Male circumcision is a surgical removal of the foreskin (preputium) of the human penis. The non-therapeutic circumcision ethics imposed on minors (infants and children) has been the source of ongoing controversy.
Some medical associations take the position that parents should determine what is best for the baby or child's interest, while others say that circumcision of minors should be limited "as much as possible," and that "it is natural to delay circumcision until the age where The child himself may decide on interventions, or may opt for any available alternatives. "
Video Ethics of circumcision
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Australia
The Royal Australasian College of Physicians (2004) commented that, " The difficulty with procedures that are not medically indicated is whether they may still be in the child's" best interest "(ie, in circumcision cases, decreased risk of UTI [urinary tract infection] and penile cancer, and ensuring acceptance in religious-cultural groups) on the one hand or whether it is an attack on a child and a human rights violation on the other. justifying the case of "best interest" is based on data to suggest a reduced risk of medical conditions later day, none, with the possible exception of UTI in boys, requires decisions in the neonatal period, and this can be seen to be an argument for delaying decisions until individuals can express their own preferences. [...] One problem, agreed , is that before parents make decisions about circumcision they should have access to unbiased information and clear about the medical risks and benefits of the procedure . "A different view of whether the limit should be placed on carers have a child who is circumcised.
Canada
The Canadian Pediatric Society (CPS) issued a position statement on September 8, 2015. With regard to ethics, it states:
Neonatal circumcision is a controversial issue in Canada. This procedure often raises ethical and legal considerations, in part because it has lifelong consequences and is committed on a child who can not give consent. Babies need alternative decision makers - usually their parents - to act in their best interest. But the authority of the substitute decision-maker is not absolute. In most jurisdictions, authority is limited only to interventions deemed medically necessary. In cases where medical needs are not established or the proposed treatment is based on personal preference, the intervention should be postponed until the individual concerned is able to make their own choice.
Denmark
The Danish Medical Association ( LÃÆ'Â|geforeningen ) has released a statement (2016) on the circumcision of boys under the age of eighteen. The organization said that the decision to circumcise should be the "informed personal choice" that a man must make for himself in adulthood. According to Dr. Lise MÃÆ'¸ller, chairman of the board of ethics of the physician association, "This is most consistent with the right of individuals to self-determination that parents are not allowed to make this decision but it is left to the individual when he is an adult."
Dutch
The Royal Dutch Medical Association (KNMG) and several Dutch medical specialists issued a position statement on male circumcision on May 27, 2010. KNMG stated that "there is no evidence which ensures that circumcision is useful or underage circumcision is necessary for prevention or health ", that" male circumcision requires the risk of medical or psychological complications, "that" underage circumcision is against the rule that the child is under age can only be exposed to medical treatment if there is a disease or an abnormality, "that" the circumcision of a minor boy is against the child's right to autonomy and physical integrity ", that circumcision of minors should be limited" as much as possible " and that "it makes sense to postpone circumcision to an age where... the boy himself may decide about the intervention, or can choose the available alt ernative. "The Royal Dutch Medical Association questioned why the ethics of male genital change should be seen differently from female genital change, when there are mild forms of female genital alteration (such as piercing the clitoral hood without removing tissue or removing the clitoral hood altogether). has expressed objection to male circumcision and all forms of female circumcision.
In 2013, the children's ombudsmen from Sweden, Norway, Finland, Denmark and Iceland, together with the Chairman of the Danish Children's Council and a children's spokesperson for Greenland, passed a resolution to, "Let the boys decide for themselves whether they want to be circumcised. "They further state that" circumcision is without medical indication to a person who can not provide informed consent of conflict with the basic principles of medical ethics. "
The Nordic Association of Clinical Sexologists supports the position of the Nordic Ombudsman Association:
"As clinical sexologists, we are concerned about the human rights aspects associated with the practice of non-therapeutic circumcision of young boys.To cut the penis foreskin in men with normal, healthy, genitals eliminate their right to grow and make their own decisions, unless there is a strong medical reason to operate before a child reaches the age and maturity level in which he is able to provide informed consent, the decision to change the appearance, sensitivity and function of the penis must be left to the owner, thereby upholding his fundamental rights for protection and integrity body. "
The medical doctors at SÃÆ'¸rland Hospital in Kristiansand, Southern Norway all refused to perform circumcision on boys, on the grounds of conscience.
