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Ethics of Circumcision

 

Contents:

1. An excerpt from the Encyclopedia of Bioethics about children and biomedicine in general
2. Prof. Margaret Somerville, a Canadian ethicist, has written a book about ethics with a chapter about infant circumcision.
2a.. Excerpts from an earlier article by her.
3. The American Medical Association's 2001 Principles of Medical Ethics.
3a. An excerpt from the American Medical Association Code of Ethics.
4. A call for circumcision to be outlawed in Sweden
5. The Ethical Triangle
6. A petition to the World Court in the Hague.
7. An extract from a textbook of medical ethics.
8. A faulty bioethics article by David and Michael Benetar, widely cited by circumcision advocates
9. The problem of "dual loyalty" - to the patient and to others - for physicians
10. An important article critcising rationalisations for genital mutilation of both sexes
11. Winners of NOCIRC's 2005 student essay contest: "Is circumcision ethical?"
12. Relevant paragraphs from the AMA Council on Ethical and Judicial Affairs
13. New study finds circumcision unethical
14. Doctor admits existing consent form understates risks.
15. Norwegian Medical Association finds ritual circumcision unethical.
16. A letter to the Journal of Medical Ethics about the ethics of infant circumcision, especially in the light of claims about HIV.
17. A Jesuit ethicist takes a strong stand one way, then the other.
18. A BBC podcast about moral relativism. Reference to the ethical equivalence of male and female genital cutting is about halfway through (~14' in).
19. Affidavit of a highly qualified doctor, Chair of the AAP Bioethics Committee, regarding proxy consent vs clinical judgement.
20. Circumcision in boys and girls: why the double standard? Letter to the British Medical Journal
21. Ethical doubts raised in a Turkish journal


i. ii. and iii. Links to articles about the "inappropriateness" of granting adult requests for elective amputations
iv. Ethics of taking a baby's umbilical blood.
v. How a Christian ethicist, Dr Douglas Diekema, reconciles faith and ethics (see also No 19)

 

1. Children and bioethics

Infant circumcision, instituted without any clinical trials and investigated only after it was customary, deserves much the same ethical scrutiny as non-therapeutic research. At present it is held to a much lower ethical standard - if any.

The following is from the Encyclopedia of Bioethics, Free Press (Macmillin) London, 1978.
My emphasis in red.

CHILDREN AND BIOMEDICINE

Implicit in all deprivations of equal status for children is the notion that it is permissible for an adult to substitute his judgment for that of the child (Dworkin; Schrag), based on the assumptions that the adult has the best interests of the child at heart, and that he or she is better qualified than the child to make decisions in the child's interest. While these assumptions are true enough to gain acceptance as general principles, the exceptions are sufficiently common to arouse concern (Fost; McCollum and Schwartz; Robertson and Fost). This concern over paternalism applies to purely therapeutic as well as experimental interventions. ... a parent who initiates a behavior modification program for his child's bed-wetting may be primarily seeking relief of his own annoyance and might have difficulty establishing that the benefit-risk ratio of the behavior program is more advantageous to the child than continuation of the symptom....

Experimentation in children

The many and complex problems of human experimentation are compounded in the pediatric setting by four factors. First, children are not simply small adults, but are biologically different in many ways, so that knowledge acquired from adult subjects often cannot be applied to children without testing them. ... Physical injuries that might be trivial in a mature person (such as radiation of the growing portion of a long bone [or damage to the penis - HY]) can become magnified when occurring early in the developmental process. Events that may have little psychological significance for an adult, such as a short hospitalization or repeated venipunctures, may have profound detrimental effects on a child. Fourth, uncoerced informned consent, the keystone of protection of human subjects, is often unattainable from the minor [and never obtainable from the newborn - HY].

There is broad consensus that therapeutic expenmentation - nonstandard interventions that have the explicit primary intent of helping the subject to whom they are being applied - can be practiced in children without major modification of the rules that apply to experimentation in general, so long as consent from a legally authorized representative is given (Curran and Beecher; Great Britain; World Medical Associaton). This is not to imply that the present regulation of of adult experimentation is satisfactory, or that parental consent for nontherapeutic experimentation is satisfactory. But it is in the realm of nontherapeutic experimentation where concerns are greatest. Ideally, risk, benefit. and consent should all reside in the same person. When nontherapeutic research is conducted on a child, it is the child who bears the risk, while future persons gain the possible benefits, and a third party, without risk or benefit, gives consent.

Whether or not parents can legally consent to nontherapeutic interventions on their children is unresolved. The Nuremberg Code does not mention children but implies they should be excluded as subjects by stating it is absolutely essential ... that the person involved should have legal capacity to give consent." The Declaration of Helsinki allows nontherapeutic studies on children with consent of the legal guardian. Current (1976) regulations of the U.S. Department of Health, Education, and Welfare (DHEW) do not distinguish between the right of the guardian to consent for nontherapeutic versus therapeutic research.

...The case of Neilsen v. Regents of University of California raised, for the first time, the explicit question of whether a parent may volunteer a child for nontherapeutic research.

Related cases come from the field of transplantation, arising when physicians and/or parents seek to use a legally incompetent person as kidney donor for a relative. The general response of courts has been to require a finding of benefit for the donor, such as the advantages derived from future experiences with the recipient should he survive, or the avoidance of remorse due to loss of companionship or later guilt from realizing that one had failed to come to the aid of his sibling (Baron, Botsford, and Cole). In instances where the donor was incapable of experiencing such benefit because of severe mental disability or where the social contact with the sibling was not close, permission to allow the transplantation has been denied (Lausier v. Pescinski; In re Richardson). While many of the cases regarding incompetent donors involved intelligent adolescents or retarded adults, the general principle of the legitimacy of proxy consent would seem applicable to children in general, and at least one appellate case did involve a seven-year-old donor (Hart v. Brown).

In contrast is the famous and much disputed case of Bonner v. Moran, in which an appellate court ruled that a skin graft taken from a fifteen-year-old boy could not be upheld unless the mother consented. One legal scholar takes the decision to imply that such parental consent would have made the procedure valid, despite the absence of a direct benefit (Curran and Beecher), but the decision as written leaves room for disagreement as to how much it can be extended to nontherapeutic experimentation (Capron).

In Great Britain the Medical Research Council has stated that "parents and guardians of minors cannot give consent on their behalf to any procedures which are of no particular benefit to them and which may carry some risk of harm," although legal precedent or authority for this is obscure (Curran and Beecher).

Proxy consent

As with other ethical issues, the already complex and unresolved problems of consent are compounded when children are involved. The assumption that parents can provide uncoerced informed consent for their children rests at least on the presumption that they can provide it for themselves. There is evidence that educated, competent adults are frequently not adequately informed to give meaningful consent (Fellner and Marshall; Fletcher; Gray), so their ability to speak for others may be questioned. The barriers may not be so much a lack of intelligence or motivation on the part of patient or physician as more complex forces such as the anxiety of illness, the intimidating milieu of the hospital, and a sense of awe, trust, and dependence on the physician-all of which may conspire to make solicitation of consent a ritual wherein few are meaningfully informed (Ingelfinger).

