In exercising that discretion, religious and cultural factors [Whose? The newborn baby does not have a religion or a culture.], though preferably subject to critical evaluation, may reasonably play a role. That our conclusion occupies the popular middle ground between those who condemn the practice outright and those who think it should be routinely performed, does not provide grounds for accepting it. [If there are no grounds for accepting the practice, it should not be done.] The middle way is sometimes the wrong way. In the circumcision debate, however, the evidence and arguments support neither of the extremes.

[Support for an extreme position is not required. It is sufficient that the medical case is not compelling, and that the boy will grow up to be an adult with his own opinion about the value to him of his own foreskin, for non-medical circumcision to be medically unethical.]

© 2003 Massachusetts Institute of Technology

David Benatar
University of Cape Town, South Africa

Michael Benatar
Harvard University, Boston, MA

3:2 Target Article author responds to Commentators

Benatar, M., and D. Benatar. 2003. {HYPERLINK "http://www.ingentaselect.com/nw=1/rpsv/cgi- bin/linker?ini=ajob&reqidx=/catchword/mitpress/15265161/v3n2/s16/p35"}

This only links to the abstract.

Between prophylaxis and child abuse: The ethics of neonatal male circumcision The American Journal of Bioethics 3(2):35-48.

A target article can be expected to draw fire. As our Target Article, "Between Prophylaxis and Child Abuse: The Ethics of Neonatal Male Circumcision," defended an intermediate position on circumcision, one would have expected the fire to come from two directions.

Why? If one defended an intermediate position on child sacrifice between compulsory and forbidden, that it was up to the parents, would one have expected much support?

However, the criticism was entirely one-sided. None of our respondents were defenders of routine neonatal circumcision.

The Benetars do not define "routine". The above seems to assume the strong definition "without consulting the parents", rather than the commoner usage, "without medical indications".

By contrast, those who take circumcision to be mutilation and child abuse were amply represented. There are a number of possible explanations for this,

... the main one being that non-therapeutic circumcision is the status quo in the US, which they are defending. Another could be that infant circumcision is mutilation and child abuse (and hence totally unethical).

but one of these is that those who oppose circumcision are more vocal because they have coalesced into an activist movement.

How so? Might not lonely voices in the wilderness be more vocal?

Although opponents of circumcision took aim at our arguments (or, more likely, at our conclusion), they missed their mark by far. They have given a fine display of how not to argue - about circumcision, or anything else. Non-sequiturs, appeals to authority, anecdotes, equivocations, question-begging, and many more such errors abound in their replies.

Cut us some slack: we're not all professional ethicists. The article made a lot of Intactivists very angry because of its pro-circumcision bias. By lumping all opposing arguments together in this way, the Benetars commit the fallacy of "guilt by association" and can write off the good with the bad.

In our response, we shall highlight these and other errors and show how these respondents have utterly failed to engage our arguments.

Not all the commentators on our paper were critical of what we said. Some treated our paper as a departure point for taking the issues further. Rebecca Dresser, for example, shows how our analysis, which maps out the realm of parental discretion, is also relevant to family decisions for incompetent adults (Dresser 2003). Dena Davis extends our treatment of cultural bias in attitudes to comparable male and female genital cutting, with a discussion of the relevant United States law (Davis 2003).

Interesting. And do the Benetars conclude that female genital cutting should be at the parents' discretion? If not, why not?

John Paul Slosar and Daniel O'Brien show how our analysis is compatible with a Catholic perspective (Slosar and O'Brien 2003).

...but incompatible with the offical Catholic position.

These, and some others, are all helpful contributions to the discussion and we are grateful for them. Our focus, however, will be on those respondents who disagreed with us.

Mutilation
Some of our respondents, in claiming that neonatal circumcision is mutilation, make the very errors that we exposed in our original paper. Petrina Fadel, for example, cites the American Heritage Dictionary definition of "mutilate": "1. To cut off or destroy a limb or essential part. 2. To render imperfect by excising or radically altering a part" (Fadel, 2003, W-2). The connection between (a) this definition and (b) what she then says is lost through circumcision, is not made explicit. We assume she thinks that the removal of the foreskin, which she calls "a protective and sexual organ",

...but which the Benetars make no attempt to demonstrate that it is not...

is the cutting off of "an essential part" or the rendering "imperfect by excising … a part". However, this begs the question. It assumes that the foreskin is indeed an essential part and that excising it renders the penis imperfect. Simply calling the foreskin a "protective and sexual organ" is not a substitute for the careful analysis we recommended and undertook regarding whether circumcision is beneficial, harmful or neither.

So did they consider each of the functions of the foreskin? Did they refer to Taylor's paper on the ridged band? Apparently not.