United Kingdom
The Medical Ethics Committee of the British Medical Association states:
"In the past, male circumcision has been considered to be medically or socially beneficial or, at least, neutral.The general perception is that there is no significant harm inflicted on the child and therefore with appropriate consent can be done. previously claimed, however, has not been proven conclusively, and is now widely accepted, including by BMA, that this surgical procedure has medical and psychological risks. Especially that doctors perform male circumcision only if this is proven in the child's best interest. demonstrating that non-therapeutic circumcision is in the interest of certain children for their parents. "
'Unnecessary invasive procedures should not be used where alternatives, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decision to perform an invasive procedure is based on the best available evidence. Therefore, to circumcise for therapeutic reasons in which medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. Male circumcision in cases where there is a clear clinical need is usually not controversial. However, the normal anatomical and physiological characteristics of the infant's foreskin in the past have been misinterpreted as abnormal.
Non-therapeutic circumcision Circumcision in males committed for any reason other than physical clinical need is referred to as non-therapeutic (or sometimes "ritual") circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to include a child into the community, and some want their son to be like their father. Circumcision is the main characteristic of some religions. There is a spectrum of views in BMA membership about whether non-therapeutic male circumcision is a useful, neutral or dangerous procedure or whether it is excessive, and whether it should be done on a child who is unable to decide for himself. A medical hazard or benefit has not been proven to be certain unless there is a clear risk of harm if the procedure is improperly performed. The Association has no policy on this issue. Indeed, it would be difficult to formulate policy because there is no clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA believes that parents should be entitled to make choices about how best to promote their children's interests, and it is the community to decide what limitations should be applied to parental choices.
Commenting on the development of the UK Medical Association's 2003 guideline on circumcision, Mussell (2004) states that the debate in the community "is very full, with individuals and groups holding opposing positions." Identifying three positions, "support," "eligible support," and "opposition," he points out that this controversy "is also reflected in multicultural membership, multifaith BMA." He identified this as a difficulty in reaching consensus on the medical ethics committee. The arguments put forward in the discussion, according to Mussell, include that circumcision "is a net benefit that is focused on concepts such as social integration and cultural acceptance", but also that it is "a net damage that is focused on violating the rights of children - the right of the child to be free from physical disturbance and the right of the child to vote in the future. "
Adult circumcision
In a paper published in June 2006, the British Medical Association Committee on Medical Ethics does not consider male male circumcision to be controversial, provided that adults have a healthy mind and give their personal consent after receiving all material information about known risks, losses, and benefits potential derived from surgical operations.
Adult circumcision as a public health measure for the purpose of reducing the spread of HIV also involves ethical issues such as informed consent and concerns about reducing attention paid to other actions. According to the CDC website, research has documented a significant reduction of HIV/AIDS transmission when a man is circumcised.
Circumcision child
In the same British Medical Association paper, the circumcision of a child to treat a clear medical indication and now after a conservative treatment trial is also not considered ethically questionable, provided that an appropriate substitute has granted a replacement permit upon receipt of all material information about known risks, and the potential benefits derived from surgical operations.
The non-consensual circumcision of children for non-therapeutic reasons is controversial. Since the baby can not speak and therefore can not agree, if circumcision must be done, then informed consent for circumcision can only be given by a replacement. Some believe that surrogates are not empowered to give consent to non-diagnostic and non-therapeutic procedures. Some believe that parents have the right to circumcise a child, regardless of the child's wishes. Some believe that a child's non-therapeutic circumcision violates the human rights and physical integrity of the child and can not be in the child's best interests. Some believe that their religion requires circumcised men. Some believe that circumcision is an irreversible permanent injury. Some believe that non-therapeutic circumcision provides certain health benefits. Some believe that the foreskin has many physiological functions and must be preserved. These conflicts have created a diversity of opinions about the modesty and ethics of childhood circumcision as discussed below.