In addition to these general barriers to informed consent, there are aspects peculiar to the parent-child relationship that complicate the matter further. The perceived vulnerability of the child may evoke excessive anxiety, which further clouds judgment. The parent may be acting out unconscious hostile wishes against the child, particularly if he is retarded or deformed. There may be a wish to repay the physician-investigator for prior service by offering the child as a sacrifice.

Even if these obstacles were overcome, the practice of proxy consent rests on other notions under challenge: the claim that a person may ever consent to a nontherapeutic intervention on another (Ramsey, 1970, 1976); the assumption that adults can reliably assess what is in a child's best interest; and the faith that they are capable of acting in a person's best interest, even if it can be accurately identified. The observation that adults frequently cannot identify or act in their own best interest - as manifested by decisions ranging from smoking and drinking to marriage and financial investments - undermines these assumptions.

Two common justifications for proxy consent are the substituted judgment doctrine, a legal doctrine which suggests that decisions be based on what the person would be likely to do if competent (Robertson), and the ethical notion that a child can be volunteered on the basis of what he ought to do (McCormick).

The substituted judgment doctrine is weakened by the inability of an adult to know the child's mind. Put another way, the adult may err by being able only to imagine what a reasonable adult would do if in the situation of the child, thereby fallaciously equating adult values and preferences with those of children. An adult might gladly consent to a venepuncture, a procedure of minimal risk and annoyance, but for a child the same event could be a major psychological trauma. Presumptions of what adults would do may suffer from misperceptions of the empirical situation. One could presume that adults probably would consent to minimally hazardous nontherapeutic procedures, but in many communities they in fact do not participate, unless offered significant inducements. One implication of this might be that a minimum requirement for the use of nonconsenting children in non therapeutic studies (assuming other objections can be overcome) would include some age-appropriate indirect benefit or reward comparable to the monetary rewards that an adult would receive.

McCormick has argued that children may be used for nontherapeutic studies to which they ought to consent, on the grounds that there are some sacrifices all members of the human community ought to make, and it is in their interest to do so. While there might be agreement on what sacrifices people ought to make, many would object to the recruitment of children without their consent, unless adults were also required to participate on the same grounds, unrelated to their consent.

Ramsey has taken the extreme view that proxy consent for nonbeneficial experiments in children are unethical without qualification (Ramsey, 1970). He later modified this by acknowledging that such research might be done so long as one acknowledged that he was "doing wrong for the sake of the public good" (1976). Reluctantly admitting that it might be wrong, in some circumstances, not to do the research, he seemed to be pointing up an aspect of all true ethical dilemmas: that they involve conflicts of two important obligations, with the inevitable consequence that something of value will be lost no matter which way the conflict is resolved.

As the child gets older - and intellectual and emotional maturity allow him increasingly to participate in decisions - some have advocated a requirement that the child consent in addition to the parent, even though the child may be legally incompetent (U.S. DHFW, National Institutes of Health). While such a practice sounds appealing, there is some evidence that a principle may be honored at the expense of the child's emotional well-being. One study concluded that children informed of the research nature of their hospitalization experienced overwhelming anxiety, due in part to fantasies aroused by their primitive notions of research (Schwartz).

Rules based on inflexible age boundaries may not serve the needs of individual persons. Many children can and should be included in discussions of their participation in research; many adults are incapable of participating meaningfully. Ideally, decisions would be based on a full consideration of the facts in each case, including the probability of discomfort and risk and the emotional and intellectual capacity for consent in each child.

Requirements for consent serve two functions: protection from unacceptable risks and respect for the autonomy of each individual. It appears that trust in consent as protection from unacceptable risks has been misplaced (Fletcher; Gray) and, in the case of young children, respecting autonomy may be impossible unless nontherapeutic research is avoided entirely. If such studies are to continue, it will be necessary to pay attention to Ramsey's reminder that it is not an unmitigated good, that something of value is being lost, and that it is possible for a subject to be "wronged without being harmed" (Ramsey, 1970).

 

2. A more direct approach

A Canadian ethicist, Dr Margaret Somerville (Gale professor of law and a professor in the faculty of medicine at the McGill Centre for Medicine, Ethics and Law), has addressed the issue of infant male circumcision directly. Here are excerpts from an article she wrote (in The Gazette, Montreal, on October 24, 1998, pB6):

"The usual ethical and legal justification of any parent-sanctioned surgical wounding of a child is that this must be undertaken with a therapeutic intent.

"As the Canadian Pediatric Society has recognized, routine infant male circumcision is not therapeutically necessary. Parents cannot give an informed consent to non-therapeutic interventions on their children that involve any more than the most trivial harm. Infant male circumcision does not fall within this description,...

"I believe that it does [have harmful effects], including the irreversible loss of healthy, erogenous tissue, the risks involved in the procedure itself and the pain that this procedure involves.

"We need to keep in mind an old saying in human rights: "Nowhere are human rights more threatened than when we act purporting to do good". This is true because when we are seeking to do good, we can be insensitive to the fact that our conduct also involves doing harm.

"Respect for [children's human] rights requires that we must have very substantial justification for subjecting a child to any risk through a surgical intervention, causing him pain or intervening to alter his body permanently, other than to provide necessary therapy for the child himself."

(Somerville's article was in answer to an HIV researcher who was defending circumcision to prevent HIV. Some other excerpts from this article are included on the page about HIV.)

Somerville has now written a book about ethics including a chapter about infant circumcision.

 

3. The American Medical Association's Principles of Ethics

The AMA has revised its Principles of Medical Ethics to add parts VIII and IX. The revised Principles were adopted in June 2001 by the AMA House of Delegates.

E- Principles of Medical Ethics

Preamble:

The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. [...and not to his parents or caregivers.]

IX. A physician shall support access to medical care for all people.

The AMA's Council on Scientific Affairs (not its Council on Ethical and Judicial Affairs) has prepared a policy statement on neonatal circumcision that makes no reference to these concerns.

 

3a. the American Medical Association Code of Ethics

3.6

Regardless of society's attitudes, do not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman, or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or convicted.

 

[4. Ban called for in Sweden This item has been moved to the page on events in Sweden.]

 

5. The Ethical Triangle

As the Encyclopedia of Bioethics item points out, there are three parties involved in a circumcision (four if the parents disagree). Their power and information relationships are wildly unequal:

ethical triangle: doctor/parents/baby

While the baby has no power, he experiences virtually all of the effects of the circumcision. For this reason, it is ethically lacking for the AAP and the AMA to say the parents should decide, based on whatever information they may have.

If the parents disagree, the present position in the US is that either may give permission for him to be circumcised. In the UK, both must. For an elective procedure now agreed by the AMA to be "non-therapeutic", the US position is untenable.

 

6. Petition
You can endorse the Ashley Montagu Resolution to End the Genital Mutilation of Children Worldwide, a Petition to the World Court, the Hague (offsite).

 

7. An extract from a textbook of medical ethics

Parental decisions regarding treatment options

In most jusrisdictions there is a fuzzy boundary between the age at which a child can give consent to her own treatment and the age at which parental consent must be sought. Most ethicists advise that the child be included as far as possible in the decision-making process, but for childre up to at least 16 years old, the parents should give consent to medical treatment.