For instance, as should be clear from the evidence we presented, it is far from clear that the foreskin "protects the sterile urinary tract environment" (Fadel 2003, W-2). There is some evidence that the foreskin may rather constitute a modest threat to the sterility of that environment, as evidenced by the slightly higher rates of urinary tract infection in the uncircumcised. It is stunning that, in response to a careful presentation and analysis of the evidence, this commentator believes it will suffice simply to assert a contrary conclusion.

It is stunning that these ethicists think "some evidence" is sufficient to maintain a conclusion contrary to a fairly simple piece of physics: the foreskin acts as a flap valve to the urethra.

Both Michelle Mullen (2003) and J. Steven Svoboda (2003) take exception to what we say, in our discussion of mutilation, about such surgical procedures as breast reduction, liposuction and rhinoplasty. They deny that these are analogous to infant circumcision because the latter is performed without the patient's consent, whereas the former cosmetic surgeries are performed with consent. This objection is off the mark - not because these procedures are analogous with respect to consent, but because the consent issue is entirely irrelevant to the point we were making. We referred to breast reduction, liposuction and rhinoplasty to illustrate the point that not every appearance- altering surgery constitutes mutilation. Consent is irrelevant to that (limited) point - unless one believes that all non-consensual appearance-altering surgery constitutes mutilation.

Consent is certainly not irrelevant when the whole point of appearance-altering surgery is to improve the appearance from the point of view of the person on whom the surgery is being performed. A person on whom non-consensual breast reduction, liposuction or rhinoplasty was performed might very well consider the result to be mutilation, and who could gainsay them?

On this latter view, reference to a lack of consent would have to be incorporated into the definition of "mutilation". But this stipulation would depart substantially from ordinary usage and would be susceptible to counter-examples.

And if someone circumcised an adult with no medical indications and without their consent, anyone - especially the adult - would legitimately regard it as mutilation.

Michelle Mullen also takes exception to our reference to the amputation of a gangrenous leg (2003). She denies that this is analogous to circumcision because a gangrenous leg, unlike an ordinary foreskin, is not healthy tissue. Here again, however, she is inattentive to the particular point we were making. Our claim was that disfiguring surgery can be morally justified even if it constitutes mutilation.

So do they grant that circumcision is disfiguring surgery?

Thus, demonstrating that a procedure constitutes mutilation is insufficient to show that it is morally wrong. Further argument is necessary. Perhaps Dr. Mullen thinks that such an argument would include a premise that all (non-consensual) disfiguring surgical removal of healthy tissue is wrongful mutilation. But to this it might reasonably be objected that if the disfiguring surgical removal of healthy tissue were to bestow a net benefit on the person on whom the procedure is performed, it is highly implausible to claim that the mutilation is wrongful. Dr. Mullen may think that there can be no such benefit, but that is a matter to be established by argument rather than by stipulative definition.

It'd be interesting to see a case where a disfiguring, non-consensual surgical removal of healthy tissue from an adult was claimed to confer a net benefit and succeeded in court at being demonstrated to be non-wrongful. A circumcision under anaesthetic during another operation to facilitate that operation might be a case in point. Such a case happened in Louisiana in 2000.

Nicholas Lund-Molfese objects to the definition of "mutilation" that we discussed. He takes that definition to be a "neutral physical description devoid of ethical conclusions" and prefers instead a value-laden definition, such that the word "mutilation" cannot be employed except in cases where the referent is morally wrong (Lund- Molfese 2003, 64). A few observations are in order here. First, the definition of mutilation to which we referred was not entirely value- neutral. It incorporated the notion of "disfigurement", which, we noted, was value-laden. Second, value-laden definitions have their advantages, but also their disadvantages. One of the latter, at least where the relevant value is moral in nature, is that a moral judgment has to be made before the definiendum can be used in reference to some practice. Put another way, in the context of circumcision, a morally value-laden definition of "mutilation" cannot be used in reference to circumcision unless one has already established that circumcision is wrong. To establish that circumcision is wrong, one cannot simply describe circumcision as mutilation (which would be circular).

Well the fact that an exactly parallel operation on females is called "mutilation" without controversy has some bearing. One might conclude is that the only reason male circumcision is not called "mutilation" is because it is already customary.

George Hill adopts a different approach. He says that the relevant question is not whether circumcision is "mutilation", but whether parents may decide to remove "extremely sensitive genital tissue from an infant for any reason other than unquestionably urgent medical necessity" (Hill 2003, W-1). We argued that the mutilation question is indeed not the relevant one. And we agree with Dr Hill's assessment of what the relevant question is. Unlike Dr Hill, however, we do not think that merely asking the question constitutes an answer to it. Our entire paper was devoted to considering the relevant evidence and arguments that must be examined in order to answer the question. Simply re-asking the question does not undermine the outcome of that deliberative work.

The difference between the Benetars' and George Hill's approach to this question is that the Benetars regard the foreskin as being guilty until proved innocent, as having to prove its worth. There is certainly a prima facie case that the foreskin is "extremely sensitive genital tissue": it has been so considered for centuries in cultures where most men still have it.

