Letter to North Dakota Board of Medical Examiners

 

North Dakota Board of Medical Examiners
Rhonda Ketterling, MD, Chair
418 East Broadway, Suite C10
Bismarck, ND 58501

To the North Dakota Board of Medical Examiners
                         and the Commission on Medical Competency:

We place the following Accusation before the Board: Routine infant
circumcisers (if individuals need be cited: Roger Allen, MD and Manuel
Neto, MD, Minot) are practicing quack medicine, namely, a pattern of
inappropriate and fraudulent care.

Request: that the NDBME discipline circumcisers (namely, Roger Allen, MD
and Manuel Neto, MD, Minot) for practicing quackery (request made under
NDCC 43-17.1-05: "All residents have the right to make or refer complaints
to the commission...").

Accusation's Legal Basis: NDCC 43-17.1-07 (Sec. 4) and 43-17-31 (Sec. 6 and 7):
        "The board of medical examiners may revoke or suspend a physician's
license to practice medicine in this state or may attach conditions or
restrictions thereto on any one or more of the following grounds:... 4. A
continued pattern of inappropriate care, including unnecessary surgery, in
the performance of his duties as a physician." (emphasis added)
        "The board may refuse to grant a license to practice medicine in
this state or may suspend or revoke such license...upon any of the
following grounds:... 6. The performance of any dishonorable, unethical, or
unprofessional conduct likely to deceive, defraud, or harm the public.  7.
The use of any false or fraudulent statement in any document connected with
the practice of medicine." (emphasis added)

Basis for Board's Authority and Need for Action: A. Michael Booth, MD, PhD,
in testimony, 2/13/95, that helped defeat ND HB 1381 (1 endnote) argued
this Bill would "cripple the State Board of Medical Examiners" by
restricting its ability to "act against a physician by suspending or
revoking his or her license on the simple finding of a continued pattern (2
endnote) of inappropriate care." (3 endnote)

We must assume Dr. Booth, as a member of NDMA and its Commission on
Legislative Affairs, and as President of the ND Chapter of the American
College of Surgeons, has a good sense for the powers of the NDBME. One of
these is the power to determine what "appropriate care" means.

Dr. Booth pointed out that quackery is inappropriate care. He quoted the
U.S. Congress Select Committee on Aging's definition of a "quack" in its
1984 report on quackery. A quack is "anyone who promotes medical schemes or
remedies known to be false, or which are unproven, for profit." (emphasis
added) He pointed out North Dakota has not been free of quacks, but "the
Board has acted appropriately to remove them." This is fortunate, according
to Booth, or the expected and needed trust in physicians would have been
seriously eroded. "Indeed, had the Board failed to act, the public would
have had every reason to believe that the relationship of trust between
patient and physician had been knowingly violated." (emphasis added)

Dr. Booth pointed out that "These practitioners of quack medicine [have]
always been difficult to deal with." They are successful
        (a) because of their ability to "take a bit of scientific fact and
then extrapolate [it] to incredible proportions to justify the use of their
therapy, oftentimes ignoring the very real toxic potential that their
treatments involve..." and
        (b) because "too often, the victims of these practitioners fail to
take action, out of embarrassment...."

Summary of Accusation

A. Circumcision is quack medicine. Routine infant circumcision meets every
definition of "quack medicine" and is, therefore, "inappropriate care." It
is:
        (1)  based on "a bit of scientific fact" which is "extrapolate[d]
to incredible proportions to justify the use of their therapy, oftentimes
ignoring the very real toxic potential that their treatments involve...."
When all the evidence is examined, it is seen to be physically and
psychologically harmful to the infant, his parents and society at large.
        (2)  fraudulent since the circumciser fails to provide full
information, either from lack of knowledge or deliberate misrepresentation.
        (3)  at least a quarter billion dollar business in the U.S.
        (4)  a subject that embarrasses people, so corrective action is not
taken.

B. Circumcision violates human rights. Infant circumcision, however, is
more than just the usual form of quack medicine. Circumcision does not just
defraud the person who is persuaded by misleading information to consent to
the procedure for him or herself. The patient, in this case, has no say at
all. The amputation is forced upon a completely non-consenting individual.
No one has the right to unnecessarily alter an infant's physical integrity.


