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The American Journal of Bioethics 3.2 Web Only (2003)

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Can Anyone Authorize the Nontherapeutic Permanent Alteration of a Child's Body?

George Hill
Doctors Opposing Circumcision

Michael Benatar and David Benatar's (2003) "cost-benefit" analysis of male circumcision rests on the premise that the major "cost" is pain during the procedure and that this can be alleviated with local anesthesia. They say nothing about pain afterward, nor do they discuss the literature on aftereffects: interference with breast feeding (Howard, Howard, and Weitzman 1994), disturbed sleep (Anders and Chalemian 1974), elevated cortisol levels (Emde et al. 1971), increased sensitivity to pain (Taddio et al. 1997), and so on. They say much more about "benefits." They recite the familiar case for "prophylaxis" against a variety of diseases. Despite the objective tone, however, their article is yet another defense of a procedure that has been in search of justification for more than a century—a matter well documented by Gollaher (2000), who the Benatars cite in another context.

The Benatars' statement that "circumcision has received negligible attention" in the bioethics literature is inaccurate. In fact, there have been extensive discussions in both the bioethics literature (Denniston 1996; Price 1997; Hodges 2002) and the general medical literature (Kluge 1993; Warren 1996; Canning 2002). In all papers, the authors found male neonatal non-therapeutic circumcision to be highly unethical. More importantly, perhaps, are the very extensive discussions that have appeared in the legal literature (Brigman 1985; Richards 1996; Povenmire 1998-99; Boyle 1999; Edge 2000; Svoboda 2000). The authors all question the lawfulness of the non-therapeutic circumcision of children. Certainly, if circumcision is an unlawful medical practice, then it is also an unethical medical practice.

The Benatars argue that the circumcision of children is a suitable matter for parental discretion. They fail to show, however, that the circumcision of children is an ethical procedure for doctors to carry out. In all cases involving children, it is essential to remember that the child is a separate person from the parents. The interests of the two may diverge and that is certainly true in the matter of male circumcision. A child has a separate set of rights and privileges, and it is to the child that the doctor's responsibilities are directed (Committee on Bioethics 1995). The doctor must keep the child-patient's interests paramount (Council 2001). The doctor must provide medical care based on the patient's needs, not what someone else desires (Committee on Bioethics 1995). Since no infant needs a circumcision, the doctor has an obligation to not perform the circumcision. Nonessential procedures should be deferred until the patient is sufficiently mature to decide for himself (Committee on Bioethics 1995). The doctor has a duty to listen to the child (Shield and Baum 1994) and, since circumcisions clearly are not essential for child health (Task Force 1999), the doctor has a duty to defer a non-therapeutic circumcision until the child can decide for himself.

The Benatars are silent on developments in Europe. Article 20(1) of the European Convention on Human Rights and Bioethics (1997), now in force in 15 nations, prohibits organ or tissue removal on a person who does not have thecapacity to consent. This obviously applies to non-therapeutic circumcision of children. The Norwegian Council for Medical Ethics has determined that the circumcision of male children is an unethical procedure because of human rights concerns and lack of consent by the patient (Gulbrandsen 2001).

The foremost "cost" of male infant circumcision—never mentioned by the Benatars—is the loss of the most heavily innervated tissue in the male genitals (Taylor, Lockwood, and Taylor 1996) and the resulting loss of substantial sexual sensation in adult life (Falliers 1970). The Benatars know this. Gollaher's book includes a chapter describing research on the anatomy and functions of the foreskin. But, rather than facing this very real issue, the authors drift into a pointless academic discussion of the meaning of mutilation—a gigantic red herring—which leads them to the comfortable conclusion that talk...


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