One of our respondents, Wayne Hampton, makes the same sorts of errors in speaking about "child abuse" as other respondents made in speaking about mutilation. He says that "permanent injury is part of the definition" of "child abuse" and that since circumcision involves permanent injury, it constitutes child abuse (Hampton 2003, W-1). However, not all permanent injuries inflicted on a child constitute child abuse. If a child with a gangrenous foot has this limb amputated, the surgeon inflicts a permanent injury on the child, but it does not follow that the surgeon abused the child.

It is debatable whether the removal of a gangrenous foot constitutes "permanent injury" since the gangrene has already caused equivalent permanent injury and the amputation is only to prevent worse injury. An intact foreskin does not present anything like the same kind of threat as gangrene. The question is whether circumcision fits all the other elements of the definition of child abuse. It could be argued that child abuse differs from circumcision in its malicious intent - but some abusers, like all circumcisors, claim to be acting "for the child's own good".

This is because some injuries - damage to tissue - do not constitute a harm, all things considered.

The Benetars proceed to beg the question that circumcision is one such injury - by failing to consider all things.

Informed consent
In our paper we considered (and rejected) the view that circumcision must be wrong because it is a medically non-essential procedure to which neonates are unable to consent. A number of our respondents simply repeated this view without engaging or undermining the arguments we advanced for its inadequacy. This is not progress, but is instead reassertion.

For example, Paul Ford simply asserts that "surgery is impermissible for incompetent patients unless it offers clear and significant net medical benefits" (Ford 2003, W-1).

This is certainly true - or at least defensible - where adult patients are "incompetent".

Rio Cruz and colleagues are happy merely to reassert that an "individual's right to bodily integrity" may not be abridged unless there is "compelling, rational, demonstrable benefit" (Cruz et al. 2003, W-1). These restatements of the view we reject, ignore the arguments we provided for an alternative view. We defended the view that parents have the right to authorize some medical interventions for their children even in the absence of clear and immediate medical necessity - generally, those (possibly beneficial) medical interventions that are not clearly harmful, particular if they yield some other (non-medical) benefit.

One assumption here is that all medical procedures (including circumcision) have only the beneficial effects claimed for them. It assumes that all circumcisions go according to (the doctors') plan. It ignores that the penis's owner may just prefer it to have been left whole. The Benetars are unquestioningly resistant to the idea that the foreskin has intrinsic merits and that replacing it with a ring of scar tissue necessarily creates a deficit.

Our argument invoked the analogy of vaccination which, where herd immunity obtains,

Parents have no way of knowing whether "herd immunity obtains" when and where they are, but they do know that vaccination provides major benefit - signification protection from deadly diseases - overall. "Herd immunity" applies to circumcision only to the extent that circumcision protects against infectious diseases - a question the Benetars do not address. (Claims that circumcision protects against STDs have been disproved.)

does not clearly provide a benefit and does carry small but serious risks to any individual child that is immunized.

Well, plenty of people maintain that vaccination is wrong. It is not a given that it is right. In any case, this is, as they admit, an analogy, which is only ever as good as the similarity of the things compared, and circumcision differs in many material ways from vaccination. Perhaps the greatest difference is that every vaccination is highly specific to a particular disease, while the benefits claimed for circumcision change with the phases of the moon.

Wayne Hampton denies that vaccination is analogous (Hampton 2003, W-2). First, he says, it constitutes a gain, rather than a loss. This claim is ambiguous. If by "gain" and "loss" are mean "benefit" and "harm", then his claim begs the question. If, instead, he means literally an addition (of biological material) and a loss (of genital tissue), then it may be countered that this gain-loss distinction is morally uninteresting. Poison may be added and malignancy may be removed. But gaining poison is clearly morally worse than losing a malignancy. Clearly it is not gain and loss but rather benefit and harm that are of interest. However, nothing Wayne Hampton says undermines the analogy, in this regard, between circumcision and vaccination.

They are being deliberately obtuse here. The old "circumcision ~ vaccination" line has been tried many times. Circumcision is unlike vaccination in permanently depriving the penis' owner of something he may well prefer to keep. That is what Hampton meant by "loss". (There is no "immunological integrity" movement.) The Benetars offer an analogy (foreskin ~ malignancy) but do nothing to back it up.

Steven Svoboda has different objections to the vaccination analogy. First, he says, the public health benefits of circumcision are "incomparably miniscule compared to" those of immunization (Svoboda 2003, 53). Here we see that Mr. Svoboda chooses to compare the public health benefits of circumcision and immunization. Our analogy, however, was between the individual health benefits of the two interventions (because we were not defending routine neonatal male circumcision).

It seems they are now using what should perhaps be called the "strong" definition of "routine" - circumcision of all babies without regard to parental choice. It might also be called "straw-man routine" because there is always (since 1972) the pretence of informed consent.