The basis for the parental right to to choose treatment for children rests in the intuition that parents are protectors of the child and responsible for the child's care. This is regarded as the 'natural role' of parents and is recognised universally in legal codes. It is assumed that the parent is training and nurturing the child to bring that child to the point where she can make her own decisions. We act on the presumption that the parents will make decisions in the best interests of the child and, on this basis, empower them to do so. However, in certain situations, this presumption cannot be sustained.

[example of parents withholding blood transfusion on religious grounds] ... the child is made a ward of the court for the the duration of her treatment because the court believes that the parents are not acting in the best interest of the child.

This decision shows what we believe to be paramount in dilemmas involving children. We believe that the child's interests should come first.

Alastair Campbell, Grant Gillett and Gareth Jones
"Practical Medical Ethics" Oxford University Press
Auckland, 1992, p75

 

8. A faulty article

 

9. "Dual loyalty" and conflict of interest

The Problem of Dual Loyalty and Human Rights for Physicians

The organization Physicians for Human Rights has a publication authored by dozens of doctors around the globe on "The Problem of Dual Loyalty and Human Rights" in regards to physicians.

From the introduction:

The problem of dual loyalty - simultaneous obligations, express or implied, to a patient and to a third party, often the state - continues to challenge health professionals. Health professional ethics have long stressed the need for loyalty to people in their care. In the modern world, however, health professionals are increasingly asked to weigh their devotion to patients against service to the objectives of government or other third parties. Dual loyalty poses particular challenges for health professionals throughout the world when the subordination of the patient's interests to state or other purposes risks violating the patient's human rights.

Since ancient times, many societies have held healthcare professionals to an ethic of undivided loyalty to the welfare of the patient. Current international codes of ethics generally mandate complete loyalty to patients. The World Medical Association (WMA) Declaration of Geneva, the modern equivalent of the Hippocratic Oath, asks physicians to pledge that "the health of my patient shall be my first consideration" and to provide medical services in "full technical and moral independence." The WMA International Code of Medical Ethics states that "a physician shall owe his patients complete loyalty and all the resources of his science."

In practice, however, health professionals often have obligations to other parties besides their patients - such as family members, employers, insurance companies and governments - that may conflict with undivided devotion to the patient. This phenomenon is dual loyalty, which may be defined as clinical role conflict between professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer or the state. The dual loyalty problem is usually understood in the context of a relationship with an individual patient. In many parts of the world, however, clinicians have responsibilities to communities of patients, for prevention, health education and clinical care. Dual loyalty conflicts can and do arise in these settings as well.

The article in full

 

10. An important article.

JOURNAL OF MEDICAL ETHICS (U.K.), Vol 30: Pages 248-253, June 2004.

SYMPOSIUM ON CIRCUMCISION

Rationalising circumcision: from tradition to fashion, from public health to individual freedom-critical notes on cultural persistence of the practice of genital mutilation

S K Hellsten

(Abstract:) Despite global and local attempts to end genital mutilation, in their various forms, whether of males or females, the practice has persisted throughout human history in most parts of the world. Various medical, scientific, hygienic, aesthetic, religious, and cultural reasons have been used to justify it. In this symposium on circumcision, against the background of the other articles by Hutson, Short, and Viens, the practice is set by the author within a wider, global context by discussing a range of rationalisations used to support different types of genital mutilation throughout time and across the globe. It is argued that in most cases the rationalisations invented to provide support for continuing the practice of genital mutilation-whether male or female-within various cultural and religious settings have very little to do with finding a critical and reflective moral justification for these practices. In order to question the ethical acceptability of the practice in its non-therapeutic forms, we need to focus on child rights protection.

This is one of the first articles in an ethical journal seriously to criticise routine (non-medically indicated) infant circumcision side by side with FGM from an ethical perspective. It carefully considers individual vs collective rights and comes firmly down on the right of the child to bodily integrity and autonomy.

 

11. AMA Council on Ethical and Judicial Affairs

Here are some opinions from the AMA Council on Ethical and Judicial Affairs that are relevant to the practice of circumcision.

E-2.035 Futile Care
Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. Patients should not be given treatments simply because they demand them. Denial of treatment should be justified by reliance on openly stated ethical principles and acceptable standards of care, as defined in Opinion 2.03, "Allocation of Limited Medical Resources," and Opinion 2.095, "The Provision of Adequate Health Care," not on the concept of "futility," which cannot be meaningfully defined.
(I, IV) Issued June 1994.

E-3.01 Nonscientific Practitioners
It is unethical to engage in or to aid and abet in treatment which has no scientific basis and is dangerous, is calculated to deceive the patient by giving false hope, or which may cause the patient to delay in seeking proper care. Physicians should also be mindful of state laws which prohibit a physician from aiding and abetting an unlicensed person in the practice of medicine, aiding or abetting a person with a limited license in providing services beyond the scope of his or her license, or undertaking the joint medical treatment of patients under the foregoing circumstances. Physicians are otherwise free to accept or decline to serve anyone who seeks their services, regardless of who has recommended that the individual see the physician.
(III, VI) Issued prior to April 1977; Updated June 1994 and June 1996.

E-8.20 Invalid Medical Treatment
The following general guidelines are offered to serve physicians when they are called upon to decide among treatments:
(1) Treatments which have no medical indication and offer no possible benefit to the patient should not be used (Opinion 2.035, "Futile Care").
(2) Treatments which have been determined scientifically to be invalid should not be used (Opinion 3.01, "Nonscientific Practitioners").
(3) Among the treatments that are scientifically valid, medically indicated, and offer a reasonable chance of benefit for patients, some are regulated or prohibited by law; physicians should comply with these laws. If physicians disagree with such laws, they should seek to change them.
(4) Among the various treatments that are scientifically valid, medically indicated, legal, and offer a reasonable chance of benefit for patients, the decision of which treatment to use should be made between the physician and patient.
(I, III, IV) Issued June 1998 based on the report "Invalid Medical Treatment," adopted December 1997.

E-10.05 Potential Patients
(1) Physicians must keep their professional obligations to provide care to patients in accord with their prerogative to choose whether to enter into a patient-physician relationship.

(2) The following instances identify the limits on physicians' prerogative:
(a) Physicians should respond to the best of their ability in cases of medical emergency (Opinion 8.11, "Neglect of Patient").
(b) Physicians cannot refuse to care for patients based on race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination (Opinion 9.12, "Patient-Physician Relationship: Respect for Law and Human Rights"), nor can they discriminate against patients with infectious diseases (Opinion 2.23, "HIV Testing").
(c) Physicians may not refuse to care for patients when operating under a contractual arrangement that requires them to treat (Opinion 10.015, "The Patient-Physician Relationship"). Exceptions to this requirement may exist when patient care is ultimately compromised by the contractual arrangement.

(3) In situations not covered above, it may be ethically permissible for physicians to decline a potential patient when:
(a) The treatment request is beyond the physician's current competence.
(b) The treatment request is known to be scientifically invalid, has no medical indication, and offers no possible benefit to the patient (Opinion 8.20, "Invalid Medical Treatment").
(c) A specific treatment sought by an individual is incompatible with the physician's personal, religious, or moral beliefs.

