INFANT MALE
CIRCUMCISION
Until recently, only public health
and religious views were taken into
consideration in the debate over infant
male circumcision. However, our
understanding of medical practice must
change as research findings become
available. The College of Physicians and
Surgeons of British Columbia is issuing
this guide for physicians regarding routine
infant male circumcision in light of
evidence-based medicine and contemporary
principles in ethics, law and human
rights.
Infant male circumcision was once
considered a preventive health measure and
was therefore adopted extensively in
Western countries. Current understanding of
the benefits, risks and potential harm of
this procedure, however, no longer supports
this practice for prophylactic health
benefit. Routine infant male circumcision
performed on a healthy infant is now
considered a non-therapeutic and medically
unnecessary intervention. From a religious
standpoint, infant male circumcision is
acknowledged to be an important ritual and
an integral part of Jewish and Islamic
religions. Male circumcision is also
practiced in other parts of the world as a
rite of puberty.
A wider societal discussion on infant male
circumcision is warranted based on a
current understanding of bioethics that
takes into account the non-therapeutic
nature of the procedure as well as the high
importance it plays in religious and
traditional customs. This paper provides a
discussion on current medical perspectives
as well as relevant legal, human rights,
and ethical considerations.
Medical Perspectives
Circumcision removes the prepuce that
covers and protects the head or the glans
of the penis. The prepuce is composed of an
outer skin and an inner mucosa that is rich
in specialized sensory nerve endings and
erogenous tissue. Circumcision is painful,
and puts the patient at risk for
complications ranging from minor, as in
mild local infections, to more serious such
as injury to the penis, meatal stenosis,
urinary retention, urinary tract infection
and, rarely, even haemorrhage leading to
death. The benefits of infant male
circumcision that have been promoted over
time include the prevention of urinary
tract infections and sexually transmitted
diseases, and the reduction in risk of
penile and cervical cancer. Current
consensus of medical opinion, including
that of the Canadian and American
Paediatric Societies and the American
Urological Society, is that there is
insufficient evidence that these benefits
outweigh the potential risks. That is,
routine infant male circumcision, i.e.
routine removal of normal tissue in a
healthy infant, is not recommended.
Legal Considerations
To date, the legality of infant male
circumcision has not been tested in the
Courts. It is thus assumed to be legal if
it is performed competently, in the child's
best interest, and after valid consent has
been obtained.
At all times the physician must perform
the procedure with competence, and at all
times, the parent and physician must act in
the best interests of the child. Signed
parental consent for any treatment is
assumed to be valid if the parent
understands the nature of the procedure and
its associated risks and benefits. However,
proxy consent by parents is now being
questioned. Many believe it should be
limited to consent for diagnosis and
treatment of medical conditions, and that
it is not relevant for non-therapeutic
procedures.
Human Rights Considerations
The matter of infant male circumcision is
particularly difficult in regards to human
rights, as it involves consideration of the
rights of the infant as well as the rights
of the parents.
Under the Canadian Charter of Rights
and Freedoms and the United Nations Universal
Declaration of Human Rights, an infant
has rights that include security of person,
life, freedom and bodily integrity. Routine
infant male circumcision is an unnecessary
and irreversible procedure. Therefore, many
consider it to be "unwarranted mutilating
surgery".
Many adult men are increasingly concerned
about whether their parents had the right
to give consent for infant male
circumcision. They claim that an infant's
rights should take priority over any
parental rights to make such a decision.
This procedure should be delayed to a later
date when the child can make his own
informed decision. Parental preference alone
does not justify a non-therapeutic
procedure.
Others argue that this stance violates the
parents' right to religious or cultural
expression, and that adherence to their
religious and cultural practices would be
in the best interests of the infant.
Ethical Considerations
Ethical
considerations regarding infant male
circumcision centre on the welfare (or
"best interests") of the infant and the
potential benefit and harm associated with
the procedure. Ethics points us to
corrective vision, i.e. to question
practices that have become routine, or
which we take for granted.
Therefore, each request for the procedure
should be carefully evaluated, and an
agreement to perform the procedure should
take into consideration the ethical
principles of beneficence (duty to
benefit); non-maleficence (do no harm);
veracity (accurate information); autonomy
(consent); and justice (fairness).
These principles are articulated in
specific responsibility statements (Items)
in the College of Physicians and
Surgeons of BC Code of Ethics. Also
included below are items relating to
physicians rights and care of the
patient.
Beneficence (duty to
benefit)
Item 1. Consider first the
well-being of the patient.
Item 14. Recommend only those diagnostic
and therapeutic procedures that you
consider to be beneficial to your patient
and not others....
For Consideration: Medical
evidence is that the benefits of routine
infant male circumcision do not outweigh
the risks of complications from the
procedure. Best interests also take into
account the infant's social
circumstances.
Non-maleficence (do no
harm)
Item
33. Refuse to participate in or support
practices that violate basic human
rights.
For Consideration: Routine infant
male circumcision does cause pain and
permanent loss of healthy
tissue.
Veracity
(adequate information)
Item
13. Make every reasonable effort to
communicate with your patients in such
way that information exchanged is
understood.
For Consideration: Discussion
should include the new understanding that
there is a lack of evidence of a real
medical benefit in routine infant male
circumcision, that it is non-therapeutic,
and that only in rare situations is there
any clinical indication for the
procedure. Specifics of potential risks
and complications should also be
explained. It is important to ensure a
meaningful discussion between physician
and parents, and that the information
provided is understood.
Autonomy
(informed consent)
Item
12. Provide your patients with the
information they need to make informed
decisions about their medical care, and
answer their questions to the best of
your ability.