Supporting Arguments for Accusations

A (cont.): Support for Statements that
Circumcision is Quack Medicine:

Support for point (1)-Harmful, not beneficial, care based on inadequate
evidence:

Published studies, considering all the known so-called physiological and
cost benefits, show no positive balance of actual benefit can be
determined, even when these studies ignore the negative weight of
psychological damage and human rights violations. (4 endnote)

For example, in an article in Family Medicine, "Circumcision: A Decision
Analysis of its Medical Value," Oct-Dec 1991, Dr. Lawler writes, "We
conclude there is no medical indication for or against circumcision. The
decision may most reasonably be made on non-medical factors such as parent
preference."
        We would like to suggest that the child's preference is the only
one that counts.

In another article in Medical Decision Making, Oct-Dec 1991, Dr. Ganiats
states: "Circumcision has essentially no effect on either dollar costs or
health. For this reason, personal factors could justly be brought into the
decision process."
        Even though those doing these studies have not faced the human
rights issue, nor long-term psychological or sexual effects, they make
clear, that circumcision is not a procedure to be justified on medical
grounds.

Thomas Wiswell's urinary tract infection studies is a typical example of
those who take "a bit of scientific fact and then extrapolate to incredible
proportions to justify the use of their therapy." He even claims God made a
mistake providing men with this erotic and protective tissue. One has to
circumcise 99 infants to prevent one UTI, even if Wiswell's retrospective
study on military babies is accurate, which other researchers question
because catherization was used to gather urine samples and may have
contaminated them, and because of invalid statistical analyses. Girls are
four times as prone to UTIs as boys in any case.

100,000 infants must be circumcised to prevent one penile cancer. Who
explains to parents that more infants die of circumcision complications in
the U.S. than older men are saved from penile cancer (about 200)? We still
hear about the cervical cancer study--proved invalid decades ago. This is
just some of the persistent misleading information the quacks dispense or
fail to correct. Their approach allows them to hood-wink a trusting public
into a procedure with "very real toxic potential."

In fact, all national and international healthcare and medical
organizations, including the American College of Obstetricians and
Gynecologists and the American Academy of Pediatrics, say these amputations
are not medically necessary. How can they, therefore, be defined as
"preventive medicine" when imposed upon a non-consenting person? They are
unnecessary surgeries, and as such must be censored by Board action
pursuant to NDCC 43-17.1-07 (Sec. 4).

Surgical amputation of normal tissue can only be called "mutilation."
Perhaps we do have a right to mutilate ourselves, but not others. As Ron
Miller, MD, Fargo, says, "What risk is acceptable when one is tampering
with something that is normal?" The following is a list of a few more North
Dakota people and organizations that have recognized the non-necessary
nature of routine infant circumcision: (5 endnote)

* Rhonda Ketterling, MD, Chair, ND Board of Medical Examiners, Medical
Director for U.S. Healthcare, Bismarck, and practicing physician, Rugby.
* Arlene Mack, RN, Vice President, Medcenter One, Support Services
(speaking for Medcenter One, she said their physicians have agreed not to
recommend circumcisions and will explain the risks).
* Shari Orser, MD, Chair, Department of Ob/Gyn, Medcenter One, Bismarck.
* Robert Wentz, MD, pediatrician, former ND State Health Officer, now
Deputy Insurance Commissioner.
* Jon Rice, MD, ND State Health Officer.
* Sister Mary Margaret Mooney, PBVM, RN, Professor and Chair, Department of
Nursing, University of Mary.
* Gladys Cairns, Director, ND Child Protective Services and Chair of the
Alliance for Sexual Abuse Prevention and Treatment.
* Craig Shoemaker, MD, Director of Neonatal Services and Chair, Department
of Pediatrics, Fargo Clinic MeritCare.
* Ron H. Miller, MD, pediatrician, Fargo Clinic MeritCare.
* Alan Lindemann, MD, Ob/Gyn, Fargo.
* Thomas W. Mausbach, MD, former President, ND Chapter of the American
Academy of Pediatrics (in a letter to the NDBME).
* Charles Severn, MD, Chair, Department of Neonatology, St. Alexius Medical
Center, Bismarck.
* Connie Kalanek, MSN, RNC, Associate Professor, Medcenter One College of
Nursing.
* Robert Roswick, MD, and Jeffrey Smith, MD, Family Medical Center, Bismarck.
* Judy Haynes, PhD, UND Counseling Center and clinical psychologist, Grand
Forks.
* Robert Pathroff, MD, urologist, Bismarck.
* Roger Allen, MD, neonatologist, Minot.
* BlueCross BlueShield of North Dakota.
* Medicaid (does not pay for this unnecessary surgery).