(4) Physicians, as professionals and members of society, should work to assure access to adequate health care (Opinion 10.01, "Fundamental Elements of the Patient-Physician Relationship").* Accordingly, physicians have an obligation to share in providing charity care (Opinion 9.065, "Caring for the Poor") but not to the degree that would seriously compromise the care provided to existing patients. When deciding whether to take on a new patient, physicians should consider the individual's need for medical service along with the needs of their current patients. Greater medical necessity of a service engenders a stronger obligation to treat.
(I, VI, VIII, IX) Issued December 2000 based on the report "Potential Patients, Ethical Considerations," adopted June 2000. Updated December 2003.

* Considerations in determining an adequate level of health care are outlined in Opinion 2.095, "The Provision of Adequate Health Care."

 

12. New study finds circumcision unethical


LAW, ETHICS, AND MEDICINE

A covenant with the status quo? Male circumcision and the new BMA guidance to doctors

M Fox and M Thomson
School of Law, Keele University, Staffordshire, UK

ABSTRACT
This article offers a critique of the recently revised BMA guidance on routine neonatal male circumcision and seeks to challenge the assumptions underpinning the guidance which construe this procedure as a matter of parental choice. Our aim is to problematise continued professional willingness to tolerate the non-therapeutic, non-consensual excision of healthy tissue, arguing that in this context both professional guidance and law are uncharacteristically tolerant of risks inflicted on young children, given the absence of clear medical benefits. By interrogating historical medical explanations for this practice, which continue to surface in contemporary justifications of non-consensual male circumcision, we demonstrate how circumcision has long existed as a procedure in need of a justification. We conclude that it is ethically inappropriate to subject children-male or female-to the acknowledged risks of circumcision and contend that there is no compelling legal authority for the common view that male circumcision is lawful.

Full text: Journal of Medical Ethics 2005;31:463-469
If this link breaks, email me.

 

14. Doctor admits existing consent form understates risks.

From the PSOT blog

To Plastibell or Not To Plastibell?

Comment for the STFM procedure list dialog on Circumcison Techniques.

I have been unhappy with the Plastibell device...

Mogen is the easiest and fastest with excellent safety, but lack of fundamental skills with needle and thread intimidate many from being able to do these procedures past the newborn period.

Since we started Medicos, we have stopped doing circumcisions in the hospital. Our group concensus is that these are cosmetic procedures performed due to cultural influences within the family. We encourage family to consider them carefully and weigh the decision carefully. The immediate newborn period is a complex one in an artificial environment. We do circumcisions at the first visit which ranges from 2d to 2 months. I will perform Gomcos and Mogens up to 2 years of age with the occasional need to use sutures for bleeders.
Wm MacMillan Rodney MD
Adjunct Professor of Family Medicine
Adjunct Professor Surgery/Emergency Medicine
Meharry/Vanderbilt School of Medicine
Medicos para la Familia
Memphis and Nashville, Tn.
www.psot.com

REPLY from PFENNINGER 2 years? How do you tie the little tykes down? Do you sedate them? After about 2 months they are too big for the papoose board. I too do them in the office if they aren’t done in the nursery. Gomco. Hospital wants $700 to do in day surgery!!! So, I just bought the instruments and board for the office. As they get older, I find it harder to do….to keep them from squirming all over.JP

REPLY-WMR Haven't you gotten a copy my book on health care for the Uninsured? In addition, Rodney's Manual of Redneck Medicine suggests that children can be successfully restrained using John Deere blankets and an assistant named Bubba.

[We think he is being satirical, but the reality is unlikely to be much different.]

...REPLY -WMR I've never seen a long term complication from a Gomco, but continue to believe that the procedure is not medically indicated. .

... REPLY WMR--Every 50 or so I intentionally use some vicryl suture as a "teachable moment". I choose Vicryl because it is soft and I believe its ends are less traumatic than gut which is bristly. Every once and awhile I will do some free hand circ technique[DR. 90210] under the guise of making a more beautiful penis. These moments are used to demonstrate common hemostatic techniques with suture material can apply to this procedure as easily as to perineal repair.

[In other words he uses babies as teaching aids, falsifying his action to the parents. The arrogance of claiming to "make" a penis more beautiful by surgery defies belief.]

As family physicians I would be willing to lead a study giving informed consent to parents [I'll show you mine at 2 days if you'll show me yours at 2 days], and ask the average parent to choose which technique they would prefer. If we did a true informed consent about the medical benefits versus risks, they would probably choose neither. However using the standard consent, I imagine there would be a statistically significant preference for the nonPlastibell methods

Wm MacMillan Rodney MD
Adjunct Professor of Family Medicine
Meharry/Vanderbilt School of Medicine
Medicos para la Familia
Memphis and Nashville, Tn.
www.psot.com

See also complications for more admissions from this doctor.

 

15. Norwegian Medical Association finds ritual circumcision unethical

Journal of the Norwegian Medical Association, Volume 121 Number 25: Page 2994, 20 October 2001

Ritual Circumcision of Boys

The Council for Medical Ethics states that ritual circumcision of boys is not consistent with important principles of medical ethics, that it is without medical value, and should not be paid for with public funds.

The council has sent a statement to the board of the Norwegian Medical Association on this matter. Among other things, the council says that ritual circumcision of boys has no established medical benefit. Even with the use of local anaesthesia, the procedure causes pain and is associated with certain risks of medical complications. The Council for Medical Ethics states that circumcision of boys is not consistent with important principles of medical ethics laid down as general determinations in Paragraph 1 (§ 1) of the Norwegian Code of Ethics for Doctors. These require doctors to uphold human health, and to cure, relieve and comfort. The council points out that it is an important factor that the child cannot give consent.

According to the council, doctors should be allowed to refuse to perform ritual circumcision as a matter of conscience. The council makes a point of noting that, when performed, even if not for medical reasons, that circumcision is a surgical operation that must be carried out according to correct principles of surgery and with proper anaesthesia. In line with the Code of Ethics for Doctors § 12, it should not be paid for by the public health service.

The council invited relevant religious leaders in our community to work on replacing circumcision with symbolic rituals that do not involve a surgical procedure.

Pål Gulbrandsen


Tidsskrift for den Norske laegeforening
2001; 121: 2994 utga

Rituell omskjæring av gutter

Rådet for legeetikk mener at rituell omskjæring av gutter ikke er i tråd med viktige legeetiske prinsipper, at det er uten medisinsk nytteverdi og ikke bør bekostes av det offentlige.

Rådet har sendt en uttalelse til sentralstyret i Legeforeningen i sakens anledning. Der heter det bl.a. at rituell omskjæring av gutter ikke har etablert medisinsk nytteverdi. Selv ved bruk av lokalbedøvelse medfører inngrepet smerte og er forbundet med en viss risiko for medisinske komplikasjoner. Rådet for legeetikk mener at omskjæring av guttebarn ikke er i tråd med viktige legeetiske prinsipper nedfelt i de alminnelige bestemmelsene i § 1 i Etiske regler for leger. Disse pålegger leger å verne menneskets helse, og å helbrede, lindre og trøste. Rådet påpeker at det er et viktig moment at barn ikke kan gi samtykke.