The individual health benefits of neonatal circumcision are also miniscule compared to those of immunisation, because circumcision at its "best" confers only a statistically significant (i.e. reliably detectable in large samples) reduction in the rare ailments it claims to prevent, not "significant" as the term is ordinarily understood (readily detectable in individual cases).

More specifically, we compared the benefits of circumcision to an individual with the benefits of immunization to an individual where herd immunity obtains (and thus the public health benefit has already been secured).

This seems to mean that where nobody in a region has a disease, vaccination against that disease does no good but no harm either, and they compare circumcision to this state of affairs. This is a most extraordinary way of arguing.

It is true that circumcision does differ from immunization, as he says, in that "circumcision constitutes a much more serious invasion of the individual's body" (53). However, two considerations are relevant here. First, even if circumcision is more invasive than vaccination,

IF? Removal of a substantial body of tissue is much more invasive than scratching the surface.

it does not follow that it is excessively invasive.

(Notice that a vaccination administered by injection is in turn more invasive than an orally administered vaccination.)

(Notice that no vaccination, however delivered, is as invasive as circumcision.)

Second, the severity of this invasion has to be weighed against the potential benefit, and the benefit of circumcision to an individual may be greater than the benefit of immunization is to that individual where herd immunity obtains.

This assumes that the invasion and loss of circumcision and immunisation are exactly equivalent.

Mr. Svoboda offers what he takes to be a better analogy to circumcision - prophylactic double mastectomy of girls whose family history suggests that they are at high risk for breast cancer (2003). He argues that although such mastectomies would much more likely save lives, nobody seriously suggests that such prophylactic surgery be performed (on young girls). However, this analogy is not very compelling. The psychological effects of performing double mastectomies on girls would generally be considerably worse than (a) performing this procedure on adult women; and (b) circumcising infant males. Put another way, if one were to have prophylactic mastectomies, most people would prefer to have them later in life,

What is the basis for this extraordinary claim? If many girls were mastectomised as neonates - and especially if most girls were - it can certainly be argued that there would be no psychological ill-effects. In this parallel universe, one can even imagine men going "Eeew! Gross!" at whole-breasted women.

whereas if one were to be circumcised most people would prefer to have this done in the neonatal period.

The Benetars make this claim without evidence. Most intact men in the non-circumcising world would like to retain their complete penises for as long in their lives as possible.

Paul Ford correctly notes that "a neonate still has to develop his own values and choices" (Ford 2003, 58) but seems to think that because informed consent cannot be obtained from the neonate, non- therapeutic circumcision must therefore be wrong.

Well it would certainly be wrong to perform a medical procedure with no therapeutic function on an adult who was temporarily incompetent to give informed consent, so it is hard to see how it can be right to do so to a child who will eventually be able to give it - or withhold it - after a longer time span.

But again, this simply constitutes an unsubstantiated rejection of a conclusion for which we argued - that parents may, subject to certain constraints, make decisions on behalf of their incompetent offspring.

Ah, good old "decisions for" where no decision needs to be made - as no decision is made in most of the developed world. What, one wonders, are the "certain constraints" that allow parents to remove part of the penis - but no other healthy body parts - from their incompetent offspring?

Wayne Hampton charges us with seeing "no value in a patient's personal autonomy and freedom of choice" (Hampton 2003, W-1). But this ignores the complexities generated where patients do not yet have the capacity for autonomy. Decisions sometimes have to be made on behalf of such patients.

What makes this a decision that "has to" be made?

It is true that the future autonomy of a currently incompetent patient must be a guiding value. This, however, does not constitute a decisive consideration against circumcision. First, what evidence there is for the beneficial nature of circumcision suggests that the benefit is greatest when circumcision is performed in infancy.

"what evidence there is...suggests that..." is a very weak reed on which to hang a decision to override an individual's choice about how much of his own genitals to retain. "Greatest" in the case of urinary tract infections (the only case in which circumcision's supposed benefits are confined to infancy) should perhaps rather be "least miniscule". And the Benetars neglect the possibility that the "evidence" (such as now-discredited claims about cancer of the penis) was specifically generated in order to justify infant circumcision.

Second, it is far from clear that non-circumcision leaves open a future person's options in every regard. It does preserve the option of future circumcised or uncircumcised status. But it makes other options far more difficult to exercise. Transforming from the uncircumcised to the circumcised state will have psychological and other costs for an adult that are absent for a child.

Only if they choose to so "transform". The Benetars beg the question that they will. Clearly, choosing not to "transform" - as the vast majority of intact men "choose" - has no such costs.

You could use the same argument - it would be harder for them to decide to have it done later - to justify cutting off any other non-essential part of the baby's body, such as a little toe joint or an earlobe.

Steven Svoboda (2003) misunderstands what these costs are . The relevant cost here is not pain - a problem that can be adequately resolved by appropriate analgesia in both children and adults.

