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Introduction

Male circumcision involves the removal of preputial tissue from the human body. The propriety of non-therapeutic circumcision of male infants and children is controversial. The three major viewpoints are the parent-centered viewpoint, the child-centered viewpoint, and the human rights-centered viewpoint.

Parent-centered View

The traditional viewpoint hold that non-therapeutic circumcision of male children is ethical provided that a parent grants consent for the operation after being informed of the possible benefits and known risks. This view is typified by the 1999 Circumcision Policy Statement (1999) of the American Academy of Pediatrics.

The practice of medicine has long respected an adult's right to self-determination in health care decision-making. This principle has been operationalized through the doctrine of informed consent. The process of informed consent obligates the physician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives for the patient to make an informed choice. For infants and young children who lack the capacity to decide for themselves, a surrogate, generally a parent, must make such choices.

Parents and physicians each have an ethical duty to the child to attempt to secure the child's best interest and well-being. However, it is often uncertain as to what is in the best interest of any individual patient. In cases such as the decision to perform a circumcision in the neonatal period when there are potential benefits and risks and the procedure is not essential to the child's current well-being, it should be the parents who determine what is in the best interest of the child. In the pluralistic society of the United States in which parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.

Physicians counseling families concerning this decision should assist the parents by explaining the potential benefits and risks and by ensuring that they understand that circumcision is an elective procedure. Parents should not be coerced by medical professionals to make this choice.

Child-centered View

Some believe that the parent-centered view is challenged by the American Academy of Pediatrics Committee on Bioethics, which places responsibility on the physician. It holds that health care providers "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."

And that:

"the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent."

And by the newer American Medical Assocation Principles of Medical Ethics which require:

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

Some interpret these to mean that circumcision is unethical, because they believe that circumcision is not in the patient's best interests.

Guidance on the circumcision of male children has been enunciated by the Committee on Medical Ethics of the British Medical Association. That view require medical doctors to proceed on a case by case basis to determine the best interests of the child before deciding to perform a circumcision. A similar position has been taken by the College of Physicians and Surgeons of British Columbia.

Hellston expresses the view that the protection of the child's rights should govern the practice.

Scandinavian View

Scandinavian nations take the strictest view of child circumcision. The Norwegian Council for Medical Ethics finds that the circumcision of boys is not consistent with important principles of medical ethics, and the children’s ombudsman says circumcisions should cease at public hospitals. Similarly, the Finnish Central Union for Child Welfare takes the position that the non-therapeutic circumcision of boys may not be acceptable because it violates bodily integrity. Sweden has passed a law that restricts the practice of circumcision to be performed by qualified professionals, as is usually the case in the US. One interpretation of a statement by the Danish Council for Children says that circumcision violates human rights.

Conclusion

The bioethics of the circumcision of male infants and children are changing under the pressure of international human rights law. There is, however, no clear consensus regarding the ethicality of the non-therapeutic circumcision of male children.

References

• American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995;95(2):314-7. URL: http://www.cirp.org/library/ethics/AAP/

• Task Force on Circumcision. Circumcision Policy Statement. Pediatrics URL: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b103/3/686

• Council on Ethical and Judical Affairs. Principles of Medical Ethics. Chicago: American Medical Association, 2001. URL: http://www.ama-assn.org/ama/pub/category/2512.html

• Gulbrandsen P. Rituell omskjæring av gutter. Tidsskr Nor Lægeforen 2001;121(25):2994. URL: http://www.cirp.org/library/ethics/gulbrandsen1/

• Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003. URL: http://www.bma.org.uk/ap.nsf/Content/malecircumcision2003