For Consideration: Parents must
be given accurate and impartial
information to assist them in making an
informed decision. The infant, the actual
patient, is unable to give consent. Proxy
consent by parents for a non-therapeutic
procedure is debatable.
Justice
(fairness)
Item
29. Recognize that community, society and
the environment are important factors in
the health of individual
patients.
For Consideration: Physicians
should understand the basis for the
request and consider the infant's social
and cultural circumstances and what might
be in the infant's best
interest.
Physician's
rights
Item 8.
Inform your patient when your personal
morality would influence the
recommendation or practice of any medical
procedure that the patient needs or
wants.
For Consideration: If your
personal beliefs dictate against infant
male circumcision, this should be made
known to your patients, with an offer of
referral to another physician competent
in performing the procedure.
Care of
the Patient
Item 3.
Provide for appropriate care for your
patient, including physical comfort and
spiritual and psychosocial support
…
Item 4. Practice the art and science
of medicine competently and without
impairment.
Item 6. Recognize your limitations and
the competence of others, and, when
indicated, recommend that additional
opinions and services be
sought.
For Consideration: As with any
medical procedure, if for religious or
cultural reasons you decide to perform an
infant male circumcision, ensure that
your skills are current. Expertise can be
maintained only if a sufficient number of
such circumcisions are
performed.
Recommendation:
Best medical practice includes the
following standards of practice for doctors
who are asked to circumcise male
infants:
-
Keep
up-to-date on the issues surrounding
infant male circumcision, including the
therapeutic medical indications and
legal and ethical issues.
-
Advise
parents that the current medical
consensus is that routine infant male
circumcision is not a recommended
procedure; it is non-therapeutic and
has no medical prophylactic basis; it
is a cosmetic surgical procedure;
current evidence indicates that
previously-thought prophylactic public
health benefits do not out-weigh the
potential risks.
-
Provide
objective medical information about the
risk of complications and potential
harm in infant male
circumcision.
-
Discuss
the new ethical considerations of
infant's rights and proxy consent in a
non-therapeutic procedure.
-
Listen
to parents and consider the basis of
their request, which may be based on
religious or cultural
practices.
This paper
is intended to help physicians use their
professional judgement when a request is
made for routine infant male circumcision.
While parental preference is important,
factors like the best available evidence
regarding potential benefits and
complications, alternatives to this
intervention, the infant's best interest,
and current understanding of bioethics
should be taken into consideration.
You are not obliged
to act upon a request to circumcise an
infant, but you must discuss the medical
evidence and the current thoughts in
bioethics that dissuade you from performing
this procedure. You must also inform
the parents that they have the right to see
another doctor.
If you decide to perform the procedure for
religious, cultural or other
reasons:
-
Ensure
that you have the necessary skills and
experience, or ensure that the parents
and child are referred to a physician
who has these skills.
-
Obtain
valid consent from both parents and
ensure that both
parents sign a consent
form.
-
Provide
the procedure under hygienic conditions
with appropriate analgesia and
aftercare.
Resources
cited:
American Academy of Pediatrics.
Task force on Circumcision.
Circumcision Policy Statement.
Pediatrics 1999; 103: 686-693
British Medical Association Committee on
Medical Ethics:
The Law and Ethics of Male
Circumcision—guidance for
doctors, March 2003
Canadian Medical Association. Code of Ethics. Can
Med Assoc J 1996; 155: 1176A-B
Canadian Paediatric Society. Neonatal circumcision
revisited. Can Med Assoc J 1996:
154(6): 769-780
College of Physicians and Surgeons of BC.
Code of Ethics. Policy
Manual.
College of Physicians and Surgeons of
Manitoba.
Neonatal Circumcision. Winnipeg:
College of Physicians and Surgeons of
Manitoba 1997
College of Physicians and Surgeons of
Saskatchewan.
Caution against Circumcision of Newborn
Male Infants. Feb 2002
Christakis DA, Harvey E, Zerr DM et al. A
Trade-off Analysis of Routine Newborn
Circumcision. Pediatrics 2000. 105:
246-249
Goodman J. Jewish Circumcision: an
alternative perspective. BJU
International 1999. 83: Suppl. 1,
22-27
Paton M. The Ethics of Circumcising Male
Babies. The Bioethics Bulletin (June
1992). Edmonton, University of
Alberta.
Richards D.
Male Circumcision: Medical or Ritual?
Journal of Law and Medicine 1996.
3:371-376
Somerville M. Altering Baby Boys' Bodies:
the ethics of male circumcision. The
Ethical Canary: Science, Society and Human
Spirit. Toronto: Viking,
2000:202-219
Szaz T. Routine Neonatal Circumcision:
Symbol of the Birth of the Therapeutic
State. Journal of Medicine and
Philosophy 1996:21:137-148
Patient resources:
We are trying to decide whether or not to
circumcise our baby boy. What should we
know?
Canadian Health Network. Canadian
Paediatric Society.
www.canadian-health-network.ca
The Circumcision Decision: Pros and Cons.
Schmidt, BD. University of Michigan
Health System. Pediatric Health Topics.
www.med.umich.edu
Answers to your questions
about the Bioethics of Infant
Circumcision. National Organization
of Circumcision Information Resource
Centers. Publications. www.nocirc.org
The circumcision decision. Mayo
Foundation for Medical Education and
Research. Mayo Clinic Health
Information. www.mayoclinic.com
Circumcision. How do I decide about
circumcision? American Academy of Family
Physicians. www.familydoctor.org
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