Ifølge rådet må leger også kunne reservere seg mot å foreta rituell omskjæring av samvittighetsgrunner. Selv om inngrepet ikke utføres på medisinsk indikasjon, påpekes det likevel at omskjæring er et kirurgisk inngrep som bare må utføres etter anerkjente kirurgiske prinsipper og med optimal bedøvelse. I tråd med Etiske regler for leger § 12 bør det ikke kreves at utgiftene belastes det offentlige helsevesen.


Rådet oppfordrer aktuelle religiøse ledere i vårt samfunn om å arbeide for å erstatte omskjæring med symbolske ritualer som ikke innebærer et kirurgisk inngrep.

Ref: Tidsskr Nor Lægeforen 2001; 121: 2994 utga

pal.gulbrandsen@legeforeningen.no

 

17. Dr Jeykell and Mr Hyde

It is hard to believe the same person was involved in writing these two papers, just 14 months apart. Both speak with the authority you'd expect from a Jesuit Professor of Ethics, but the first is more carefully argued, more nuanced and has 64 references, compared to the second with only 25 (of which the first paper is one). The first makes extensive references to previous Catholic teaching, the second, none. Theories about why Prof. Clark did this include demonic possession, but more likely is that he meant to mark his student's essay F, but then accidentally put it in the wrong envelope.
Health Progress
September-October 2006 Volume 87, Number 5

To Circumcise or Not to Circumcise?

A Catholic Ethicist Argues That the Practice Is Not in the Best Interest of Male Infants

BY FR. PETER A. CLARK, SJ, PhD
Fr. Clark is professor, theology and health administration, and director, Institute of Catholic Bioethics, Saint Joseph's University; as well as bioethicist, Mercy Health System. Both organizations are in Philadelphia.

Routine neonatal male circumcision is the most frequent surgical operation performed on males in the United States. In recent years, however, there has been a widespread debate in the medical, ethical and, most recently, the legal communities concerning the surgery's appropriateness. At first glance, the issue appears to be solely medical. But, after further analysis, one can see that it has religious, cultural, and even socioeconomic implications. A comprehensive review of the medical literature reveals arguments both for and against this routine procedure. One writer notes that "of the at least 16 national and international medical organizations that have spoken on routine neonatal circumcision, not a single group has recommended it. This includes five leading American organizations, including the American Medical Association and the American Academy of Pediatrics."

...

Neonatal male circumcision fails the test of beneficence because the minor benefits that might result from the procedure do not outweigh its potential harms and risks. Indeed, recent policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision. The procedure also fails the test of nonmaleficence because the removal of functioning, healthy body tissue in the name of tradition, custom, or a non-disease-related cause intentionally inflicts bodily harm, injury, and, in rare cases, even death on vulnerable minors. This is clearly contrary to the basic tenet of medical ethics: "First do no harm."

Justice

This principle recognizes that each person should be treated fairly and equitably and be given his or her due. It can be applied to neonatal circumcision in two ways.

First, questions of justice have been raised about the legal right to bodily integrity of these vulnerable patients. One problem with circumcision, besides pain and possible complications, is the loss by the infant of the inherent value of an intact penis. To circumcise a person is to violate his bodily integrity, which is a direct violation of the principle of justice. Many people see male circumcision as cruel and degrading because it detracts from the appearance and function of the male sex organ by removing large amounts of healthy, functional, protective erogenous tissue. To mutilate and degrade any individual is a violation of the principle of justice.

Second, circumcision specifically involves the issue of distributive justice, which concerns the fair and equitable allocation of medical resources. As noted, more than a million U.S. males are circumcised each year, at a cost estimated to be as high as $270 million. A cost-benefit analysis of neonatal male circumcision has found it not to be cost effective; indeed, in contrast to most medical interventions, which cost money but preserve or restore health, neonatal male circumcision costs money and may reduce health. Today the United States has 46 million uninsured people and countless others who are underinsured. Spending hundreds of millions of dollars a year on a nontherapeutic surgery that has, at best, debatable benefits for the child is a direct violation of the principle of distributive justice. The primary beneficiary of male circumcision seems to be the medical community. As an organization opposed to the procedure notes, "Physicians receive an estimated $200 million in fees for 1,100,000 circumcisions performed annually in the United States, while hospitals receive an estimated $500 million due to longer stays for both mother and infant when circumcision is performed." Medical resources in this country and worldwide are limited and must be conserved. Proper stewardship of these resources entails not wasting them on treatments that have questionable outcomes and can be deemed inappropriate. These resources must be rationally allocated; to waste them is ethically irresponsible and morally objectionable.

The Catholic Perspective

In the Ethical and Religious Directives for Catholic Health Care Services (ERDs), Directive 29 states clearly that "bodily integrity" must always be respected:

"All persons served by Catholic health care have the right and duty to protect and preserve their bodily and functional integrity. The functional integrity of the person may be sacrificed to maintain the health or life of the person when no other morally permissible means is available."

Directive 33 states that any therapeutic procedure that causes harm to apatient can be justified only if the benefits outweigh the burdens: "The well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology. Therapeutic procedures that are likely to cause harm or undesirable side-effects can be justified only by a proportionate benefit to the patient." The Catechism of the Catholic Church states that "except when performed for strictly therapeutic reasons, directly intended amputations, mutilations, and sterilizations performed on innocent persons are against the moral law." Examining neonatal male circumcision in light of these moral directives, one can conclude that the amputation of normal, healthy foreskin for nontherapeutic purposes not only violates the child;s bodily integrity but also is a medical procedure whose benefits do not clearly outweigh the risks.

... The Catholic Church teaches that God created us in God;s image and likeness (Gn 1:27-28). It follows then that God created males with normal, healthy foreskins for the purpose of protecting the glans, providing natural lubrication to prevent dryness, and contributing significantly to the sexual response of the intact male. To surgically remove the foreskin for hygienic reasons, and/or to obtain other questionable benefits that absorb medical resources costing over $200 million a year is not only ethically unjustifiable but morally irresponsible, especially when such procedures can lead to serious injury and even death. Besides the possible harm the procedure can inflict on a child - which violates the basic tenet of Catholic health care of treating every person with dignity and respect - it also violates Catholic health care;s mandate to be responsible stewards of medical resources. When millions of people in the United States and around the world lack basic health care, the provision of a nontherapeutic procedure - especially one that is unnecessary, costly, and in some cases fatal - is irresponsible and a violation of the moral law.

... As the Benatars have noted, "It is all too easy (and common) to privilege those cultural ways to which one is accustomed on account of their familiarity. There is value in stepping back from one;s cultural assumptions. When one views male circumcision from another cultural perspective, one can only wonder what possessed ancient people to first think of removing the foreskin." To justify male circumcision for cultural reasons could be seen as a precedent that supports the justification of female circumcision for cultural reasons. To justify one of these practices because of its cultural acceptance is to start down the slippery slope toward justifying the other as socially acceptable. Barring religious obligation, there is little to recommend routine neonatal male circumcision. If promoting the dignity and respect of every human person is a priority for the United States and for Catholic health care, then it is time to better educate the public about this issue and protect those who are the most vulnerable in our society. Doing so is not only a social responsibility; it is a moral imperative as well.

...