False. Much more adequately in the adult, who can self-medicate and regulate their own level of pain relief. And a pain one has chosen to undergo is invariably easier to control than one that is imposed on one.

Instead the relevant costs can include (1) the embarrassment of having one's genitals exposed and operated upon, (2) having one's genital alteration become the subject of curiosity and discussion by one's acquaintances and co-workers;

Oh diddums! So in order to protect the feelings of the tiny minority of men who (a) want to be circumcised and (b) are embarassed about being operated on or talked about - presumably not the same men who want to be circumcised in front of an audience - an unknown but large number of babies should be circumcised in infancy whether they will ever want to be circumcised later or not. The outrage of those men who were circumcised in infancy and wish they had not been is ignored. The Benetars' bias is showing.

(3) the possible difficulties of adapting to the new appearance of one' genitals (no matter how much one wants the change),

So an unknown but large number of babies should be circumcised because later they might grow to be men who want to be circumcised but have difficulty adjusting to looking circumcised? This is called straining out gnats and swallowing camels.

and (4) a recovery period that interferes with the pursuit of one's other projects. An infants suffers no embarrassment from circumcision, has none of the anxieties of a knife being taken to his penis, is immune to gossip, has no difficulty adjusting to the new appearance of his genitals, and does not need to take off time from work (or school) to recover.

Nor does an adult who does not get circumcised! Duh! What an extraordinary line of argument - yet it is commonly presented in informal form as a circumstition.

Given the costs of adult circumcision, many uncircumcised adult males who would wish to be connected with religious and cultural communities in which circumcision is a central tenet would have circumcision stand in the way of their exercising this option. These men would face a significant obstacle to religious and cultural expression.

Are they seriously suggesting that gentile/infidel babies should be circumcised in infancy IN CASE they might want to convert to Judaism or Islam in adulthood? (Actor/director Stephen Fry is one such, but in the event, he didn't want to.) Since religious circumcision was instituted in order to set its members apart, it was deliberately made difficult for adults and hence an obstacle to conversion. And conversely, if the babies grow up to want to become Sikhs, being circumcised would be an impediment.

Critics of circumcision might wish to dismiss this impediment by noting that such men would still have the option of religious and cultural affiliation by undergoing circumcision. This retort is too quick, however. Consider the following analogy. Many people, presumably including many opponents of circumcision, support compulsory primary and secondary education for children. Those children who elected not to go to school would be able, later in life, to gain the education they had missed, if they decided to pursue a career that required a higher level of education than that which they had obtained. So their option for education would be preserved if primary and secondary education were not compulsory, and their autonomy would thereby be respected. Yet it is clear that an adult's choices would be severely constrained, in practice, if he or she lacked primary or secondary education.

This is an extraordinarily strained argument. It is generally agreed that any education is better than bone ignorance. It is not generally agreed that all religions requiring circumcision are better than other religions or none. And the Benetars don't seem to know that children learn many things, such as languages, much better and faster than adults, so the costs of leaving a child uneducated are inevitable. Circumcision is mandatory in some religions only because most adherents think it is. Small but growing Intactivist movements within those religions make it quite possible to be an adherent without getting circumcised.

Now rectifying an education deficit would certainly take much more time and effort than would subjecting oneself to circumcision, and thus we are not suggesting that these two constraints on options are equally strong. All we are suggesting is that being uncircumcised can limit options in practice and thus erring on the side of a child's autonomy is not without cost.

Nor are these costs "negligible", as Wayne Hampton (2003, W-1) suggests they are. (A fortiori, they are not "zero" as he elsewhere says they are.) At the very least, they are not more negligible than the risks and costs of circumcision.

Oh really? Isn't THAT question-begging?

Wayne Hampton's claim that the negligible costs of waiting are preferable to "making a permanent ethical mistake" (2003, W-1) is question-begging.

Costs and Benefits
Mark Sheldon correctly notes that much of our argument about circumcision depends on whether the empirical evidence about the medical costs and benefits of circumcision is as we suggest it is. Had the risks and harms of circumcision been much greater, and if there were clearly no benefits, then the balance of considerations would have been against circumcision. Mark Sheldon does not take issue with our presentation of the actual evidence, which he describes as "dispassionate, thoughtful and apparently fair" (Sheldon 2003, 61).

But the question arises, is it up to them to weigh the evidence? This is just another instance of unilaterally and permanently withdrawing the choice from the person most directly involved, who, when he reaches adulthood, is perfectly capable of weighing the evidence himself, and may well come to the opposite conclusion from the Benetars.

Indeed we attempted to present the evidence as clearly and as fairly as possible. Some of our respondents, however, have taken issue, either explicitly or implicitly, with our discussion of the costs and benefits.

Steven Svoboda criticizes our analysis of the costs and benefits of circumcision for "ignoring the elephant in the room - the inherent value of the intact penis" (Svoboda 2003, 53) What he fails to realize, however, is that the very point of contention is whether there is indeed an elephant in the room or whether this pachyderm is instead an artifact of circumcision opponents' virtual reality.