It also argues that there is no reason to commit non-therapeutic circumcision in children since circumcision can be done later in life when the child has been able to provide informed consent.
Criticism and revision of BMA statement
The 2003 BMA statement takes the position that non-therapeutic childrens circumcision is legitimate in the UK. British law professor, Fox & amp; Thomson (2005), citing the House of Lords case of R v Brown, challenged this statement. They argue that consent can not make unlawful acts. BMA accepted this criticism and revised its statement to include certain changes based on criticism by Fox & amp; Thomson. The revised statement (2006) now reports controversy over the validity of non-therapeutic child circumcision and recommends that physicians obtain consent from the second of parents before committing non-therapeutic circumcision from small men.
United States
The American Academy of Pediatrics (1999) states that parents and doctors have an ethical obligation to secure the child's best interests and well-being. They state that in circumcision cases, where there are potential benefits and risks, but this procedure is not important for the welfare of children today, parents should determine what is in the best interests of the child, and it is legitimate for parents to consider culture, religion , and ethnic traditions, as well as medical factors. They state that physicians should not coerce parents, but should assist parents in their decisions by "explaining potential benefits and risks and by ensuring that they [parents] understand that circumcision is an elective procedure." The Bioethics Academy Committee approved this policy statement.
Neonatal circumcision is performed with a surrogate permit, described as follows by the American Academy of Pediatrics (1999):
"The practice of medicine has long respected the right of adults to self-determination in health care decision-making.The principle has been operationalized through the doctrine of informed consent.The process of informed consent requires the physician to explain the procedure or treatment and specify the risks, benefits, and alternatives for the patient to make choice based on information.For babies and young children who do not have the capacity to decide on their own, substitutes, generally parents, should make such choices. "
"Doctors who advise the family about this decision should help parents by explaining the potential benefits and risks and by ensuring that they understand that circumcision is an elective procedure. Parents can not be forced by medical professionals to make this choice."
The Academy (2012) states partly to ethics:
"In such cases the decision to commit circumcision in the newborn period (where there is reasonable disagreement about the balance between medical benefits and hazards, where there are nonmedical benefits and dangers that can result from decisions on whether to perform procedures, and where procedures are unimportant for the immediate welfare of the child, the parent must determine what is best for the child's interest. In a pluralistic society of the United States, where parents are given wide authority to determine what is appropriate for child rearing and child welfare, it is legal for parents to take account of culture their own, religion, and ethnic traditions, in addition to medical factors, when making this choice.
"Doctors who advise families on this decision should help parents by objectively explaining the potential benefits and risks of circumcising their baby.Since some families may choose to circumcise as part of a traditional or religious practice, the discussion should also include the risks and benefits of having a professional performing procedure this is in a clinical setting rather than done by traditional providers/religions in a non-medical environment. "
Criticism
The American Academy of Pediatrics (AAP) position statement on male circumcision (2012) has attracted significant critical comments.
Van Howe & amp; Svoboda (2013) mengatakan:
"These shortcomings include topic exclusion and important discussions, incomplete and apparently partisan travel through medical literature, improper analysis of available information, poorly documented and often inaccurate presentations of relevant findings, and conclusions that are not supported by evidence which are given. "
Frisch et al. (2013) mengatakan:
"Viewed from the outside, cultural biases reflecting the normality of nontherapeutic male circumcision in the United States are clear, and reporting conclusions are different from those achieved by doctors in other parts of the Western world, including Europe, Canada and Australia."
