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The American Journal of Bioethics 3.2 (2003) 59-60



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Neonatal Male Circumcision:
Ethical Issues and Physician Responsibility

Caroline McGee Jones
The University of Texas Health Science Center, San Antonio

The controversy surrounding the practice of neonatal male circumcision is long-standing and emotionally charged. Medical literature on the topic reveals vastly disparate opinions concerning the value and moral acceptability of the procedure. At one end of the spectrum are individuals who view the procedure as a medical necessity and an important component of preventive healthcare. At the other extreme are those who maintain that circumcision represents bodily mutilation and is thus tantamount to child abuse. In their article on the ethics of neonatal male circumcision, Michael Benatar and David Benatar (2003) reject both extremes. The American Academy of Pediatrics (AAP) adopts a similar position in its most recent policy statement on neonatal male circumcision (1999). In this statement the AAP examines the risks and benefits of the procedure and concludes that parents should ultimately decide what is in the child's best interests. This recommendation raises two important issues that warrant further analysis. The first seeks to define the term "best interests" and to identify factors that contribute to a child's well-being. The second evaluates the physician's responsibility in contributing to the decision process and in establishing standards for performing the procedure.

The Best-Interests Standard

Critics of neonatal male circumcision cite the infant's inability to give informed consent as a compelling reason to abolish the procedure. However, parents and pediatricians routinely make decisions that have significant impact on and long-term consequences for a child's health and well-being. This proxy decision making is morally acceptable as long as the decision is based on considerations of the child's best interests. Thus, the relevant issue is not who has the moral authority to authorize the procedure. Rather, emphasis should be on defining a best-interests standard and determining whether circumcision is compatible with this definition.

In some situations a child's best interests may be defined exclusively in terms of medical criteria. For example, if a child experiences an acute asthma exacerbation and stops breathing, he or she is likely to die unless placed on a ventilator. In this scenario there is no question as to what course of action serves the child's best interests. In most situations, however, the choices and potential consequences are less straightforward. Deciding what course of action to take involves weighing the benefits and risks associated with the decision. An action is morally acceptable when the potential for benefit outweighs the potential harm.

Efforts to settle the dispute over the ethical acceptability of neonatal circumcision have adopted an evidence-based approach to evaluating the potential risks and benefits of the procedure. Such efforts have failed to identify definitive and objective evidence in support of or opposition to the routine practice of neonatal male circumcision. Benatar and Benatar provide a helpful review of [End Page 59] existing medical evidence on the risks and benefits of circumcision. This evidence suggests that circumcision confers some medical benefit, primarily by means of slight reductions in the incidence of penile cancer, urinary tract infection, and transmission of HIV. These benefits, however, are offset by risks associated with the procedure. The primary risks include pain, infection, and bleeding.

The conclusion to be drawn from existing evidence on the risks and benefits of neonatal circumcision is that the procedure neither promotes nor threatens a child's physical well-being. Thus, it is ethically acceptable for parents to make the decision based on what they believe to be in the child's best interests. This freedom allows for a more comprehensive approach to promoting health and well-being. After all, a child's well-being is not determined by medical criteria alone. Children grow and develop in an environment shaped by the values and experiences of their parents, teachers, friends, and so on. Thus, well-being is the cumulative effect of social, economic, and cultural factors. Studies have shown that parental beliefs about...

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