Medical Ethics and the Circumcision of Children
A report from Doctors Opposing Circumcision
The surgical operation of male circumcision permanently and irreversibly excises and destroys a functional body part consisting of specialized tissue [1, 2].
For this reason, the medical ethics associated with the operation must carefully be scrutinized and doctors who contemplate performing a circumcision must carefully consider and adhere to proper ethical conduct.
Doctors, especially in the U. S., frequently are asked to perform medically unnecessary, non-therapeutic circumcision on minors. Since minors cannot consent, special ethical rules applicable to paediatrics must be applied. One must always remember that the child is the patient. The doctor must consider first the well-being of the patient [3] and keep the interests of the child-patient paramount [4, 5].
Some older authorities simplistically maintain that the non-therapeutic circumcision of a child is ethical if parents request and consent to the circumcision [6-9]. As Fox and Thomson note:
Only limited consideration is given to the seemingly obvious fact that circumcision is the excision of healthy tissue from a child unable to give his consent for no demonstrable medical benefit [10].
The view espoused by these authorities is outmoded and inadequate because it fails to consider the doctor’s duties to the child, the child‘s legal rights, the child’s human rights, and limitations on the power of surrogate consent. Moreover, these statements favor parent privilege over the child’s legal rights and best interests. According to Fox and Thomson:
Particular attention is devoted to the privileging of parental choice, notwithstanding documented medical risks and the absence of conclusive evidence of medical benefit [10].
This report considers the medical ethics of non-therapeutic circumcision of children by several ethical tests.
1. Lawfulness
Doctors must respect the law [11] because they are subject to the general laws [12]. If a proposed circumcision operation is unlawful in a particular locale or under the existing circumstances, then it also is unethical and must not be performed.
2. Human Rights
Doctors have a general duty to respect the human rights of the patient [5, 10, 11, 13]. According to the World Medical Association:
“Ethics and human rights are no longer the 'two solitudes' that did not have much to do with each other. Increasingly, human rights organizations are recognizing the ethical dimension of their work, and organizations whose primary concern is ethics are discovering that human rights is a foundational element of ethics. …” [14].
Human rights are now an integral part of medical ethics. As reported in the report on human rights, children have both general and special human rights that must be considered. As previously stated, non-therapeutic circumcision of children violates the child-patient’s human rights. Both parents and professionals have a duty to respect human rights.
3. The four cardinal principles of medical ethics
The four cardinal principles of medical ethics are beneficence, non-maleficence, justice, and autonomy [15]
Beneficence. This is about “doing good.” We have previously demonstrated that the alleged prophylactic benefits cannot be shown to actually exist. Therefore, there is no provable beneficence to the non-therapeutic circumcision of male children, so non-therapeutic circumcision violates the principle of beneficence.
Non-maleficence. This is about “not doing harm.” We have previously demonstrated that male circumcision is harmful, so non-therapeutic circumcision violates the principle of non-maleficence.
Justice. This is about “treating patients fairly.” We have previously demonstrated that non-therapeutic circumcision inflicts needless injury on a patient and violates his legal right to bodily integrity and his human rights. This is not fair treatment, so non-therapeutic circumcision violates the principle of justice.
Autonomy. This is about letting the patient control his/her own treatment. Consent for the circumcision of children must be given by surrogates. In this case, the patient does not control his own treatment, so non-therapeutic circumcision violates the principle of autonomy.
4. Provision of futile or ineffective treatment.
Non-therapeutic circumcision is performed on healthy persons. Under this circumstance, there can be no effect so the treatment is both ineffective and futile. Physicians have no duty to provide futile or ineffective treatment [16-18].
5. Misuse of medical resources.
Physicians have an ethical duty to conserve medical resources and use them wisely [19, 20]. The provision of non-therapeutic circumcision wastes such medical resources as physician time, hospital space, insurance money, and medical staff. Provision of medically unnecessary, non-therapeutic circumcision may consume resources needed for the medically necessary treatment of other patients.
6. Surrogate consent
The necessity for consent by surrogates poses many ethical problems. Competent adult patients have full powers to consent to treatment, but surrogates have limited powers. The American Academy of Pediatrics states that the surrogate is limited to providing “informed permission for diagnosis and treatment of children.” [21]
Both parents and physicians must act in the best interests of the child [14, 21-26]. In considering the best interests of the child, one must remember that parents have a primary duty to the child to protect his bodily integrity. The best interests of the child must include the protection of his legal right to bodily integrity except when the presence of clinically identifiable disease makes invasion of the child’s bodily integrity necessary. Therefore, there should be an assumption that protection of the child’s bodily integrity is in his best interests unless proven otherwise by clear and convincing evidence.
In surrogate consent for circumcision, the necessary prerequisites are:
1. a physical complaint, followed by
2. a diagnosis by a medical doctor, followed by
3. a medical recommendation for treatment, followed by
4. a trial of conservative treatment, [5] followed by
5. a recommendation for circumcision only after conservative treatment fails, and where circumcision is proven to be effective, followed by
6. presentation of all relevant material information, [5, 21, 22, 25, 27, 28] followed by
7. granting of consent by his representative.
These would be present in the case of therapeutic circumcision, but they are absent in the case of non-therapeutic circumcision at parental request. A consent obtained without these prerequisites would lack validity. Performance of a circumcision without valid consent would be unethical.