The Benetars' attempt at humour is as ponderous as the "pachyderm". Just because something may be an "artifact" of Intactivists' "virtual reality" does not mean that it should be ignored, or assumed not to exist. The Benetars use their little "joke" to do both.

In other words he begs the question. The value of an intact penis cannot be fully assessed without knowing the benefits and costs of a circumcised penis. It will not do simply to assume the value of the intact penis.

Well, actually it can. There are plenty of benefits that derive entirely from the presence of a foreskin, that it can safely be concluded that circumcision deprives one of. Some intrinsic value should be assigned to an intact penis, just as to an intact hand, tongue, ear or clitoris, without regard to the alternatives. Some inherent demerit should be attached to the inevitable scarring associated with cutting off a healthy body part. And in any ethical calculus, some (considerable) inherent merit should be attached to the person most concerned making his own determination of the value of his own body parts.

Wayne Hampton accuses us of not doing a proper calculation of the costs and benefits of circumcision (Hampton 2003). He seems to think that we underestimate the risk of death and dismemberment by noting the infrequency of these complications. On his view, any risk of death or dismemberment, no matter how small, is unacceptable. But this trumping weight can be granted to rare death and dismemberment only if there are no benefits to be derived from circumcision. Once there are some benefits, the complications need to be weighed against these. Then the rarity of the complications becomes relevant. Wayne Hampton also seeks support for his claim that we underestimate the costs of circumcision, by referring to the elevated risks of death and dismemberment characteristic of traditional Xhosa circumcision. But it is manifestly inappropriate, when considering risks and costs, to compare the practice of infant circumcision in sterile conditions by trained professionals, with circumcision of youths by inadequately trained tribal figures in non-sterile conditions.

Who says they are "inadequately trained"? Who says the professionals are fully trained, when circumcision is commonly used for training? The difference between the risks of traditional Xhosa circumcision and US non-therapeutic circumcision are differences of degree, not of kind.

It is thus he, not we, who is doing the mathematics incorrectly. Moreover, he ignores our argument that a cost-benefit calculus is not simply a matter of weighing medical evidence. Personal values affect the equation. Thus, for example, it is not unreasonable for somebody to rank the death and morbidity (from penile cancer) of an adult

At a very old age, as is usually the case?

as worse than the death (from circumcision) of an infant who may be less invested in his life.

Tell that to the grieving parents, who were very much "invested in his life".

The point here is not that we must rank the costs in this way, but that a ranking (one way or the other) involves not only medical but also value judgments.

George Hill claims that we say more about the benefits than the costs of circumcision (Hill 2003). This makes it seem as though we devote disproportionate space to outlining the benefits. However, discussing the alleged benefits is not the same as defending the view that these really are (significant) benefits. Much of our discussion of the benefits was directed to the limitations of the evidence of benefit. Similarly, our discussion of the costs included an assessment of whether the alleged costs were real, how great they were and whether they could be avoided.

Pain
George Hill (Hill 2003, W-1) complains that we ignore post-operative pain. But we did discuss this. We indicated that we "are not aware of any studies on such pain and its control in neonates" but that there "seems to be no reason … why simple topical or systemic analgesics should not suffice".

Well, one is that unnecessary doping up of neonates - especially at the time they should be establishing the breast-feeding bond with their mothers - should be avoided.

Michelle Mullen acknowledges that we discuss post-operative pain, but dismisses our arguments by saying that although there may be no studies, "there is a prima facie case to suggest that scalpel wounds to the genitals which are then exposed to regular coatings of urine and feces (a diaper) would be painful" (Mullen 2003, 49).

And create a new risk of infection.

This response misses the point. We agree that there will be postoperative pain. In fact, there is more than a prima facie case for thinking that there will be such pain. The relevant question, though, is whether that pain can be controlled. Given that postoperative pain can be well controlled for much more radical surgical procedures,

In neonates?

it is reasonable to assume that it can be adequately controlled after circumcision.

Can be, perhaps, but is it?

Both George Hill (Hill 2003) and Michelle Mullen (Mullen 2003) also criticize our failure to discuss those papers that suggest that inadequately controlled pain in infancy leads to greater pain perception later in life. In offering this criticism they ignore how its force rests on the inadequate control of pain. We indicated that circumcision should not be performed without adequate pain control, both intra-operatively and post-operatively. If the analgesic condition is met, then the concern about after-effects of inadequately controlled pain from circumcision simply does not arise.

The Benetars seem to live in an ideal world when it suits them, a world which is ideally suited to the practice of infant circumcision. The Taddios' study of the delayed effect of pain did not find any pain control that was adequate.