American Medical Association Views
The American Medical Association (2013) states, "There is strong evidence documenting the health benefits of male circumcision, and it is a low-risk procedure," said Peter W. Carmel, MD, president of the AMA. " Today AMA once again made it clear. that it would oppose any attempt to disrupt the legitimate medical practice and informed patient choice. "
"The AMA supports the general principles of the 2012 Academy of Pediatrics Circumcision Policy Statement, which reads as follows:" the current assessment of evidence suggests that the health benefits of circumcised newborn males outweigh the risks; furthermore, the benefits of circumcising newborn males justify access to this procedure for the families who choose it. Specific benefits of male circumcision are identified for the prevention of urinary tract infections, HIV transmission, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not seem to affect sexual function/sexual sensitivity or sexual satisfaction "
American Medical Association Ethics Journal
In August 2017, the American Medical Association Journal of Ethics featured two separate articles that challenged the morality of performing non-therapeutic infant circumcision.
- Svoboda J. Stephen (2017). "Non-therapeutic circumcision of minors as an ethical form of Iatrogenic injury". AMA Journal of Ethics . 19 (8): 815-824. doi: 10.1001/journalofethetics.2017.19.8.msoc2-1708.
Non-therapeutic circumcision (NTC) in boys and boys is a common form of misunderstood iatrogenic injury that causes damage by removing functional tissues that are known to have sensitive, protective, and immunological properties.
The foreskin is a complex genital structure that covers the head of the penis and performs various sexual, immunological, and protective functions. With a total surface area of ​​mature 30-50 cm2 [1, 2] and dense innervation, the foreskin is a network that is very sensitive to touch [3]. Konkongnya muscle fibers excluding contaminants [4], while the surface of the mucus provides immunologic protection layer both [5, 6]. The foreskin keeps the glands moist and facilitates gliding action that encourages pleasurable sexual sensations [7-10].
- Reis-Dennis Samuel, Elizabeth Reis (2017). "Is Doctor Blameworthy for IATrogenic Harm produced from Unnecessary Genital Surgery?". AMA Journal of Ethics . 19 (8): 825-833. doi: 10.1001/journalofethetics.2017.19.8.msoc3-1708.
We argue that physicians should, in certain cases, be held accountable by patients and their families for the dangers caused by "successful" genital surgery done for social and aesthetic reasons... [including] routine infant circumcision.
we support the general principle that pediatricians should not recommend irreversible surgeries, such as permanent foreskin removal, for nonmedical reasons. When pediatricians perform circumcision to respect unquestioned parental habits, they may be the right target to blame attitudes, even anger, expressed by parents and by patients after they grow up.
Maps Ethics of circumcision
More views
JME symposium on circumcision, June 2004
The Journal of Medical Ethics published a "symposium on circumcision" in its June 2004 issue. The Symposium published an original version (2003) of the BMA policy statement and six articles by various individuals with a broad spectrum of views on the ethics of childhood circumcision in underage. In the introduction, Holm (2004) states:
"It is therefore very interesting that the evidence we really need to be able to assess the circumcision status is very poor.We do not have a valid comparative data regarding the effects of early circumcision on adult sexual function and Until such data is available, the circumcision debate can not be brought to conclusion satisfactory, and there will always be a long suspicion that a rather violent opposition to circumcision is partly driven by cultural prejudice, dressed as an ethical argument. "
Hutson (2004) states:
"The most basic principle of surgery is that there is no surgery to do if there is no disease, because it can not be justified if the risk of the procedure is not matched by the risk of disease, even when the patient has a significant, potentially dangerous disease." surgery is almost unjustified if the risk is much greater than the disease itself. The problem for routine circumcision is because there is no illness, no complications that can be tolerated, because the risk of the procedure is not balanced with the current disease risk. "
Short (2004) disputes Hutson's claim and argues that male circumcision has future prophylactic benefits that make it valuable. He concluded:
"If we believe in evidence-based medicine, then there is no debate about male circumcision, it has become a desirable option for the whole world.Peradoxically, this simple procedure is a lifesaver, it can also bring great improvements to men and health female reproduction rather than condemn it, we in developed countries have an obligation to develop better procedures that are not physically cruel or potentially dangerous, so male circumcision can take the right place as the best piece of all. "
Viens (2004) argues that "we do not know in a strong or definite sense that male circumcision in infants is dangerous in itself, nor can we say the same thing with respect to the harmful consequences alleged to him." He suggested that one should distinguish between very dangerous practices and those that enhance a child's cultural or religious identity. He suggested that medical professionals, and bioethicists in particular, "should take their starting point the fact that a reasonable person will not agree on what is valuable and what is harmful."
