Physician Obligation, Cultural Factors, and Neonatal Male Circumcision

In general, Michael Benatar and David Benatar (2003) provide a solid review of important considerations in neonatal male circumcision. It is in the second-to-last section of the text, subtitled "The Burden of Proof," that greater analysis is needed (they themselves recognize this). If the medical risks and benefits do not dictate or prohibit the practice of neonatal male circumcision, then the authors leave us to weigh the nonmedical benefits for permissibility. They posit that medical benefits should not be presumed to trump other types of benefits. This leads the authors to conclude that neonatal male circumcision appropriately could be performed at the discretion of the parents. However, this conclusion focuses on permissible or reasonable choices that a particular set of parents might make about a particular child. Even if parents are reasonable to request circumcision, it does not mean that the medical profession should be involved in the practice. Some benefits should be privileged above other benefits in understanding the role of a physician as a professional. The degree to which medicine can be used for cultural benefits relies both on what might be permitted for parents to have performed and what physicians should perform, encourage, or discourage. In the case of neonatal male circumcision, physicians should actively discourage the practice and not simply leave it as an unproblematic decision for parents.

The authors' stance hinges on a presumption identified in their first formulation of "surgery is impermissible unless it offers clear and significant net medical benefit." Although they seem to reject this for a second formulation in which "medical" is omitted, the first formulation fits well with the goals of contemporary medicine. The presumption in their first formulation needs to be modified in order to make it most relevant to the current discussion. The formulation should be, "surgery is impermissible for incompetent patients unless it offers clear and significant net medical benefit." This modification distinguishes between elective procedures performed on competent, consenting adults and procedures performed on incompetent patients whose interests are represented by surrogate decision makers. Although contemporary medicine values social context and particular patients' health and values, a neonate must still develop his own values and make choices within his context. Unlike incompetent adults, we cannot predict a neonate's future values by looking to his past values. The family's values act as vague but grossly incomplete indicators. In order to protect future options and value development for the child, as a member of a vulnerable population, medical professionals should not be active in the promulgation of the practice.

Formal religious reasons for circumcision often carry the day in discussions of permissibility. As the authors rightly point out, American society has not allowed formal religious practices to permit even the least destructive forms of female circumcision. Although religious traditions should be respected, they can be tolerated and condoned only within understandings of societally acceptable practices. Again, this suggests a move toward rejecting the modification of healthy "normal" tissue in an infant when there are no clear medical indications.

Reasons given to support circumcision are often sociological. One of the most common formulations is, "I do not want to have my son ridiculed in the locker room." On the surface it is reasonable for particular parents to use this concern for social development in guiding decisions about their son. However, it is unfortunate that this distinction in circumcision status becomes a reason for ridicule in a locker room. The ridicule is based on intolerance and a particular view of the normalized altered body as good. For physicians to promulgate circumcision because of the "locker room" reason would be reinforcing these biases. Further, the "locker room" argument rests on the misconception that almost all North American males are circumcised, when only approximately 60% are circumcised (Smith 1998). Finally, in other circumstances the "locker room" reasoning would be judged egregious. For instance, a parent might say that he does not want his son making friends with a person of another "race," since this might create ridicule for his son while living in a relatively racially homogenous community. We would find this type of racism unacceptable even...