Med Sci Monit
December 1, 2007; 13(12): RA205-213

Mandatory[*] neonatal male circumcision in Sub-Saharan Africa: Medical and ethical analysis

[* The term "mandatory is used 30 times in the paper, but nowhere defined. Whose mandate? The Church? The government? Is the decision whether to circumcise to be taken away even from the parents?]

Peter A Clark, Justin Eisenman, and Stephen Szapor,
Institute of Catholic Bioethics, St. Joseph's University, Philadelphia, PA, U.S.A.

[Abstract]

... Three recent randomized controlled trials undertaken in Kisumu, Kenya, Raki District, Uganda and Orange Farm, South Africa have confirmed that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 51% to 60%. These three studies provide a solid evidence-base for future health policy. The procedure for adolescents and adults is expensive compared to abstinence [Anything is expensive compared to abstinence], condoms [Yet governments are throwing money at adult circumcision while refusing to pay for condoms; the authors of this study, of course, have an ideological objection to the use of condoms at all] or other methods; and the surgery is not without serious risks if performed by traditional healers using unsterilized blades as often happens in rural Africa [It's not without serious risks if performed by doctors in surgeries, either.]. However, neonatally, the procedure is relatively inexpensive [It is? It demands no less skill, and requires as much or more equipment] and the risks diminish considerably [And the evidence for that is...? The baby's penis is smaller, and any mistakes on it are magnified when he grows up.]. Mandating neonatal male circumcision is an effective therapy that has minimal risks, is cost efficient and will save human lives. To deny individuals access [Strapping a baby down and cutting part of his penis off is not "giving him access"] to this effective therapy [whatever else it is, it's not "therapy"] is to deny them the dignity and respect all persons deserve. Neonatal male circumcision is medically necessary and ethically imperative.

From the article:

An uncircumcised penis consists of a cylindrical shaft and a rounded tip (glans) which is separated by a tissue groove called the coronal sulcus. [They've defined the foreskin out of existence, leaving nothing to remove! (Perhaps they've never seen one...) ] During the circumcision procedure the foreskin is removed to a point near the coronal sulcus 8

8. Clark P: To Circumcise or Not to Circumcise. Health Progress, 2006; 87: 30–39 [The article on the left, which quotes the AAP definition of the foreskin and circumcision. The fact that that article diametrically opposes this one is not acknowledged.]

... The principle of double effect specifies four conditions that must be fulfilled for an action with both a good and a bad effect to be morally justified.

  • The action, considered by itself and independently of its effects, must not be morally evil. The object of the action must be good or indifferent.
  • The evil effect must not be the means of producing the good effect.
  • The evil effect is sincerely not intended, but merely tolerated.
  • There must be a proportionate reason for performing the action, in spite of its evil consequence.
It should be noted that a number of ethicists known as proportionalists have argued that the first three conditions of the principle of double effect are incidental to the principle, and that in reality it is reducible to the fourth condition of proportionate reason. While this is a legitimate argument, it is not the purpose of this article to reopen the controversy on the validity of the first three conditions. This article will remain within the framework of the four conditions of the principle of double effect and apply these conditions to mandatory neonatal male circumcision as an effective method of prevention against HIV infection in sub-Saharan Africa.

The principle of double effect is applicable to the issue of mandatory neonatal male circumcision in sub-Saharan Africa because it has two effects: one good and the other evil. The good effect is that three recent randomized clinical trials in Africa have shown that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 51% to 60%. The evil effect concerns the removal of a child’s healthy foreskin without his informed consent which violates the principle of autonomy. It also violates the principle of nonmaleficence in that less invasive and more effective methods of HIV prevention may be discovered before the child reaches sexual maturity. [They seem to say this and then forget it.] Mandatory neonatal male circumcision in sub-Saharan Africa is ethically justified because it meets the four conditions of the principle of double effect. [They assert this, but go nowhere near demonstrating it. This argument is so simplistic, as if good and evil can be turned on and off like a light switch, and balanced against each other like apples, it is hard to believe a Professer of Ethics could have anything to do with writing it.]

... The first condition allows for neonatal male circumcision because the action in and of itself is good, in that clinical research studies have proven that it can effectively reduce male heterosexual HIV infection by 60%. [Fr Clark seems to have forgotten what he wrote just 14 months ago.]

... In addition, male circumcision at a later age can cause more serious medical complications and is more costly. The medical complications include pain, hematoma, bleeding, damage to the penis, infection and even death. [... exactly as they do at an earlier age.]

... If the guidelines proposed are implemented and safeguards are assured, then mandatory neonatal male circumcision is not only medically necessary, it is ethically imperative. [The authors give no indication whether or how those conditions can be fulfilled.] If the protection and preservation of human life is a priority in sub-Saharan Africa, then it is time to initiate mandatory neonatal male circumcision before it is too late for the most vulnerable. [The authors nowhere address the point made in Fr Clark's earlier article, that we have more than 10 years before childen born today become sexually active.] This must become an immediate priority, because human lives hang in the balance.

...


Neonatal circumcision is neither medically necessary nor ethically permissible: A response to Clark et al. by Robert S. Van Howe and J. Steven Svoboda will be published in Med Sci 2008 Aug; 14(8):LE7-13.

 

20. Letter to the British Medical Journal

British Medical Journal
February 19, 2011

Circumcision in boys and girls: why the double standard?

Personal View
by Mihail Evans

New legislation in France has led to more debate on whether wearing the veil amounts to the sexual repression of Muslim women. Islam's treatment of women is a regular topic in the Western press, yet few jump to the defence of Muslim and other little boys subjected to childhood circumcision. Indeed, the circumcision of the grandson of President Sarkozy, ironically a proponent of the veil ban, made only the gossip pages in France. As a permanent surgical genital alteration, circumcision is arguably a much more serious matter. After all, a Muslim woman has, at least in theory, the option to throw away her veil. The circumcised man's foreskin has been thrown away already.

Few countries have banned male circumcision, but even symbolic alternatives to female genital mutilation are banned in almost all Western jurisdictions. While I was a student, a female academic at my institution published a piece supportive of male circumcision. This prompted a thought experiment: suppose we found a male academic supportive of the surgical modification of female genitals. Would his views be accepted? Why can a Jewish woman speak openly to defend male circumcision and a Somali man not defend female circumcision?

Physiological research has undermined beliefs that the foreskin is "just a flap of skin" and shown it to be an integral part of the penis. With the foreskin considered an erogenous, multifunctional tissue, the established view of circumcision as a non-damaging excision is fatally undermined. It would be more appropriate to change our terminology, to speak of male genital mutilation rather than circumcision in the same way that we use female genital mutilation and not cliteradectomy.

Finland is among the few places where male circumcision is illegal, although recent judicial decisions have backtracked on this law, making exceptions for some religious circumcisions. Bulgaria banned male circumcision in the 1980s, but more as part of a cultural war on its Muslim minority than out of any overtly humanitarian concern. My partner is Bulgarian, and it amazes me that under law in the United Kingdom I could legally take my son there and subject him to the sort of horrific circumcision recorded by a Bulgarian current affairs programme (www.vbox7.com/play:72a1576e), yet my Somali neighbours would be prosecuted for attempting to appease traditional opinion by replacing female circumcision with a symbolic pinprick to the clitoral hood.

