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Volume 12, Number 2

Original Article
Circumcision and the Code of Ethics

George C. Denniston, MD, MPH

Over the past few decades, many doctors have become aware that routine neonatal circumcision is unnecessary and should not be performed. In Canada, the rates of circumcision paid for by all provincial and territorial health agencies have declined from 44% in 1975 to 4% in 1995.1 In the United States, there has been a marked decline in circumcision, but the procedure still is done with considerable frequency. According to the National Center for Health Statistics, the rate of newborn circumcision is now 59%, down from approximately 90% twenty years ago.

The Procedure

Circumcision is the act of one person removing a part of the penis of another person. If done for religious reasons, it is performed by a mohel on male infants of the Jewish faith on the eighth day, and by a street surgeon on Moslem boys later in life. In the four Western countries where it is still done, it is performed by doctors of medicine or osteopathy, under the supposition of medical necessity.

The foreskin is the forward continuation of the skin of the penile shaft, which covers the head of the penis (glans penis). The inner lining of this skin is highly specialized erogenous tissue.2 This foreskin has several known functions: it protects the glans penis throughout life; it covers the penis during an erection, when the shaft enlarges and elongates; and it provides great pleasure to its owner, and to his partner. As one man who had a circumcision, after he had become sexually active, said: "Stimuli that had previously aroused ecstasy now have relatively little effect." Many individuals now claim that its removal has been harmful to them.

Canadian physicians now will ask whether those circumcisions done by their colleagues for "medical necessity" (still reimbursable) are legitimate. Since the neonatal circumcision rate in Finland, where virtually every male wishes to preserve his foreskin, is zero, and since the risk of needing a late circumcision in Finland is one in 16,667, it follows that almost all of the circumcisions still being done in North America have no medical necessity, and in fact, are contraindicated. Therefore, in Canada, most requests to provincial health agencies for payment for circumcisions may be viewed as fraudulent.

Violation of Ethical Principles

First, circumcision violates the Golden Rule: Do unto others as you would have them do unto you. If the doctor were intact, it may be fairly assumed that he would not want anyone to remove his foreskin without his permission.

Secondly, it violates a major tenet of medical practice: First, do no harm.

Last, but not least, circumcision violates all seven Principles of Medical Ethics. Let us look at each principle in turn (AMA 1992).

"Principle I. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity."

"Competent medical service" implies that each procedure is medically indicated, and is done only with fully informed consent. Since 1971, both the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists (1975) have stated: "There are no medical indications for routine neonatal circumcision."3 In addition, informed consent is never obtained from these young patients, and fully informed consent rarely, if ever, from the parents.

Circumcision causes severe pain.4 Does a doctor who unnecessarily causes severe pain practice "with compassion?" Doctors may use a local anaesthetic; this does nothing for pain and suffering during the healing process. Also, does a doctor who removes a normal part of another person's body without his consent "respect human dignity?" Every individual is entitled to an intact body and to fully informed consent before any part of his body is removed. These principles apply even more strongly to a healthy normal body part.

"Principle II. A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception."

Physicians do not "deal honestly" with patients if they fail to provide fully informed consent. For example, some doctors use the threat of penile cancer and urinary tract infection to promote circumcision and, thus, misinform the public. Penile cancer is so rare that one cannot possibly justify a routine surgical procedure as a preventive measure. Urinary tract infections, also quite rare, are treated with antibiotics, not by operation.1

"Principle III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient."

The law permits a doctor to operate on another human being, but only if it is in the best interest of that individual. Many men who now speak out against the circumcision that was imposed on them claim that it was not in their best interests.

"Principle IV A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences within the constraints of the law"

A patient has the right to an intact body, and has the right (and duty) to refuse to have a normal, valuable part of his penis removed unnecessarily.

"Principle V A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated."

Telling the parent that circumcision is in any way useful constitutes a failure to make "relevant scientific information available to that parent." However, even if we could show that some disease is more likely to occur in the intact male, it does not follow that it is ethical to use this risk as a reason to circumcise. In all studies to date, the risks of circumcision have always exceeded any alleged benefits, a fact that often is not made clear to parents.

"Principle VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services."

A physician is free to choose not to remove part of the penis of a male infant, especially if it is "inappropriate patient care," even if the parents "demand" it. Modern medical ethics state that parents may make medical decisions for their child, but their actions must be "in his best interest." Circumcision is unnecessary and harmful: therefore, not in the infant's best interest. Maimonides, the great Jewish sage, said, "Circumcision should never be done except for reasons of pure faith." In the absence of religious reasons, no such claims can be proved. How can physicians continue to claim that they must carry out the wishes of the infants' parents?

"Principle VII. A physician shall recognize a responsibility to participate in activities contributing to an improved community."

The United States is the only country in the world that removes part of the normal penis from a majority of its males for nonreligious reasons. Thus, stopping a procedure that many consider profoundly harmful and sexually debilitating will contribute to an improved community.

Why Does the Practice Persist?

Circumcision persists because circumcision has produced circumcisers. Many men who have been cut have yet to acknowledge that an injury has been done to them. As a consequence, they may have their son cut; if they become doctors, they may perform this procedure on thousands of innocent males. A conspiracy of silence among doctors, and in the community, has helped to perpetuate this practice, because circumcision could not continue in the United States and Canada without the doctors who perform it.

Usually, neonatal circumcision is performed without anaesthesia. It is excruciatingly painful.4 Some experts recognize it as a betrayal of the trust that an infant has in its mother and hence it may interrupt maternal-infant bonding. Some scientists postulate that circumcision encodes violence into the brain at a highly susceptible moment in its development.6 Finally, circumcision carries risks of infection, bleeding, damage to adjacent tissues and organs, and death.7,8

Besides all of these harmful aspects, nonreligious circumcision, male and female, is a basic human rights violation- a violation by one person of the right of another person to an intact body.

The Solution

The solution to this ethical and human rights dilemma is simple: Do not perform circumcision on infants. By ceasing to perform infant circumcision, nothing is lost. Any adult male may, with fully informed consent, have a circumcision whenever he wishes.

As the public becomes aware of the accumulating scientific evidence, circumcision is declining, and with the current attention to unnecessary cost, insurance plans are ceasing to pay for circumcision. Most hopeful of all, caring physicians are reviewing this operation in the light of their own ethical standards and are ceasing to perform infant circumcision.

References

  1. Denniston GC: Coverage of circumcision. CMAJ 1995; 153 (10): 1420
  2. Taylor JR, Lockwood AP, Taylor Al. The Pispuce: Specialized mucosa of the penis and its loss to circumcision. Br J. Urol 1996: 77:291-5.
  3. Report of the Ad Hoc Task Force on Circumcision. Pediatrics 1975; 56 (4): 610
  4. Amand KJS, Hickey PR: Pain and its effects in the human neonate and fetus. N Engl J Med 1986; 317: 1321-1326
  5. Denniston GC: Unnecessary circumcision. The Female Patient 1992; (17): 13-14
  6. Prescott J: Genital pain vs genital pleasure: Why the one and not the other? The Truthseeker 1989; 1 (3): 14-21
  7. Gairdner D: Fate of the foreskin. BMJ 1949; 2:1433-1437
  8. Wallerstein E.: Circumcision, the uniquely American medical enigma. Urol Clin North Am 1985; 12 (1): 123-132
Clinical Assistant Professor, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington, U.S.A.
Correspondence and reprint requests to: Dr G. C. Denniston, 2442 Newmarket Street, Suite 42, Seattle WA 98107