Hellsten (2004), however, illustrates the argument in favor of circumcision as "rationalization", and states that circumcision in infants can be "clearly condemned as a violation of the rights of children whether they cause direct pain." He argues that, to question the ethical acceptance of the practice, "we need to focus on the protection of children's rights." Hellsten concluded, "By contrast, with education and further knowledge the cultural smokescreen around real reasons for maintenance practices can be addressed in all societies no matter what their cultural background is.
Mussell (2004) examines the process by which BMA arrives at a position in non-therapeutic underage boys, when organizations have diverse groups and individuals from diverse ethnic, religious, cultural, and point of view.
The argument argued that non-therapeutic male circumcision is a net benefit for some people because it helps them to integrate within the community.
The argument has also been put forward that male non-therapeutic male circumcision is damaged because it is seen as a violation of the rights of the child - the right of the child to be free from physical disturbance and the rights of the children. child to vote in the future. This argument is emphasized by the incorporation of British European Convention on Human Rights (1950) into domestic law by the Human Rights Act 1998.
The BMA produces documents that set legal and ethical concerns but leave the final decision on whether or not to perform non-therapeutic circumcision to the present physician.
The latest document published by the Journal of Medical Ethics in a symposium on circumcision is a reprint of the BMA statement: "The law and ethics of male circumcision: a guide for physicians (2003).
Journal of the Medical Ethics Circumcision issue, July 2013
The Journal of Medical Ethics devotes the entire issue of July 2013 to the controversial issue of male non-therapeutic circumcision. Many articles represent multiple views.
More views
Povenmire (1988) argues that parents should not have the power to approve neonatal non-therapeutic circumcision.
Richards (1996) argues that parents only have the power to approve therapeutic procedures.
Somerville (2000) argues that the nature of the medical benefits referred to as justification for infant circumcision is such that potential medical problems can be avoided or, if so, treated in a much more invasive way than circumcision. He stated that the elimination of healthy genital tissues of minors should not be subject to parental discretion, or that doctors performing the procedure do not act in accordance with their ethical obligations to the patient, regardless of parental consent.
Canning (2002) commented that "[i] f circumcision is becoming less common in North America [...] the legal system may no longer be able to ignore the conflict between circumcision practice and the legal and ethical duties of medical specialists."
Benatar and Benatar (2003) argue that "it is far from clear that circumcision diminishes sexual pleasure," and that "it is far from clear that non-circumcision leaves open the choices of future people in everything." They continue: "It maintains the choice of circumcision or uncircumcised status in the future, but it makes other choices much harder to exercise. Transformations from uncircumcised to circumcised circumstances will have psychological and other costs for adults who are absent for children... Also these costs are "insignificant", [...] At least they are no more important than the risks and costs of circumcision. "
The Medical Ethics Committee of the British Medical Association (2003) published a paper to guide physicians on the law and ethics of circumcision. It advises the doctor to proceed on a case by case basis to determine the best interests of the child before deciding to perform circumcision. The doctor should consider the legal and human rights of the child in making his decision. It states that a physician has the right to refuse non-therapeutic circumcision. The College of Physicians and Surgeons of British Columbia took the same position.
Fox and Thomson (2005) state that in the absence of "clear evidence of medical benefits", "it is ethically inappropriate to surrender a child at the recognized risk of male infant circumcision." Thus, they believe, "the emerging consensus, in which the choice of the parent in power, appears ethically untenable".
Morris et al . (2014) argue that "... the failure to circumcise a baby boy may be unethical because it diminishes his right to good health."
The Belgian Federal Consultative Committee on Bioethics (2015), after three years of study, has decided that male circumcision for non-therapeutic purposes is unethical. in Belgium. The process can not be changed, has no medical justification in most cases, and is done on minors who can not give their own permission, according to the committee. Paul Schotsmans of the University of Leuven, on behalf of the committee, noted "the child's right to physical integrity, protected by the International Treaty on the Rights of the Child, and in particular his protection from physical injury."
