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Contents:
1. An excerpt from the Encyclopedia of Bioethics about children and biomedicine in general 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. |
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):
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"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
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[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:
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.
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
9. "Dual loyalty" and conflict of interest
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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: 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. |
10. An important article.
JOURNAL OF MEDICAL ETHICS (U.K.), Vol 30: Pages 248-253, June 2004. 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
E-3.01 Nonscientific Practitioners
E-8.20 Invalid Medical Treatment
E-10.05 Potential Patients
* 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
ABSTRACT
Full text: Journal of Medical Ethics 2005;31:463-469
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14. Doctor admits existing consent form understates risks.
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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.
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.
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... 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
See also complications for more admissions from this doctor.
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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
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Tidsskrift for den Norske laegeforening 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.
Ref: Tidsskr Nor Lægeforen 2001; 121: 2994 utga
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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. | |
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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
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. ... | |