7. Patient exploitation.
Some doctors may exploit the presence of the foreskin by performing a circumcision simply to collect a fee for the procedure. According to the Boston Globe, quoting Thomas E. Wiswell, M.D.:
“I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it," says Wiswell. "Each one is that much money. Heck, if you do 10 a week, that's over $1,000 a week, and they don't take that much time."” [29]
Patient exploitation is a violation of human rights and is unethical [30, 31].
Discussion
Doctors 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.” [21] Genital integrity provides the highest state of health and well-being, therefore, doctors have an ethical duty to their child-patients to abstain from performing circumcision at parental request.
Summation
Child circumcision was introduced into medical practice in the nineteenth century. Medical ethics has changed over the years. In this report, non-therapeutic circumcision of children has been subjected to seven tests by contemporary standards of medical ethics. It has failed all seven. Although non-therapeutic circumcision of children remains a common practice, under contemporary standards of medical ethics, it has become unethical and needs to cease. Medical societies have a duty to revise their guidance regarding non-therapeutic male circumcision to reflect 21st century medical ethics. Similarly, medical doctors have a duty to change their practices regarding non-therapeutic circumcision of children.
References
1. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision.Br J Urol 1996;77:291-5. Available at: http://www.cirp.org/library/anatomy/taylor/
2. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44. Available at:
3. Principle 1. CMA Code of Ethics. Ottawa: Canadian Medical Association, 2004. Available at:
4. Council on Ethical and Judicial Affairs. Principle III, Principles of Medical Ethics. Chicago: American Medical Association, 2001. Available at: http://www.ama-assn.org/ama/pub/category/2512.html
5. Committee on Medical Ethics. The law & ethics of male circumcision - guidance for Doctors. London: British Medical Association, 2006. Available at: http://www.bma.org.uk/ap.nsf/Content/malecircumcision2006
6. Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. (CPS) Canadian Medical Association Journal 1996; 154(6): 769-780. Available at:
7. Task Force on Circumcision, American Academy of Pediatrics. Circumcision policy statement. Pediatrics1999;103(3):686-93. Available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686
8. Council on Scientific Affairs, American Medical Association. Neonatal circumcision. Chicago: American Medical Association, December 1999. Available at: http://www.ama-assn.org/ama/pub/category/13585.html
9. Beasley S, Darlow B, Craig J, et al. Position statement on circumcision. Sydney: Royal Australasian College
of Physicians, 2004. Available at: http://www.racp.edu.au/hpu/paed/circumcision/legal.html
10. Fox M, Thomson M. Short changed? The law and ethics of male circumcision Int J Children's Rights 2005;13:161-81. Available at: http://www.cirp.org/library/legal/UKlaw/fox-ijcr-2006/
11. Council on Ethical and Judicial Affairs. Principle I, Principles of Medical Ethics. Chicago: American Medical Association, 2001. Available at: http://www.ama-assn.org/ama/pub/category/2512.html
12. Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 19. Available at:
13. Principle 9. CMA Code of Ethics. Ottawa, Canadian Medical Association, 2004. Available at:
14. Ethics Unit. Ethics and Human Rights, Ferney-Voltaire, France, World Medical Association, 2006.
Available at: http://www.wma.net/e/ethicsunit/human_rights.html
15. Beauchamp TL, Childress JF. Principals of Biomedical Ethics. 3rd ed. New
York, NY: Oxford University Press; 1989.
16. Weijer C, Singer PA, Dickens BM, Workman S. Bioethics for clinicians: 16. Dealing with demands for inappropriate treatment. Can Med Assoc J 1998;159:817-21 Available at:
17. Opinion E-8:20, Code of Medical Ethics. Chicago: American Medical Association. Available at:
18. Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 46. Available at:
19. Principle 44. CMA Code of Ethics. Ottawa: Canadian Medical Association, 2004. Available at:
20. Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 67-70. Available
21. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-7. Available at: http://www.cirp.org/library/ethics/AAP/
22. Bioethics Committee, Canadian Paediatric Society. Treatment decisions regarding infants, children and adolescents. Paediatrics & Child Health 2004; 9(2): 99-103. Available at:
23. Principle 29. CMA Code of Ethics. Ottawa, Canadian Medical Association, 2004. Available at:
24. Principle 3d. Code of Ethics. Barton, ACT: Australian Medical Association, 2004. Available at:
25. College of Physicians and Surgeons of British Columbia. Infant Male Circumcision. In: Resource Manual
for Physicians. Vancouver, BC: College of Physicians and Surgeons of British Columbia, 2004. Available at:
26. Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 49. Available at:
27. Seeking patients' consent: the ethical considerations. London, General Medical Council, 1998. Available at:
28. Williams J. Medical Ethics Manual. Ferney-Voltaire, France: World Medical Organization: 42-3. Available at: http://www.wma.net/e/ethicsunit/pdf/manual/chap_2.pdf
29. Lehman BA. The age old question of circumcision. Boston Globe, Boston, Massachusetts, 22 June 1987:41,43. Available at: http://www.cirp.org/news/bostonglobe06-22-87
30. Principle 2. CMA Code of Ethics. Ottawa: Canadian Medical Association, 2004. Available at:
31. Principle 1.1h. Code of Ethics. Barton, ACT: Australian Medical Association, 2004. Available at:
Doctors Opposing Circumcision
Seattle, Washington
June 2006
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