What is Mutilation?

Michael Benatar and David Benatar (2003) present us with a detailed and balanced analysis of the relevant literature regarding the benefits and risks associated with the routine circumcision of infant boys. In the course of doing so, they conduct a brief analysis of the concept of mutilation and its application to the topic at hand. I believe a developed understanding of "mutilation" is important for medical ethics, and it is to this topic that I devote my commentary.

The Stedman's Medical Dictionary entry on mutilation, quoted by Benatar and Benatar, is somewhat ethically underdeveloped. In baldly defining mutilation as a "[d]isfigurement or injury by removal or destruction of any conspicuous or essential part of the body," it gives a neutral physical description devoid of ethical conclusions. This way of defining is appropriate for scientific facts and medical procedures but is inadequate as a starting point for ethical analysis. It is as if one defined bank robbery as the gaining of large sums of money from financial institutions. The description might be physically accurate, but it is completely misleading for ethical analysis. The Stedman's definition, applied literally, would cover various forms of cosmetic surgery, but that would enlarge the scope of mutilation to denude the term of its focal meaning.

In common usage, mutilation denotes a harmful and illicit action. My Merriam Webster's Collegiate Dictionary, 10th ed. (1999), defines mutilation as follows, "1: to cut up or alter radically so as to make imperfect; 2: to cut off or permanently destroy a limb or essential part of: cripple." The implication is that acts of mutilation violate the physical integrity of a person. Doing harm to the patient is then the essence of mutilation. Medicine has as its first principle, "do no harm"; mutilation is therefore outside the practice of medicine. A medical professional who performs an act of mutilation is not practicing medicine.

So, rather than saying that "[w]here a mutilation is, all things considered, a benefit, it can be considered morally justifiable," as Benatar and Benatar do, I think a clearer analysis is produced by considering these situations in a different way. A surgical procedure such as the removal of a gangrenous foot is not a justifiable mutilation; it is simply not a mutilation at all. No patient in that situation should believe their doctor mutilated them. The physical action of removing the foot is ethically described as an amputation, with amputation being understood as a kind of surgical cure performed on diseased appendages of the body. Likewise, we do not speak of doctors "justifiably harming" their patients in performing an appendectomy but rather view the foreseeable physical detriments suffered by the patient as a result of treatment (bleeding, pain) as unintended side effects. If those unintended bad effects are proportionate to the benefit, then the procedure can be ethically justified.

Thus far I have spoken in generalities, but I would also like to provide some concrete advice to practitioners. One implication of my analysis is a limitation on patient autonomy. While Benatar and Benatar state that "[e]ven the most ardent opponents of circumcision have no opposition to an autonomous adult's choosing to be circumcised," I would hold that if in a given case an act of circumcision was properly described as an act of mutilation, then a doctor would be acting unethically to perform the procedure even where the request for the procedure comes from an adult patient. Likewise, if the routine circumcision of newborns is not a medically justifiable prophylactic procedure but an act of mutilation, then no doctor should perform such procedures. Currently, the mixed nature of the evidence and my lack of familiarity with the literature make me ill-equipped to come to a definitive opinion on the issue. There are inherent difficulties in balancing the prophylactic benefits against rare diseases against the incommensurable negative burdens of the procedure, such as pain and suffering to the newborn...