To cut or not to cut: the circumcision wars

 

The American Academy of Pediatrics recently revised its policy on male infant circumcision. Its former policy, formulated in 1999, held that there were “potential” benefits to circumcision, but not enough to recommend it routinely. The new policy, drafted after a review of the most recent medical studies, states that the potential benefits of circumcision outweigh the potential risks, and that “the procedure’s benefits justify access to this procedure for families who choose it.” The benefits are not strong enough to recommend universal circumcision; the policy states that the decision should be left to parents.

Is this a major ethical issue? There are many groups that ardently believe it is. Anti-circumcision groups (“Intactivists”) have raged against the policy statement. Listening to the argument from both sides is like a primer on ethical theory.

One side appeals primarily to consequentialist or utilitarian arguments: the overall benefits outweigh the overall risks, so it’s ethically permissible. The other side responds to the consequentialist arguments (“You overstated the benefits and understated the risks!”), but uses primarily deontological arguments: to do a medically unnecessary procedure is always wrong. Genital integrity is a human right. From a virtue ethics viewpoint, circumcision proponents have portrayed the decision to circumcise one’s infant son as an example of virtuous parenting, and I can imagine an “intactivist” group asking, “What kind of doctor (or parent) would do that?”

The argument has also been couched in the language of The Four Principles. Some appeal to non-maleficence: to circumcise risks causing harm, so it should not be done. Others appeal to beneficence: circumcision might do some good, so it is justifiable. Others cite autonomy as the most important principle: an infant cannot consent to a circumcision, so it should not be done before adulthood and only if the patient consents. There are even appeals to justice; a recent article in the Archives of Pediatrics and Adolescent Medicine estimated that the avoidable medical costs to the US medical system caused by the decline in circumcision rates could exceed $4.4 billion.

On the surface, the current debate over circumcision is unresolvable, because the argument isn’t about verifiable scientific data; the different sides are speaking different ethical languages. Depending on which ethical calculus one uses, either side could be understood to have the more compelling position. The debate also highlights the glaring weakness of appealing to the Four Principles to resolve ethical differences: there is no inherent hierarchy for which principle is more important, and in the case of infants the usual recourse to “Autonomy trumps everything else” doesn’t work well.

I am personally agnostic on the question. I perform circumcisions, so I suppose that excludes me from the “intactivist” camp. But I do not advocate for or against circumcision; I find that most parents come with an idea of what they want to do, and nothing I say in the informed consent changes that. I think the vehemence of some on either side is misplaced; on a topic of such “un-clarity,” a charitable tone is far more appropriate than incriminating rhetoric.

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James Anderson

“Just as we call sex without consent ‘rape’, circumcision without consent or reasonable justification should be called ‘mutilation’.”

Johns Hopkins – Bioethics