We rarely glimpse more than the very tip of the iceberg of the sexual and psychological damage caused by male circumcision. One symptom is the considerable number of men interested in foreskin restoration. That any man would be prepared to spend several hours a day for several years using taped, weighted, and tensioned devices to try to regrow a foreskin is testimony to the suffering caused in some cases. In browsing online forums such as www. restoringforeskin.org, you get a sense of the great missing continent of male conversations that are unspeakable in public: the Iranian brought up in the West who always feels something is missing when he sleeps with a woman, or the gay US man depressed that he does not have the penis he was born with, like his European lover. Male circumcision in developed countries is treated simply as a question of opinion. Most women in the UK do not circumcise their sons, but if a mother says she has had her son circumcised "to be like daddy" or for "tradition," hardly an eyelid is batted.

I was shocked by some comments from mothers, which seemed more callous than would be tolerated if gender roles were reversed. In one a mother wrote "LOL" ("laugh out loud") after telling the forum that her circumcised 4 year old "wants his old penis back." In another, a mother from South Africa says she has kept the dried foreskin "in case he wants it back later." Elsewhere on the web, it is completely acceptable to express a preference for a "cleaner" circumcised penis on women's sites. I cannot imagine that a man who advocated ways of making the vagina more "attractive" and "hygienic," let alone by surgical means, would be given a moment's hearing.

Legislation to outlaw male circumcision was put forward in Massachusetts, and although it was defeated campaigns continue in other states (see www.mgmbill.org). Dutch doctors also discussed a ban last year (BMJ 2010;340:c2987). A better way to protect the genitals of young boys might simply be to use existing laws. The Tasmanian Law Reform Institute has suggested that male circumcision may breach existing child protection laws (http://bit.ly/eLfxId). And the media have hinted at the possibility of a test case in the UK (http:// bit.ly/4GviWc). Finally, little boys in the West might be given the same rights as their sisters, but resistance is peculiarly high and comes from the most surprising quarters.

Mihail Evans is former postdoctoral researcher in ethics, University of the West of England mihail@riseup.net Cite this as: BMJ 2011;342:d978

 

21. Ethical doubts in Turkish journal

Turkish Journal of Psychiatry 2014

Ethical Evaluation of Non-Therapeutic Male Circumcision

M. Cumhur ?sgi MD, PhD, University Lecturer,
Akdeniz University Faculty of Medicine, Department of Medicine History and Ethics, Antalya, Turkey

SUMMARY
Elective circumcision for nonmedical reasons is a surgical approach which is historically long standing and accepted as the most performed procedure. The necessity of the procedure is usually for religious and traditional reasons alongside some medical ground related benefits to enable its social acceptability. The discussion of the subject from the aspect of ethics becomes necessary as there is no consensus about the benefits or harmfulness of nonmedical circumcision. Fundamental ethical discussions about circumcision, which contradicts legal acceptance criteria of any medical application, are related to the basic concepts of the existence of an individual such as sovereignty, the loss of bodily integrity, and privacy. The recent leagal processes and the fact that the European Council and the American Academy of Pediatrics have put the issue on their agenda have increased the necessity of these ethical evaluations. The responsibility of consideration and evaluation of ethical permission of every circumcision procedure, besides discussing the necessity of circumcision for improvement and protection of health rests on the shoulders of the physicians because the dignity and intellectual identity of the profession require so.


 

i. Voluntary Amputation forbidden

Voluntary amputations of adults' limbs "inappropriate"

BBC News, February 1, 2000

NO more private patients suffering from a psychological condition will have amputations carried out at Falkirk and District Royal Infirmary, the hospital trust has ruled. Amputations...

Let me know if this link fails and I will put the whole story here.

 

ii. Voluntary Amputation "only if not sexual"

Amputee 'was not sex motivated'

Sunday Mirror, February 8, 2000
By JACQUI THORNTON in London

A surgeon in Britain who cut off a man's healthy leg knew that his patient ran a website for those sexually interested in amputees, The Sunday Telegraph has revealed.

Robert Smith, a consultant surgeon at Falkirk and District Royal Infirmary in Scotland, was aware that Kevin Wright was involved with OverGround, a website which describes itself as "a support group for people who are attracted to those who have physical disabilities".

An investigation by The Sunday Telegraph has revealed that the website is linked to other web addresses, whose names include Amputees are Beautiful, Fascination, and Ampix, which includes colour photographs of female amputees.

Other graphics on linked pages include a woman in black leather fetish wear with one leg amputated above the knee and her arms around another woman.

However, Mr Wright, who suffers from a rare pyschiatric disorder, had told Mr Smith that there was no sexual motivation for the removal of his leg. Instead he believed that he had an "extra" limb.

The operation was paid for privately by Mr Wright, but took place in an National Health Service hospital with NHS staff. He paid $3,500 for the facilities and Mr Smith did not charge a fee.

Mr Smith insisted that he would not have carried out the operation if a sexual fetish had been a factor.

In an exclusive interview with The Sunday Telegraph, he denied that he had been "duped" and said that he was fully aware of Mr Wright's "informative" website" s contents. He said he was, and is, convinced that Mr Wright had no sexual reason for the amputation.

He defended Mr Wright's website as an information provider. "The website Mr Wright started was an information website and covered the whole spectrum of the problem, although Kevin's own problem was at the far right of the spectrum, the "need to be's" of those who want an amputation. At the other far end you have the devotees who are interested in amputee partners.

"I looked at the website before I decided what I was going to do and I wanted to make sure that I was dealing with the right problem. I do not feel I have been duped.

"At the end of the day, I have done the right thing because the patient is extemely satisfied and has made a major lifestyle change for the better."

Mr Smith revealed how the patient's wife had begged him to amputate so that they could lead a "normal life".

The controversial operation, which was followed by a second on a German patient two years' later, has caused widespread protest, and Dennis Canavan, the Labour MP, has called for an inquiry.

He said: "I find it almost incredible that a reputable surgeon would amputate a perfectly healthy limb. The existence of the website raises grave concerns."

Mr Smith said last week that he believed his patient was no longer involved with OverGround. However, Mr Wright's name and address was printed as the contact for more information before the site was clsoed. The surgeon admitted that the condition was "incomprehensible" to him, and that he was extremely apprehensive at the start of the operation, but was ultimately "gratified" by the excellent result.

He has kept in touch with both amputees, Mr Wright who was operated on in 1997 , and the German patient who he operated on last year who asked for help through Mr Wright.

Mr Smith said both were "delighted" by the results of the above-the-knee amputation, which they had specifically requested.

"There has been an absolute change in their lives. As soon as they knew they were getting the operation their demeanours and attitudes changed," he said."Curiously, they seem more active than they were before, they are more interested in life and their lives are much happier."

Mr Smith said that two pyschiatrists and a psychologist had already assessed Mr Wright, and they confirmed that he was suffering from a form of Body Dysmorphic Disorder called Apotemnophilia, which has two forms. The first group fantasises about being an amputee as a form of sexual arousal.

The second group, of which he said Mr Wright was a member, regards their body as incomplete with four limbs but complete after amputation, and who always wanted the same limb amputated. He added that this group was a very small sub-section of Apotemnophiliacs and would injure themselves to achieve amputation.

