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The American Journal of Bioethics 3.2 (2003) 49-50

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Who Speaks for Sons?

Michelle A. Mullen
University of Ottawa

Concluding that the benefit/risk ratio is equivocal, Benatar and Benatar (2003) also conclude "nontherapeutic circumcision of infant boys" with normal healthy penises "is a suitable matter for parental discretion." Absent from their analysis are the following questions:

  1. What is the moral foundation for altering the genitalia/bodies of healthy infants for nonmedical reasons?
  2. What short- and long-term suffering from the procedure is justifiable?
  3. Are provided analogies authentic (e.g., procedure akin to amputating a gangrenous limb)?
  4. If there is a failure for moral foundation to support the procedure, what, if anything, ought we to do about it?

How Parents (Ought to) Decide for Children

The moral foundation for healthcare decisions for infants and young children arises, however unsteadily, from the idea of "best interests" of the child. Thus healthcare decisions are predicated primarily on benefits we hope accrue to the child—for example, protection from fatal or debilitating diseases with vaccination, despite attendant risks that are seen to be generally far more infrequent and less severe than the disease vaccinated for. In the circumcision of healthy male infants, however, the benefits are equivocal. Uniform effects are the irreversible removal of healthy erogenous tissue and acute pain. Infrequent but catastrophic risks include penile mutilation or amputation, hemorrhage, and, extremely rarely, death (Kaplan 1983; Goldman 1997). Benefits to neonatal circumcision may include religious and cultural acceptance and continuity. These are remote from the medical risks/benefits, however, and I will return to them.

Control and Impact of Pain

Appropriately, Benatar and Benatar explore the problem of absent or inadequate analgesia as the norm for infant circumcision. They cite research that demonstrates nerve block techniques are superior to topical creams such as EMLA. They assert that the limited use of blocks is attributable to "misperceptions" that it is difficult to perform, and they further assert that the analgesia can be "administered with ease." The reluctance of experienced pediatric practitioners to undertake the practice (which, to be clear, involves sticking needles into small neonatal penises) merits some concern. The authors are dismissive of any reasons for concern about postoperative pain, stating that they are unaware of any studies in this area. Absent the studies may be, but there is a prima facie case to suggest that scalpel wounds to genitals that are then exposed to regular coatings of urine and feces (as in a diaper) would be painful. Neither is there any accounting of a growing literature that indicates that not only do neonates experience pain, but they might sustain long-term changes in sensitivity to pain and worsened pain perception as a result of inadequately controlled pain in infancy (Anand 2000).

Analogical Problems:
Aesthetic Preference or Mutilation?

The authors devote some energy in developing analogies to the procedure in an effort to minimize assertions by some that it is mutilating. On their account, comparisons to major cosmetic procedures such as liposuction, rhinoplasty, and breast reduction suggest that infant male circumcision can be seen as altering, not disfiguring. This analogy fails because capable adults who wish them for their own reasons seek these elective procedures. Further, the authors pursue a false analogy, arguing that mutilating procedures are sometimes necessary for health reasons: in their example, amputation of a gangrenous limb. The fundamental difference and the heart of the problem is that the tissues removed during routine infant male circumcision are healthy tissues. While in my view this overstates the case, the correct comparison would see elective circumcision as akin to amputation of a healthy limb.

What's a Person to Do?

On the issues cited here, the Benatars' analysis reads as something of an apologia for parents wanting their healthy sons circumcised. Yet there is important value in their work: it has placed an almost taboo subject back onto the ethics and pediatrics radar. Moreover, there is real value in positioning the issue outside extreme polar views. We do have an interest in the health, safety, and comfort of infant male children. The (medical...