Even Roger Allen, MD, Minot, cited above as being a circumciser, said
parents make up their minds about circumcision, not on any scientific or
medical basis, but on emotion, one of the hallmarks of quackery. In a
television interview (KMOT, 11/92) he said "There is no compelling reason
to do a circumcision, but on the other hand, there is no compelling reason
not to." The only adequate response to such a self-serving statement was
made by Janet Wentz, North Dakota Republican Legislator, "If there is no
compelling reason to do a circumcision, that is a compelling reason not to
do one." This, we hope, will be the appropriate response of the NDBME.

Since science, not custom, must be the final arbiter of appropriateness for
procedures forced upon non-consenting individuals, circumcisers must
scientifically justify their practice, or it simply stands as a quack
procedure. We ask you, where are the studies to justify this painful,
disfiguring and sexually de-sensitizing practice?

Support for point (2)-Fraudulent or incompetent practitioners and practices:

Perhaps there are circumcisers who do not know the facts. But ignorance can
no longer justify the continuation of this practice. It certainly cannot be
a basis for not censoring them. It is a reason that makes Board action more
imperative, since well-meaning practitioners, who believe in their own
quack procedures, may work their damage even more insidiously on society.

The prestige of the medical profession is truly at stake here. Numerous and
angry people can be brought before the Commission to testify to how little
information they were given, or how misleading it was, before giving
uninformed consent to maim their sons. They know they were defrauded, and
some are even looking into law suits. Some did not provide written consent
to the unnecessary surgery.

Support for point (3)-Financially self-serving at amputee's expense:

Journals providing medical statistics use the quarter billion dollar
figure. It does not include the multi-million dollar law suits arising out
of "botched jobs" nor the reconstructive costs to the 1 in 500 which are
seriously botched, according the American Academy of Pediatrics. (6
endnote) Of course, any unnecessary amputation is a "botched job," as so
well put by the obstetric nursing staff at St. Vincent Hospital, Sante Fe,
NM, who refuse to participate in the procedure. Their conscientious
objector status has just been negotiated into a legally binding agreement.

Support for point (4)-Embarrassment prevents exposure:

Discussion of genitals is taboo in our society. Acquiring and dispensing
accurate information on any taboo subject is difficult. Circumcisers, and
all quacks, profit from lack of exposure. The media has a hard time
providing information from fear of offending the public. Once someone has
been circumcised, has allowed it or done it, the ritualization of the act
often keeps one from publicly admitting a wrong. Passing an act on to the
next generation is often easier than admitting the act was wrongfully done
to oneself.

B (cont.): Support for Accusation that
Circumcision Violates Human Rights.

Parental rights do not extend to unnecessary genital amputations. Now, it
is true that "Parents, guardians, and custodians are authorized to consent
to healthcare on behalf of children" (NDCC Sec. 23-11-13, emphasis added),
but routine infant circumcision is not a healthcare issue. No study with
its "bit of scientific fact" (Booth) offered to support the purported
positive effects of prepuce amputation, has ever been able to establish
that the negative physiological effects are not more significant, not to
mention other physiological and psychological effects that result from
functioning with a violated body.

Historically, medical rationalizations are a recent approach used by
quacks. Except for the last hundred years in the U.S., circumcision has
never been done for health reasons. The appeal to scientific evidence to
justify it as a healthcare issue is major healthcare fraud. (7 endnote)
Since most men in the developed and underdeveloped countries of the world
are intact and do not have the dire problems circumcisers threaten will
occur, the procedure in the U.S. is obviously a non-medical ritual. This is
understood by many North Dakota physicians.

