August 26, 2013 | Posted By Marleen Eijkholt, PhD

Circumcision has been on my radar in different ways during my training as a health lawyer/bioethicist. Mostly, the issues presented in the form of ethical controversy about female circumcision; is it a form of mutilation or suppression of women on cultural/religious grounds?; as a tensions between religion, culture and resources, and sometimes in the form of questions around legality. However, these encounters were theoretical, and mostly based on extreme examples, interesting but abstract. When I saw a neonatal male circumcision (infant male circumcision: IMC) in my rounds through the hospital as a clinical ethicist, thoughts about the topic of circumcision revived even though this was male circumcision.

Witnessing this IMC, I observed the medical procedure, I saw that there were no parents at the bedside and that the child hardly cried on the sugar drip. This clinical picture was not what I expected. I never expected circumcision as such a routine procedure, seemingly performed without ritual or cultural significance at the bedside. My cultural bias took over, wondering why such an invasive procedure would be performed on a young child without capacity to consent, even though I also witnessed that the child hardly noticed it. Asking the physician about the reasons for it, he referred to the AAP statements, suggestions about health benefits, and to the fact that it is very common in America and mostly done: ‘because this is what Dads looks like’, without much thought.  Looking into the issue, I found a contemporary discussion regarding controversies about male circumcision, cultural biases and evidence based practices. I imagined and asked myself: how would I advise if I received a consult request about IMC? How should I conceive of right and wrong, also in the face of controversial evidence based studies? Especially since even the AAP encourages readers to “draw their own conclusions” (about the technical report and the primary resources). How can I assess this practice?

Lots of arguments exist around the health benefits of IMC, with arguments both supporting and rejecting the procedure. Two recent papers contradict the evidence purported by the other, both commenting on the AAP statement of 2012. The authors accuse the other of applying methodologically flawed research; choosing evidence that only supports their point of view about the benefits and the risks; about the risk of HIV, HPV infections, suffering, sexual behavior etc. The papers were full of accusations around cherry picking evidence for the question if IMC entails significant benefit or not. On the one hand, papers and statements like those of the AAP say that there is enough benefit that justifies the practice (as opposed to reject the practice) and the suggestion that third parties (insurance companies) should pay for it. Even though the AAP does not recommend it any longer, it says that parents should be able to choose this procedure. On the other hand, papers propose that there is insufficient evidence and evidence contraindicating routine circumcision and that if AAP cannot recommend the practice, it should refrain from suggesting that third parties should pay for it. The one paper concludes that there is an American bias PRO circumcision, while the other paper concludes that there is a European bias AGAINST circumcision.

So what if we look beyond the empirical arguments, how does the controversy do with the bioethical arguments? As I find the accusations about cherry picking the empirical evidence extremely confusing could I recommend anything based on the bioethical arguments? The AAP statement uses bioethical arguments in its advice: “parents should weigh the health benefits and risks in light of their own religious, cultural and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families”.

A first paper suggests that the AAP insufficiently addresses bioethical arguments and that it builds around the idea of parental choice. AAP’s report would disregard arguments around “respect for autonomy, the child’s right to an open future, and the normally high bar set for surgical interventions on minors” as well as “a child’s well established human and legal rights… of a child to decide for himself upon reaching an appropriate age whether he wants to part with his foreskin”. The other paper suggests that the AAP should have “confined its report and recommendations to medical issues”, and should not have built on so much non medical issues. The paper, however, contradicts that the AAP statement lacks in medical ethics. As ethical reasons, this paper suggests that the risks of not doing the procedure (exposure to HIV, HPV and STIs) are bigger than the risks of doing the procedure, and that doing it on an infant is preferable over an doing it during adulthood. They particularly refer to the “psychological issues for the (adult) male contemplating the procedure” and it being more costly.  Additionally it suggests that the “bodily integrity as such is not generally accepted as a fundamental right”. 

If I leave the reference to the risk/benefit assessment on empirical claims aside, I find references to the open future, the essence of autonomous choice, bodily integrity more convincing than psychological issues for the adult male contemplating the procedure, including arguments about it taking time to recover and ensuing costs. The procedure is invasive and irreversible. This contrasts with the piercing of ears, for example, or tattoos, which are nearly reversible these days. I therefore argue on bioethical grounds that we can certainly not recommend IMC. This agrees with the AAP statement. However, I disagree on bioethical grounds with the suggestion that insurance companies should pay for it.  AAP’s suggestion rests on parental choice, but I disagree that this argument is so strong that it justifies payment requirement in the face of the other bioethical arguments against it. Parental choice in the face of these objections should not be met with financial endorsement. However, I admit that I may be culturally biased in preferring these bioethical arguments

How would I phrase this in a consult? I believe that it would be my task to ensure that the parties are aware of the controversy and its arguments, including the controversy about the empirical evidence. Parental choice is a very valuable argument in the debate, but not the only one. I would refer to culture in my interactions and try to ensure that we’re not cutting corners when discussing the bioethical pros and cons. Empirical evidence cannot be the only piece in the discussion. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

4 comments | Topics: Ethics and Morality , Patient Autonomy , Religion , Research Methods


sheila otto

sheila otto wrote on 08/26/13 4:13 PM

Well said. I think there is an unspoken political element at play here as well. Many in the US are adamant that their son should have it done and are not dissuaded by the lukewarm, changing recommendations of the AAP.
Paul Burcher

Paul Burcher wrote on 08/27/13 12:31 PM

Although circumcision has declined slightly in the United States over the last decade, it is not (I think) because parents have been persuaded by empirical evidence or ethical arguments against it. I suspect it has more to do with changing demographics, that is, minorities who do not have it as part of their culture or traditions. I agree that insurance should not be required to pay for circumcision, except when medically indicated, but I also find the emotion surrounding this issue a bit perplexing and amusing at times. I have done probably thousands of circumcisions without any serious complications, and circumcision is by no means the most disturbing aspect of hospital-based care in the peripartum and neonatal period.
john fitton

john fitton wrote on 04/12/14 5:57 AM

Well said. In the US, and the cutting clinics that have sprung up in UK towns colonised by those from afar and which offer this genital mutilation under the protective cloak of religious requirement [my last uneducated parent of my distressed infant patient from Africa said 'Christianity' when asked], it is clearly a highly profitable trade.

No-one mentions the blunting of sexual pleasure, especially after middle age. Surely the question must occasionally cross the mind, after all that frantic pumping and scraping to achieve satisfaction, 'I wonder what it would be like if I was normal?'
Jay Davis

Jay Davis wrote on 01/26/16 12:08 PM

I come late to this ever debate that in the US will never end. What I find disgusting is CDC and AAP attempting to encourage RIC and having third parties pay. At the same time in a shameless way suggesting doctors should recommend RIC.
The African studies are fraudulent and shoddy, and in any event, cannot apply to the US or infants and children.
The AAP also had pro circumcision persons on its panel. They had religious and cultural excuse to wish a recommendation. They know well, people will circumcise if they know somebody else, the tax payers will pick up the bills. It is a 300 million dollar enterprise in the US.

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