He said: "It is part of their daily life. They imagine themselves as an amputee going along the street shopping. It's not just during sexual activity. The last people you want to operate on are those who are doing it for sexual arousal."

Mr Smith said that after 18 months he decided to accept Mr Wright as a patient having discussed the issue with the hospital's medical director, the chief executive, the General Medical Council and the Scottish Medical Defence Union.

The British Medical Association said Saturday that their Ethics Committee was not investigating the case. A spokesman said: "We do not look at individual cases like this."

But he added: "This surgeon thought long and hard about this, for 18 months in fact, and considered all the psychiatric reports before he came to his decision."

Mr Smith said that the patient came for a consultation with his wife. "We had a long discussion about the problem. He explained that he had this feeling for most of his life that he should be an amputee, he really only had one leg, and he wanted the leg removed. He had had considerable problems over the years, a very troubled life and psychiatric treatment which had not solved the problem.

"His wife was saying: 'I wish to God someone could take his leg off and then we can lead a normal life.'

"I ultimately became convinced that this was really the only way in which we could attempt to resolve the problems."

He said Mr Wright was even happier it had come out in the open. "He doesn't have that fear hanging over him that he's going to get found out," he said. The hospital trust where it was carried out, Forth Valley Acute Hospital NHS Trust , banned the surgery last year after an internal inquiry. A spokesman declined to comment on the revelation that Mr Smith had known about his patient's involvement in websites.

"For reasons of medical confidentiality, we never discuss an individual patient's case. If Mr Smith has decided to comment that is a matter for him."

Mr Wright, a teaching assistant at the University of Essex, England, would only say that he regarded the operation a "private and personal medical matter."

The OverGround website was closed down on Wednesday, the day after news of the operation broke."

Since the publicity, two partners of apotemnophiliac men have contacted the surgeon asking for advice. A further two patients have been assessed and were waiting for surgery when the hospital banned the operation.

Some experts believe that amputation can exacerbate the problem because it increases pre-occupation with the imagined defect.

- The Sunday Telegraph

[The striking thing about this story is the high level of concern shown by doctors for the mental health of a person wanting to have one of his own limbs cut off (and rightly so). A sexual reason would have instantly disqualified Mr Wright from having his leg amputated. Yet doctors such as Williamson and Williamson viewed with equanimity, even approval, women who wanted to have part of their sons' genitals cut off to suit their sexual tastes.]

 

iii. Voluntary amputation "unethical and we wouldn't do it"

The Dominion Post (New Zealand), June 23, 2005

'I need to remove my leg in order to feel whole'

 AUSTRALIA

SURGEONS should be allowed to cut off the healthy limbs of some "amputee wannabes", two Australian philosophers believe.

Neil Levy and Tim Bayne argue that patients obsessed with having a limb amputated should be able to have it safely removed by a surgeon, so long as they are deemed sane. ...

But vascular surgeon John Quinn said removing a normal limb would be considered unethical in Australia.

There are some people who've got psychiatric disorders who want all sorts of things done," said Dr Quinn, the Royal Australasian College of Surgeons' executive director of surgical affairs.

"It's different than removing normal kidneys for transplantation, which has a different purpose and it's helping different people. But to remove a normal limb because somebody thinks it would be a good thing is unethical and we wouldn't do it."
AAP

[And the difference from infant circumcision is? "The foreskin is not a limb." And the significance of that is what? Echo answers "What?"]

 

 

iv. Ethics of taking umbilical blood

The blood from a baby's umbilical cord is a rich source of haematopoeic [blood-making] stem cells, which can give rise to any of the blood's valuable components. They are especially valuable in treating leukaemia. Cord blood is storable and more likely to be compatible than bone marrow.

The April 2001 edition of Scientific American pays particular attention to the ethics of using one baby's umbilical stem-cells in another person - even though the baby would in all probability have no use for them him/herself. The front cover reads:

Whose
Blood Is It,
Anyway?

CORD STEM CELLS SAVE
LIVES BUT RAISE QUESTIONS

And the story includes:

... the doctor usually tosses it into a stainless steel bucket with the rest of the medical waste bound for incineration.

But more and more physicians and parents are realising the value of what they used to regard as merely birth's by-product. ...

But like many new scientific discoveries, umbilical cord blood transplantation brings with it a set of ethical questions. [see box on next page]. Who owns umbilical cord blood: both parents, the mother or the infant? What happens if a mother donates her baby's cord blood to a bank but the child later develops leukemia and needs it? The ethical questions are compounded by the advent of for-profit companies that collect and preserve a newborn's cord blood for possible use by the family later.

 

- followed by this sidebar:

But Is It Ethical?
Marketing tactics and privacy issues raise eyebrows
LAST SEPTEMBER, a little girl...received a lifesaving transplant of umbilical cord blood from her newborn brother, Adam....Was this ethically appropriate? A panel of bioethicists decided that it was, because donating cord blood would have no effect on Adam's health.

...Questions have been raised in the past concerning the ownership of cord blood. But bioethcist Jeremy Sugarman of Duke University states that it is now fairly clear that although an infant owns his or her own cord blood, parents have legal guardianship over it - just as they do over the child - until he or she reaches the age of 18.

One interesting thing about this article is the parallel between the ethics of taking a baby's umbilical cord blood (which s/he will almost certainly never need) and taking his foreskin (which the great majority of intact men value highly), and its sale and use by other people.

Another is the immediate concern shown with the ethical issues of this brand new (and so far tiny) area of medicine, compared with the deafening silence about - and refusal to consider - the ethical issues raised by infant circumcision.

 

v. How a Christian ethicist reconciles faith and ethics

One of the challenges of being a Christian who does ethics in a secular medical setting is struggling with how to integrate your own personal beliefs in a setting where overt religious and theological considerations really aren’t considered appropriate, unless they are the patient’s or family’s religious beliefs. What I’ve discovered is that where my religious beliefs take me is rarely different from where a standard bioethics analysis might take me. And, I think one of the skills I’ve had to learn is that if I do arrive at a decision about what I think is the right thing to do and my reasons for believing that are related to my religious beliefs, I have to be able to craft secular arguments to support that view. The real art of bioethics is convincing other people why something is right or something is wrong and why something shouldn’t be done or should be done. Many people aren’t going to pay attention to you if that argument is crafted purely in religious language. One of the things that I’ve had to do is craft arguments in the language of the world, which I have not found to be particularly difficult. The reality is that medical ethics has its roots largely in theological ethics, so the basic principles that many people who are not religious subscribe to actually have very strong roots in the Bible and in religious belief.

- Dr Douglas Diekema in the Calvin College Spark Winter 2007

Dr Diekema is ethicist at the Children’s Hospital and Regional Medical Center in Seattle. He led the ethics panel that agreed that a severely disabled girl identified as Ashley should have hormones, a hysterectomy and breast-bud removal to prevent her ever maturing.
He was chair of the AAP Bioethics Committee that in 2010 recommended allowing a token ritual nick to girls, "much less extensive than male genital cutting" (until public outcry made it back down).
And he was ethicist to the 2012 AAP Task Force on Circumcision.

 

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