Medical ethics clearly requires physicians to decline to do follow a
parent's wish to alter a child surgically for non-medical reasons. The
physician is even required to  prevent others from doing so! (see NDCC
50-25.1-03-Persons required to report child abuse and neglect). No one in
our society can morally (and we believe, legally) alter another surgically
against his will for non-medical reasons, even if he is one's own son.
Property rights do not extend to one's son or daughter (8 endnote).

Sexism is inherent in the present practice. The physician's responsibility
to protect a helpless patient is recognized when it comes to all other
operations and for genital amputations on female children (9 endnote)
(which has now been formalized in ND SB2454, 1995) along with NDCC
50-25.1-03.

Summary and Request for Action

Information and testimony to support this allegation will be gladly
provided. (10 endnote) However, we ardently maintain the evidence is such,
despite the cultural conditioning and prevalence of prepucial amputations,
that circumcisers are the ones who must justify their actions to the Board
on sound medical and scientific evidence. They must prove routine infant
circumcision is in line with the physician's oath: First Do No Harm. This
justification must not be the little piece of scientific evidence that
quacks use. It must be the whole spectrum, including the physical injuries
and deaths as well the increasing evidence of negative long-term
psychological effects and diminishment of sexual function.

The citizens of North Dakota have a right to expect the Board is monitoring
and preventing unnecessary surgical procedures and fraudulent practices.
Amputations of healthy prepuces from non-consenting individuals is
unnecessary surgery, or more accurately, contraindicated, surgery. It harms
our children and violates their human rights. It is a practice
international community views as abhorrent as we do female genital
mutilations. Now that North Dakota is taking the lead nationally in
outlawing FGM, a move supported by the ND Medical Association, citizens and
legislators are asking why male circumcisers are allowed to traumatize our
male infants. They want to know why our appointed state officials and
medical associations do not advocate for protection of male infants.

Yet, with the recognition that in some way we are all victims of the
anti-masturbation hysteria which established the practice of routine infant
circumcision a hundred years ago, we ask not that circumcisers (namely,
Neto and Allen) be harshly disciplined for past acts, but we do ask the
Board to declare the procedure to be inappropriate care and to warn
potential circumcisers that future amputations of a healthy prepuces will
be treated by the Board for what they are: quack medicine.

If the Board or Commission does not declare routine infant circumcision to
be inappropriate care, the citizens of North Dakota deserve a point by
point explanation why not, giving scientific evidence to support the
points. We trust the Board will act to protect those who are too helpless
to protect themselves.

History will not be kind to us in our perpetuation and tolerance of this
grave violation of human rights and dignity.

Sincerely,



Duane Voskuil, PhD
Philosophy & Ethics
Bismarck State College


Enclosures:
"Quotations and Comments by Some North Dakotans"
"Circumcision as Child Abuse: The Legal and Constitutional Issues"
"A Review of Medical Literature." NOHARMM.
"Parents' Religion and Children's Welfare: Debunking the Doctrine of
Parents' Rights," California Law Review.
"Routine Neonatal Circumcision: An Update," Robert S.Van Howe, M.D. FAAP.

Endnotes:
 (1) Defeated HB 1381 read: "A physician's use of complementary or
alternative therapies does not constitute a continued pattern of
inappropriate care, unless there is demonstrable physical harm to
patients."

 (2) Ralph Kilzer, MD, in response to a question, 2/27/95, from the ND
House Human Services Committee as to why the state needed a bill outlawing
FGM when this seems like an issue the NDBME should be able to handle,
responded that the NDBME generally looks for a pattern of inappropriate
care, whereas one unnecessary amputation of normal female genital tissue
would be grounds for criminal action. He said "for normal tissue there is
no useful medical purpose for amputating [female?] genital tissue."
Circumcisers who do prepuce amputations routinely have such a pattern of
inappropriate care.