Michelle Mullen seeks to elicit her readers' disapproval of employing (the most effective forms of) analgesia - penile nerve blocks - by graphically describing this as "sticking needles into small neonatal penises" (Mullen 2003, 49). This rhetorical trick obscures the evidence (Kirya 1978; Stang 1988, and Williamson 1983) we cited that "the administration of the injections themselves have not been found to elicit a pain response" (Benatar and Benatar 2003, 38).

Which doesn't mean that it doesn't. There is certainly a prima facie case that it would.

Frances Batzer and Josh Hurwitz seem more confused. They state that the "seminal issue of inflicting pain in a newborn is important" and reassure their readers that the "technique of dorsal penile nerve block … appears to be effective" (Batzer and Hurwitz 2003, W-1). However, in the same paragraph they go on to say that it "is a misconception that amputating the foreskin causes pain" (Ibid). If that latter claim were true, one wonders in what way penile nerve block is "effective".

The latter claim is certainly not true. The former is highly debatable. Batzer and Herwitz seem even more determined to defend circumcision than the Benetars, to the latters' embarassment.

Sexual pleasure
A number of our respondents claim that sexual pleasure is diminished as a result of circumcision. In doing so, they ignore our earlier arguments against this claim. Rio Cruz and colleagues, for example, are content to tell us how richly innervated and vascularized the foreskin is and that removing it "deprives an individual … of the full range and depth of sexual pleasure" (Cruz et al. 2003, W-1). However, as we noted in our paper, it does not follow from the fact that the prepuce is highly innervated and vascularized, that removing it diminishes sexual pleasure. This is because more than enough erogenous tissue may remain to facilitate the same degree of sexual pleasure.

A very strange claim. Would they make it about the tongue and sensations of taste, or the removal of any erogenous tissue from women? Some day it might be possible to cleave humans down the middle and each half would have "enough" of everything to "facilitate the same degree" of enjoyment of life.... Would that justify doing it to neonates? Where does that "may" come from? Certainly not from any peer-reviewed research.

The Benetars seem to assume that "erogenous tissue" may be graphed against "degree of sexual pleasure" (and that the curve rises to a plateau) using the same graph for all men at all times. They seem to be confusing "degree of sexual pleasure" with "ability to reach orgasm" without reference to the quality of the journey.

It is possible that additional increments of erogenous tissue do not increase sexual pleasure.

It is possible. Certainly men with bigger penises don't necessarily enjoy sex more. (But do they have any more nerves?) But the amount of erogenous tissue any intact man was born with seems to be the optimum amount for him, so what justification is there for saying that less is "enough".

Thus, it is a misrepresentation of our view to suggest, as Wayne Hampton does, that we claim that men are only "entitled to" the penile innervation of the circumcised penis (W. Hampton, 2003, W-1). The language of "entitlement" is a red herring here.

On the contrary, throughout, they argue as if circumcision were not just the status quo but an ethical norm, from which any departure must be justified. (Consider a parallel universe - or Sweden - where circumcision is not the norm and see how these arguments stack up. Or consider a parallel operation that is not the norm. The Benetars' paper would have equal force if "circumcision" were globally searched-and-changed to "earlobeotomy" but the bizarre nature of their thinking would then be thrown into high relief.)

It should also be apparent that we do not, as George Hill claims, ignore the "loss of the most heavily innervated tissue in the male genitals" (Hill 2003, W-1) Rio Cruz and colleagues say that it "should be self-evident that cutting off primary sexual tissue unalterably changes the way sexual acts are perceived and performed" (Cruz et al. 2003, W-1) and that we therefore bear burden of proof that we fail to provide (Cruz et al. 2003, W-1). However, it is far from obvious that circumcision reduces sexual pleasure.

Well it should be. Is it obvious that penectomy reduces sexual pleasure? Yes. Is circumcision anything but partial penectomy? No. Q.E.D.

As our original paper provided evidence of this, we did in fact meet any burden of proof they may think we bear.

The "evidence" in toto was

Petrina Fadel says that circumcision "is documented to cause erectile problems, a serious impairment of function" (Fadel 2003, W-1) One of the papers she cites, by John Coursey and colleagues, does not support this conclusion. In this study, erectile function was evaluated following anterior urethroplasty and therapeutic circumcision and compared with recollected function prior to surgery (Coursey 2001). While a minority of patients in each group reported dissatisfaction with erection, the substantial majority of men (about 70%) reported either no change or an improvement in erectile function. The second study she cites, performed by Kenneth Fink and colleagues (Fink et al, 2002), investigated the effect of circumcision on erectile function, penile sensitivity, sexual activity and overall sexual satisfaction. The low response rate introduced a potential selection bias and reduced the sample size sufficiently to compromise the reliability of the results. Compared to before therapeutic circumcision, men reported decreased erectile function and decreased penile sensitivity but overall improved sexual satisfaction. Given these apparently conflicting results, and the fact that sexual activity before circumcision was undertaken while suffering from the medical problem that was the indication for circumcision, it is difficult to know how to interpret these findings. What does one make of reduced erectile function in the face of increased overall sexual satisfaction?

