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NOCIRC Information Series: Infant Bioethics



Answers to Your Questions About the Bioethics of Infant Circumcision

from the

National Organization of Circumcision Information Resource Centers


Educating A New Generation For The Well-Being Of All Children.

www.nocirc.org




When a parent presents a child for circumcision, who is the patient?

The child is a distinct person from the parent.1 The child, not the parent, is the patient.2

What are the responsibilities of the attending physician to the child-patient.

A physician, while caring for a patient, must regard responsibility to the patient as paramount and act in the best interests of the patient.2,3 The physician must provide competent medical care with respect for human dignity and human rights.2,3

Physicians have legal and ethical duties to their child-patient to render competent necessary care based on what the patient needs, not what someone else, including a parent, expresses.4

What are the rights of the child?

The child has a legal right to bodily integrity.5 Upon reaching adulthood, the child may have a right to sue to recover damages for injuries or unnecessary surgery sustained in childhood.6

Under international law, a child has the right to security of the person,7 freedom from torture,7 inhuman and degrading treatment,7 and the right to special protection during his minority.7,8 The child has a right to be consulted when decisions are made regarding his welfare.2,4,8

What are the rights of the parents?

The parent does not have rights with regard to the child except against all others. The parent does have duties and responsibilities to the child.1 The parent does not have unlimited power to carry out his/her duties and responsibilities.1

The parent must make decisions for the child based solely on the best interests of the child, not mere whim.2,5,9 The parent has a limited power to grant permission for investigation, diagnosis, and treatment of disease, when actually present.

Is circumcision harmful?

Circumcision amputates approximately 50 percent of the heavily innervated skin and mucosa of the penis,5,10 tissue that is a specific erogenous zone.11 Excision of the foreskin renders the remaining skin taut and immovable, eliminates its protective, sensory, and sexual functions, and destroys the gliding action of the foreskin, changing the natural mechanics of normal human reproduction.12

Circumcision puts the patient at risk of surgical mishap, adhesions, meatitis, meatal ulceration, infections, bleeding, and even death.5,13

Circumcision is an extremely painful procedure5,14,15 with long-lasting post-operative pain.15,16

Circumcision creates an abnormal physical appearance with a disfiguring scar encircling the shaft of the penis and the glans penis permanently exposed to drying, abrasion, and mechanical injury.16

Is circumcision a lawful procedure?

Male circumcision is not unlawful,16 however, in the absence of a medical indication, it is conceivable that general laws for the protection of children could be applied to non-therapeutic circumcision.17 As with any surgery, a valid informed consent must be obtained.5 The power of parents to grant proxy permission to the non-therapeutic excision of healthy functional tissue from a child's body is unclear and the law, therefore, is unstable.5

What information must a physician provide?

A physician, prior to obtaining permission for a circumcision, must provide all relevant and material information about the proposed course of treatment and all relevant and material information about alternative treatments.4,5 Information must be provided about the actual extent of amputation, possible benefits, known risks, disadvantages, complications, and possible outcomes.4,5,18 Non-circumcision is a viable alternative to circumcision, so similar information must be provided about noncircumcision.18

How long should a physician maintain records relating to an infant circumcision?

Brown recommends that doctors keep records until the child-patient's 28th birthday.6

Must a physician provide a circumcision at parental request?

No, a physician, except in emergencies, may choose whom to serve.3 Physicians have no obligation to provide ineffective, experimental, or outdated treatment.19 Doctors may refuse to perform circumcision as a matter of conscience.2,20

Who should make the decision about non-therapeutic circumcision?

Circumcision is a non-therapeutic procedure21 that is not essential to current wellbeing.22 Although it is traditional for parents to decide, such procedures should be deferred until the child is of age and can decide for himself.2,4 Physicians have a duty to consider the feelings of the child because the child has to live with the consequences of the circumcision.23

Is the non-therapeutic circumcision of a child an ethical procedure?

The Norwegian Council for Medical Ethics has advised the Norwegian Medical Association that the circumcision of boys is not consistent with important principles of medical ethics.20 Canning says there is conflict between circumcision and the legal and ethical duties of medical specialists.24 The subjection of childpatients to unnecessary non-therapeutic painful procedures is unethical.25

References:

  1. Dwyer JG. Parents' religion and children's welfare: debunking the doctrine of parents' rights. California Law Review 1994;92(6):1371-447.
  2. Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003.
  3. Council on Ethical and Judicial Affairs. Principles of Medical Ethics. Chicago: American Medical Association, 2001.
  4. Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-317.
  5. Svoboda JS, Van Howe RS, Dwyer JC. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Contemp Health Law Policy 2000;17:61-133.
  6. Brown RH. The pediatrician and malpractice. Pediatrics 1976; 57(3): 392-401.
  7. Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948).
  8. UN Convention on the Rights of the Child (1989). UN General Assembly Document A/RES/44/25.
  9. Bioethics Committee Reference B86-01: Treatment Decisions for Infants and Children. Ottawa: Canadian Paediatric Society, March 2000.
  10. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295.
  11. Winkelmann RK. The erogenous zones: their nerve supply and significance. Mayo Clinic Proc 1959;34(2):39-47.
  12. Warren J, Bigelow J. The case against circumcision. Br J Sex Med 1994; Sept/Oct: 6-8.
  13. Williams N, Kapila L. Complications of Circumcision. Brit J Surg 1993; 80: 1231-6.
  14. Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997; 278:2158-62.
  15. Howard CR, Howard FM, and Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994;93(4):641-6.
  16. Povenmire R. Do parents have the legal authority to consent to the surgical amputation of normal, healthy tissue from their infant children? The practice of circumcision in the United States. J Gender Soc Pol Law 1998; 7:87-123.
  17. Edge PW, Male circumcision after the human rights act 1998. 5 J Civil Liberties 2000;5:320-37.
  18. Hill G. Informed consent for circumcision. South Med J 2002;95(8):946.
  19. Weijer C, Singer PA, Dickens BM, Workman S. Bioethics for clinicians: 16. Dealing with demands for inappropriate treatment. CMAJ 1998;159:817-21.
  20. Gulbrandsen P. Rituell omskjæring av gutter. [Ritual circumcision of boys.] Tidsskr Nor Lægeforen [Journal of the Norwegian Medical Association] 2001;121(25):2994.
  21. Council on Scientific Affairs. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999.
  22. Task Force on Circumcision. Circumcision Policy Statement, Pediatrics 1999;103(3):686-93.
  23. Shield JPH, Baum JD. Children's consent to treatment. BMJ 1994;308:1182-83.
  24. Canning DA. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Urol 2002;168 (4 Pt 1): 1650-1.
  25. Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery. Prevention and Management of Pain and Stress in the Neonate. Pediatrics 2000;105(2):454-461.


"Regardless of whether a child is a boy or a girl, neither should be subject to a tradition which is harmful."

Jacqueline Smith



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National Organization of Circumcision
Information Resource Centers

Post Office Box 2512
San Anselmo, CA 94979-2512 USA
Telephone: 415-488-9883
Fax: 415-488-9660

www.nocirc.org


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