HIV in southern and eastern Africa
Rennie et al. (2007) stated that the results of three randomized controlled trials in sub-Saharan Africa showed a reduced risk of HIV among circumcised men, "changing the terms of the debate on the ethics of male circumcision." However, it should be noted that the African RCT methodology has been heavily criticized, thus abandoning claims that circumcision reduces sexual transmission of HIV.
Circumcision advocates argue that using circumcision and other means available to stop the spread of HIV is for the common good (but ignoring the fact that HIV is transmitted in semen). Rennie et al. argues that "it is unethical not to seriously consider one of the most promising approaches - albeit also one of the most controversial - new approaches to HIV prevention in the 25-year history of the epidemic." However, there remains a clear risk of transmission or transmission of HIV during unprotected sex and other high-risk behaviors (circumcised or not).
The World Health Organization (2007) states that circumcision provisions should be consistent with "medical ethics and human rights principles." They declare that "[i] Consent, confidentiality and absence of coercion should be guaranteed Parents responsible for consent, including for male infant circumcision, should be given sufficient information about the benefits and risks of the procedure to determine what is best for the sake of the child. "However, because infants and children are not sexually active, sexually transmitted infections are not a relevant issue. Critics of non-therapeutic circumcision argue that advocating circumcision to prevent HIV infection may reduce other efforts to prevent the spread of viruses such as using condoms. If an adult chooses to remain celibate or if the partner remains monogamous, or if HIV is eliminated by the time the child is fully grown, a sexual reduction operation will not be necessary. In addition, they argue that circumcising a child who is said to protect some of HIV infection in adulthood can be seen as granting permission to engage in dangerous sexual practices. Obviously boy babies do not need such protection and can choose themselves as adults who agree if they want circumcision.
The UK National Health Service (NHS) has criticized African studies, and has stated that practicing safer sex including condom use is the best way to prevent sexually transmitted diseases during sex.
Substitute approval
Patient autonomy is an important principle of medical ethics. Some believe that approval for non-therapeutic surgery offends the principle of autonomy, when awarded by a substitute.
Because children, and especially infants, are legally incompetent to provide informed consent for medical or surgical treatment, the consent must be provided by a substitute - someone appointed to act on behalf of the patient's child, if treatment will occur.
The substitute power for approval is more limited than the authority granted to competent individuals acting on their own behalf. A substitute can only act in the best interests of the patient. A replacement may not put a child at risk for religious reasons. A replacement may give consent to a medical procedure that has no medical indication of only if it is in the child's best interest.
The attending physician shall provide a substitute with all material information regarding the proposed benefits, risks, benefits and losses of the proposed treatment or procedure.
The Bioethics Committee of AAP (1995) states that parents can only grant written permission for diagnosis and treatment with the consent of the child whenever necessary.
There are unresolved questions as to whether the replacement can provide effective approval for non-therapeutic child circumcision. Richards (1996) argues that parents can only approve medical care, so it is not empowered to give consent to a child's non-therapeutic circumcision because it is not a medical treatment. The Canadian Pediatric Society (2015) recommends that circumcision performed without medical indication or for personal reasons "should be suspended until the individual concerned is able to make their own choices."
Regardless of these issues, the general practice of the medical community in the United States is to receive notices of consent or consent from a parent or legal guardian for childhood non-therapeutic circumcision.
See also
- Applied ethics
- Brit shalom (naming ceremony)
- Children's rights
- FGM
- Medical ethics
- Male rights
- The prevalence of circumcision
- Violence against men
References
- The child's right to circumcision [PDF]. BJU Int . January 1999; 83 (Suppl.1): 74-78. doi: 10.1046/j.1464-410x.1999.0830s1074.x. PMID 10349417.
- Goodman J. Jewish circumcision: an alternative perspective. BJU Int . 1999; 83 Suppl. 1: 22-27. doi: 10.1046/j.1464-410x.1999.0830s1022.x. PMID 10349411.
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