NEW NEW NEW!!!
British Columbia's new policy on infant male circumcision, released on June 3rd!!!
The policy throws the
spotlight on ethical and human rights problems, noting that
parental consent for non-therapeutic circumcision may not be
valid.
The media drove the point home with headlines like "B.C.
doctors take stand against circumcision" and "Docs fear
circumcision violates human rights."
Perhaps the most dramatic media event occurred on Wednesday, when
Dr. Peter Seland, spokesperson for the College of Physicians and
Surgeons of B.C., was interviewed on national television:
mms://tinyurl.com/5ollp (fast-forward to 5:20)
The interview was remarkable for its focus on ethics and human
rights. Medical benefits were hardly mentioned, while the
politically charged phrase "human rights violation"
filled the air repeatedly. For the first time in Canada, a
spokesperson for a statutory body admitted publicly that infant
male circumcision could be a violation of basic human
rights.
Host Seamus O'Regan (see note) took a provocative tack.
"You're obviously saying don't do it," observed Seamus.
"We're...um...saying don't do it if you're doing it for
medical reasons," countered Seland.
The strategic value of this media coverage lies in the way it
shows that opposition to circumcision is not confined to a few
activists. The phrases "human rights violation" and
"unwarranted mutilating surgery" were put out there by
the governing body for doctors in B.C. The parallels with female
circumcision were pointed out by Dr. Perry Kendall, Provincial
Health Officer.
As TV host Seamus O'Regan noted, changes in policy can have a
ripple effect that leads ultimately to changes in application of
the law. That, of course, is precisely what we are aiming for.
The statements released in Saskatchewan and B.C. are stepping
stones on the path to obtaining public funding for a
constitutional challenge.
NOTE: Seamus O'Regan, 33, has impressive credentials for a TV
host. Born in St. John's, Newfoundland, he studied politics at
University College, Dublin, and marketing strategies at
L'Institut européen d'administration des affaires, near Paris.
He received his Masters of Philosophy in Politics from the
University of Cambridge, England.
Reproduced Courtesy of the
Association for Genital Integrity, http://www.courtchallenge.com
Some Legal Abstract:
Dr. Joel Yelland, vice-president of the Saskatchewan Medical Association, says parents pressure FPs to perform circumcisions but because of the medical and legal risks involved he cannot understand why FPs would give in.
Kendel says the threat of litigation is now producing "a great deal of sober second thought" among physicians. "It could have what we call ‘long-tail liability’ if this societal movement takes on more steam and more men become angry because they think they ought not to have been circumcised." There are numerous Web sites opposing circumcision, including Doctors Opposing Circumcision and Mothers Against Circumcision.
COLLEGE OF PHYSICIANS &
SURGEONS OF BRITISH COLUMBIA
INFANT MALE CIRCUMCISION
Source : http://www.cpsbc.bc.ca/policymanual/c/c13.htm
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. Wes' Note : This
may change soon; - check out www.intact.ca for further informations about current
circumcision lawsuits...
For further information
regarding circumcision legalities in Canada, check this out.
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.
Wes' Note: AMEN!!!
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 CMA Code of Ethics (as adopted by this
College). 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.
http://www.canadian-health-network.ca/
The Circumcision Decision: Pros and Cons. Schmidt, BD. University
of Michigan Health System. Pediatric Health Topics.
http://www.med.umich.edu/
Answers to your questions about the Bioethics of Infant
Circumcision. National Organization of Circumcision Information
Resource Centers. Publications. http://www.nocirc.org/
The circumcision decision. Mayo Foundation for Medical Education
and Research. Mayo Clinic Health Information.
http://www.mayoclinic.com/
Circumcision. How do I decide about circumcision? American
Academy of Family Physicians. http://www.familydoctor.org/