I Paid Out-of-Pocket for My Son's Circumcision at Happy Valley Tattoo and Piercing: Alternative Framings of the Debate over Routine Neonatal Male Circumcision

Michael Benatar and David Benatar (2003) frame their analysis of routine neonatal male circumcision (RNMC) in terms of the "medical" costs and benefits of a surgical procedure. This is a common structure for the analysis of this issue, used for example by the American Academy of Pediatrics' (AAP) Task Force on Circumcision and the Canadian Paediatric Society's Fetus and Newborn Committee. The authors argue that the claims that RNMC is unethical because it constitutes mutilation, unacceptable mutilation, or is performed without the infant's consent are contingent on the procedure's costs and benefits. The authors, however, neglect to consider other possible framings that entail important ethical considerations:

1. they neglect to consider the economic costs of the procedure;
2. they do not analyze it from a community perspective;
3. they ignore parents' actual reasons for having the procedure performed; and
4. they contend that analyzing what "nonmedical" benefits medicine should be used to secure is beyond the scope of their paper.

Analysis of these alternative framings could yield vastly different normative conclusions, ranging from "RNMC is mandatory to decrease the transmission of the Human Immunodeficiency Virus (HIV)" to "it is discretionary but should not be performed by physicians."

An analysis of costs and benefits should be comprehensive. In their analysis the authors focus on the "medical" costs and benefits: the pain and complications of the procedure, as well as the prevention of penile cancer, urinary tract infections, and sexually transmitted diseases. The authors do not consider the dollar cost in their analysis of "Alleged Costs and Benefits." If the potential benefits only slightly outweigh the costs, the monetary cost of the procedure is surely a legitimate consideration in the parents' decision making. The profitability of the procedure might also have an indirect effect on physicians' attitudes toward it.

The authors do refer to financial costs under the heading "Culture," where they state, "Two papers that performed a formal cost-benefit analysis of neonatal male circumcision also reached the conclusion, given the nature of the medical evidence, that cultural and religious considerations should determine whether circumcision is performed." Ganiats et al. (1991) do not fully support this interpretation. Their cost-utility analysis includes most of the common considerations, such as preventing urinary tract infections, but it eliminates other factors, including the prevention of sexually transmitted disease. They conclude that RNMC is not cost-effective: in contrast to most medical interventions that cost money to save health, RNMC both costs money and decreases health. When the net dollar costs and health effects are calculated per person, they are $102 and 14 hours of healthy life. Ganiats and colleagues assert that these effects are negligible and that personal factors are therefore legitimate considerations. Benatar and Benatar cite the latter conclusion, privileging the analysis at the individual level over the community level without justification.

The aggregate cost-effectiveness of RNMC is important for decisions regarding community healthcare expenditures such as Medicaid. Several states, including South Carolina and Arizona, have withdrawn Medicaid funding of RNMC. Arizona's recent decision to eliminate funding was, in part, an attempt to balance the state's budget and was estimated to save the state $554,400 in direct Medicaid payments (Griffiths 2002). Alternatively, one could use cost-effectiveness data to compare RNMC to other potential medical interventions.

RNMC could also be framed as a public-health issue rather than as a decision made by parents. Public health focuses on the prevention of disease and premature death through collective action. Interestingly, the discussion of RNMC focuses on prevention but tends to be individualist rather than community focused. The authors argue that circumcision seems to lower susceptibility to HIV infection in high-risk heterosexual groups. This...