 (3)In this regard, the letter from the ND Commission on Medical Competency
to Ramona T. Goheen, 11/29/94,  responding to her complaint against Manuel
Neto's inappropriate handling of her son's genitals, fails once again to
address the real issue. Even if it were true that the Commission could,
somehow, find no law (such as battery) under which to discipline Neto for a
single act of forcibly separating the immature preputial tissue from the
glans (against the express wishes of Ms. Goheen) and recommending
circumcision for a child with hypospadias (contrary to textbook
recommendations), and doing so while saying it must be done so he doesn't
get picked on by other boys and so he will to do better in school, still
Neto has been following "a pattern of inappropriate care"  in forcible
retraction of immature prepuces and in surgically removing healthy
functioning tissue from non-consenting people. The law is clear enough on
this. What is at issue here is not whether a law exists, but whether the
Commission has the will to apply it. No law gives physicians the right to
remove healthy functioning tissue from non-consenting people, be it the
male genitalia or any other tissue. Circumcision, in Neto's mind, it seems,
as in many others, is surgical alteration to accomplish  psychological
ends.

 (4) See, for example, "Birth Complications Combined with Early Maternal
Rejection at Age One Year Predispose to Violent Crime at Age 18 Years,"
Archives of General Psychiatry, Adrian Raine, DPhil; Patricia Brennan, PhD;
Sarnoff A. Mednik, PhD, Vol. 51. No. 12. Dec. 1994, pp. 984-988.

 (5) See appended list of North Dakota Quotations.

 (6) These figures are likely at the low end. The following quotation is
from the Journal of Family Law (copy enclosed), Vol. 23, No. 3, 1985, by
William E. Brigman, PhD: "Not only is routine surgery unwarranted, but an
article published in 1966 in The Canadian Medical Association Journal ['The
Problem of Routine Circumcision'] reported a complication rate running as
high as 55% for hospital-performed routine neonatal circumcision. Other
studies showed that approximately 10% of all circumcisions had to be
repeated [Id.]. While most of the surgical complications were minor, Dr.
Robert L. Baker, writing in a 1979 issue of Sexual Medicine Today
calculated that 229 infants died in the United States per year as a result
of circumcision [Baker, 'Newborn Male Circumcision: Needless and
Dangerous,' Sexual Med. Today, Nov. 1979].

 (7) The fraud began over a hundred years ago as people were persuaded to
mutilate genitals in many ways in order to discourage masturbation. Quacks
played on people's fear that "self-pleasuring" would cause nearly every
known ailment. Circumcision was actually thought to be one of the least
painful ways prescribed to "cure" masturbation. Females were also genitally
maimed, one we know of had her clitoris excised by a Wahpeton, ND,
physician forty-some years ago.

 (8) Rights of parents to do what they will with their children must be
limited, testified Burleigh County States Attorney Patricia Burke opposing
HCR3036, otherwise the law would not be able to do anything about the
father "who initiated this teenaged daughter into sex because he wanted her
to learn about it from 'someone who really cares.'" Quoted from the
Bismarck Tribune, 3/2/95, Sec. B. Also see an excellent article in
the California Law Review, "Parents' Religion and Children's Welfare:
Debunking the Doctrine of Parents' Rights," Dec. 1994. The notion that a
person can own another only survives in some court judgments (since the
freeing of slaves and wives) in the parent/child relationship to the
child's detriment.

(9) Ralph Kilzer, MD, speaking for the ND Medical Association in support of
SB 2454 said the NDMA endorsed the AMA's Policy Recommendations which read:

        "1. That the AMA support legislation to eliminate the performance
of female genital mutilation in the United States and to protect young
girls and women at risk of undergoing the procedure.
        "2. That physicians who are requested to perform female genital
mutilation on a patient provide culturally sensitive counseling to educate
the patient and her family members about the negative health consequences
of the procedure, and discourage them from having the procedure performed.
Where possible, physicians should refer the patient to social support
groups that can help them cope with changing societal mores."
        The AMA's policy statement ends with an Action Recommendation:
"That the AMA join other organizations, including the World Health
Organization, the World Medical Association, interested national medical
societies, UNICEF and the International Federation of Gynecology and
Obstetrics in strongly opposing all forms of medically unnecessary surgical
modification of the female genitalia, promoting awareness of female genital
mutilation to the public and health care workers, and education health
professionals around the world to eliminate the practice of female genital
mutilation." (emphasis added) No reasons were given for the exclusion of
males in this formal statement.

 (10) See the enclosed, "A Review of Medical Literature Exposes
Circumcision Myths," from NOHARMM.

Cite as:
(File revised 29 September 2001)
http://www.cirp.org/library/legal/USA/voskuil-ND/