Assoc J 1996;155:387-91.
  26. Amnesty International. Declaration on the Role of Health Professionals in the Exposure of Torture and Ill-treatment. (1996)
  27. Etchells E, Sharpe G, Elliot C, Singer PA. Bioethics for Clinicians: 3. Capacity. Can Med Assoc J 1996; 155:657-661.
  28. Etchells E, Sharpe G, Dykeman ML, et al. Bioethics for clinicians: 4. Voluntariness. Can Med Assoc J 1996; 155:1083-1086.
  29. Lazar MN, Greiner GG, Robertson G, Singer PA. Bioethics for clinicians: 5. Substitute decision-making. Can Med Assoc J 1996;155:1435-7.
  30. Harrison C, Kenny NP, Sidarous M, Rowell M. Bioethics for clinicians: 9. Involving children in medical decisions. CMAJ 1997;156:825-8.
  31. Price C. Male Circumcision: an ethical and legal affront. Bulletin of Medical Ethics (May) 1997;128:13-19.
  32. Dalton J. Circumcision: Is the GMC wrong? GP   1997; 27 June:44.
  33. Committee on Bioethics, American Academy of Pediatrics. Religious objections to medical care. Pediatrics 1997; 99(2):279-281.
  34. Weijer C, Singer PA, Dickens BM, Workman S. Bioethics for clinicians: 16. Dealing with demands for inappropriate treatment. CMAJ 1998;159:817-21.
  35. Wilks M. Parental wishes are not the determining factor. BMA News Review, London, 12 September 1998.
  36. Seeking Patients Consent: The Ethical Considerations. London: General Medical Council, 1998.
  37. Holman JR, Stuessi KA. Adult circumcision. American Family Physician 1999;59(6:):1514-8.
  38. Bioethics Committee Reference B86-01: Treatment Decisions for Infants and Children. Ottawa: Canadian Paediatric Society, March 2000.
  39. Margaret Somerville. Altering baby boys' bodies: the ethics of infant male circumcision In: Margaret A. Somerville. The Ethical Canary: Science, Society and the Human Spirit. Toronto: Viking, 2000. (ISBN 0-670-89302-1)
  40. Code of Ethics for Doctors. The Norwegian Medical Association. Adopted by the Representative Body in 1961 and subsequently amended, most recently in 2000.
  41. Clare Dyer. Guide to ethics of treating children published. BMJ 2000;321:1491.
  42. Council on Ethical and Judicial Affairs. Principles of Medical Ethics. Chicago: American Medical Association (2001)
  43. Gulbrandsen P. Rituell omskjæring av gutter. [Ritual circumcision of boys.] Tidsskr Nor Lægeforen [Journal of the Norwegian Medical Association] 2001;121(25):2994.
  44. Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol 2001;166(6):2273-6.
  45. Hodges FM, Svoboda JS, Van Howe RS. Prophylactic interventions on children: balancing human rights with public health. J Med Ethics 2002;28(1):10-16.
  46. Kendel, D. A. Caution Against Routine Circumcision of Newborn Male Infants (Memorandum to physicians and surgeons of Saskatchewan). Saskatoon: College of Physicians and Surgeons of Saskatchewan, February 20, 2002. Photocopy.
  47. Fink KS, Carson CC, DeVellis RF. Adult Circumcision Outcomes Study: Effect on Erectile Function, Penile Sensitivity, Sexual Activity and Satisfaction. J Urol 2002;167(5):2113-6.
  48. Hill G. Informed consent for circumcision. South Med J 2002;95(8):946.
  49. Canning DA. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Urol 2002;168 (4 Pt 1): 1650-1.
  50. Denniston GD. Letter to the President of the American Academy of Pediatrics. October 15, 2002.
  51. Conference of Catholic Bishops. Ethical and religious directives for Catholic health care services, 4th ed. Washington: United States Conference of Catholic Bishops, 2001.
  52. Committee on Medical Ethics. The law and ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003.
  53. College of Physicians and Surgeons of British Columbia. Policy Manual: Infant Male Circumcision. Vancouver, BC: College of Physicians and Surgeons of British Columbia, 2004.
  54. Hellsten SK. Rationalising circumcision: from tradition to fashion, from public health to individual freedom—critical notes on cultural persistence of the practice of genital mutilation. J Med Ethics 2004;30:248-53.
  55. Denniston GC, Hill G. Circumcision in adults: effect on sexual function. Urology 2004;64(6);1267.
  56. Fox M, Thomson M. A covenant with the status quo? Male circumcision and the new BMA guidance to doctors. J Med Ethics 2005;31(8):463-9.
  57. Masood S, Patel HRH, Himpson RC, et al. Penile sensitivity and sexual satisfaction after circumcision: Are we informing men correctly? Urol Int 2005;75(1):62-5.
  58. Medical Ethics and the Circumcision of Children. Seattle: Doctors Opposing Circumcision, 2006.
  59. Clark PA. To circumcise or not to circumcise?: a Catholic ethicist argues that the practice is not in the best interest of male infants. Health Prog 2006;87(5):30-9.

