Is Circumcision Research Ethical?

The New England Journal of Medicine, Volume 337: Page 568, 21 August 1997.

Correspondence

Lidocaine-Prilocaine Cream for Pain during Circumcision

To the Editor: The study by Taddio et al. (April 24 issue)¹ raises several troubling questions. First, if neonatal circumcision is not undertaken for medical reasons, is it ethical to conduct medical research on it? In the vast majority of cases, circumcision is done for religious or cultural reasons. The Canadian Paediatric Society reviewed the literature extensively and concluded that any small medical benefits do not outweigh the risks and that neonatal circumcision should not be routinely performed.² Moreover, neonatal circumcision is done without the consent of the subject, removes healthy tissue with a unique anatomical structure and function, and leads to differences is adult sexual behavior.³

Circumcision can be deeply connected with religious belief, and any interference with this requires profound consideration and justification. We need, therefore, to address the issue directly and end the persistent effort to find a medical rationale for circumcision by removing the cloak of medicine from this procedure. Should nonmedical infant circumcision or research involving it be carried out, and if so, should it be conducted by physicians, and under what conditions?

Second, assuming that is was ethically acceptable for Taddio et al. to undertake this study, was it ethical for them to include in it a group of infants circumcised without anesthesia? Generally accepted principles governing the ethics of research require clinical equipoise⁴ – that is, before a randomized trial can be undertaken, the generally accepted medical opinion must be that no one treatment is superior to another, and the researchers must share this opinion. In this case, was there clinical equipoise at the outset of the study?

MARGARET A. SOMERVILLE, F.R.S.C., LL.D.
McGill Centre for Medicine, Ethics, and Law
Montreal, QC H3A 1W9, Canada

DAVID M. ALWIN, M.D.
St. Mary's Hospital
Montreal, QC H3T 1M5, Canada

References

Taddio A. Stevens B, Craig K, et. al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med 1997;336:1197-201. [Abstract]
Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996; 154:769-80.
Laumann EO, Masi CM, Zuckermann EW. Circumcision in the United States: prevalence prophylactic effects, and sexual practice. JAMA 1997;277:1052-7.
Freedman B. Equipoise and the ethics of clinical research. N Engl J Med 1987;317:141-5. [Abstract]

Citation:

Somerville, MA, Alwin DM. Lidocaine-Prilocaine Cream for Pain During Circumcision (Letter). N Engl J Med 1997;337:568.

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