Human Rights

  1. San Francisco Conference. Charter of the United Nations (1945).



  2. United Nations General Assembly. Universal Declaration of Human Rights (1948).



  3. United Nations General Assembly. Declaration of the Rights of the Child (1959).



  4. United Nations General Assembly. Covenant on Civil and Political Rights (1966).



  5. United Nations General Assembly. Declaration on Torture (1975)



  6. United Nations General Assembly. Convention on the Rights of the Child (1989).



  7. Institute of Medical Ethics. Briefings in Medical Ethics No. 9: The UN Convention on the Rights of the Child. J Med Ethics 1991;17:1-4.



  8. Milos MF. Macris D. Circumcision: A Medical or Human Rights Issue J Nurse-Midwifery 1992:37(2) Suppl.



  9. Haggerty RJ. Convention on the Rights of the Child: It's Time for the United States to Ratify. Pediatrics 1994;94(5):746-7.



  10. United Nations Security Council. Commission of Experts' Final Report [on the Former Yugoslavia] (S/1994/674, part IV, section F).



  11. Lansdown G. Waterston T, Baum B. Implementing the UN Convention on the Rights of the Child. BMJ 1996;313(7072):1565-6.



  12. Valencia Declaration on Sexual Rights. Adopted by the XIII World Congress on Sexology, Valencia, Spain, June 1997.



  13. Jacqueline Smith. Male Circumcision and the Rights of the Child. In: Mielle Bulterman, Aart Hendriks and Jacqueline Smith (Eds.), To Baehr in Our Minds: Essays in Human Rights from the Heart of the Netherlands (SIM Special No. 21). Netherlands Institute of Human Rights (SIM), University of Utrecht, Utrecht, Netherlands, 1998: pp. 465-498.



  14. European Convention on Human Rights and Biomedicine (1997). Adopted at Oviedo, 4 April 1997.



  15. Committee on Medical Ethics, British Medical Association. The impact of the Human Rights Act 1998 on medical decision making. London: British Medical Association, 2000.






  16. Arif Bhimji, M.D. Infant Male Circumcision: A violation of the Canadian Charter of Rights and Freedoms. Heath Care Law (Toronto) 2000:January 1;1-22.



  17. Charter of Fundamental Rights of the European Union. Proclaimed at Nice, 7 December 2000.


  18. Written statement* submitted by the National Organization of Circumcision Information Resource Centers (NOCIRC), a non-governmental organization on the Roster, Commission on Human Rights, Sub-Commission on the Promotion and Protection of Human Rights, Fifty-fourth session, Item 6 (c) of the provisional agenda, E/CN.4/Sub.2/2002/NGO/1, 23 March 2002.









  19. UNESCO. Universal Declaration on Bioethics and Human Rights. Adopted by the UNESCO General Conference, 19 October 2005.





  20. International Human Rights Law and the Circumcision of Children. Seattle: Doctors Opposing Circumcision, 2006.


  21. Committee on Social Affairs, Health and Sustainable Development. Children's Right to Physical Integrity, Doc. 13297. Parliamentary Assembly of the Council of Europe, 6 September 2013.

  22. Parliamentary Assembly, Council of Europe. Children's Right to Physical Integrity, Resolution 1952., Adopted Tuesday, 1 October 2013.

  23. Parliamentary Assembly, Council of Europe. Children's Right to Physical Integrity, Recommendation 2023. Adopted Tuesday, 1 October 2013.

(File revised 7 October 2013)

http://www.cirp.org/library/ethics/