Nothing relevant to non-therapeutic circumcision.

Penile cancer
George Hill, in what he obviously takes to be a response to our discussion of penile carcinoma, alludes to a number of countries where circumcision is uncommon and the incidence of this disease is low. He evidently takes this to be a decisive objection to the claim that circumcision offers some protection against penile cancer. However, as we indicated in our paper, this sort of evidence is indirect. Proponents of routine circumcision employ a similar method in reference to a different set of countries in order to prove their point. For this reason, we recommended a more direct and therefore more reliable approach to the question of whether circumcision protects against penile cancer. Mr. Hill ignores this more rigorous approach to the question.

The Benetars don't seem to address the fact that penile cancer is 1) extremely rare and 2) of very late onset - both factors militating against circumcision of neonates as prophylaxis.

Death
Steven Svoboda says we ignore those cases of death resulting from circumcision (2003). However, we do not. We explicitly mentioned the risk of death but indicated that the risk was very low - less than 1 per 500 000 circumcisions. In support of this widely accepted statistic, we cited an article, containing relevant data, in a peer- reviewed journal.

This assumes that all deaths from haemorrage or infection are all properly sheeted home to their ultimate cause in circumcision. And even if the figure is accurate, that's pretty cold comfort to at least two US families per year who lose a son to non-therapeutic circumcision.

Mr. Svoboda sees fit to ignore this, citing instead an opinion piece that makes a claim of 16 deaths per 90 000 circumcisions - a claim that is neither based on presented data nor referenced. Even if we have underestimated the actual incidence of death from circumcision, Mr. Svoboda's claim of over 200 circumcision related deaths per year in the United States is about a 100-fold greater risk than the best evidence suggests. Mr. Svoboda says that we should focus on the deaths from circumcision rather than on the prevention of penile cancer, which he calls a "vanishing[ly] rare condition" (Svoboda 2003, 53). Death from circumcision, however, is rarer still.

But one deprives a person of a lot more of his life than the other.

Cervical cancer
Not all our respondents thought that we overstated the benefits of circumcision. Armand Antommaria suggests that there is more evidence than we indicated, for the claim that the sexual partners of circumcised men are relatively protected from cervical cancer (Antommaria 2003). In support of this claim, he cites a recent study (Castellsagué 2002), which was published after we had written and submitted our paper. This study does lend some support to circumcision's protective effect against cervical cancer.

No it doesn't. In short, it compares women in the Philippines with women in four other countries, while we know there are many regional, lifestyle and genetic factors affecting the incidence of cervical cancer.

It is worth noting, however, that this benefit was identified only in a subgroup analysis of the female partners of those men who themselves had had more than six sexual partners. This study suggests that matters are more complicated than Frances Batzer and Josh Hurwitz think, when they claim that varying cervical cancer rates are (solely?) attributable to "social issues such as the number of sexual partners and … monogamy" (Batzer and Hurwitz 2003, W-1). Social issues are clearly relevant variables, but it would seem that circumcision status is also relevant.

Financial
Armand Antommaria notes, quite correctly, that the medical costs and benefits are not the only relevant ones (2003). Indeed, our argument considered a number of important non-medical benefits, including cultural ones. The monetary cost of circumcision is relevant to considering the allocation of public health care resources, and thus has bearing on publicly funded (especially routine)

What do they mean by "routine" this time? Apparently this is "weak routine" - non-therapeutic circumcision at the parent's request.

neonatal circumcision. But the question of whether circumcision may be publicly funded was not one that occupied us in "Between Prophylaxis and Child Abuse". We doubt that the financial costs, privately borne, could render impermissible the choice of particular parents to circumcise their child. (If they did, then people's moral freedom to spend their money in a manner of their choosing would have to be severely limited in other ways too.)

Which they are, of course.

Medical associations and medical indications
A number of our critics note that no medical associations recommend infant circumcision. These critics (eg. Cruz et al., Fadel, Hill) either charge us with ignoring this, or they suggest that our conclusions are at odds with the views of these organizations. What these critics have ignored, however, is that we do not recommend infant circumcision. In other words, we do not think that it ought to be performed routinely. Nor do we recommend against it, however. Our view is that it is a morally permissible practice.

Steven Svoboda and George Hill seem to ignore the difference between taking circumcision to be permissible and taking it to be preferable, when they attribute to us a position that is ambiguous between these possibilities. Steven Svoboda says that we "come out in favor of the procedure" (Svoboda 2003, 53) and George Hill claims that we offer a "defense" of circumcision (Hill 2003, W-1). These claims could mean that we take circumcision to be morally preferable and that we defend circumcision against those who deny that it is. That is not the view we take. We are "in favour' of circumcision only in the sense that we are not opposed to it. Similarly, we "defend" circumcision only against those who think it is morally impermissible. We do not defend it against those who deny that it is morally preferable.

Petrina Fadel makes the overly confident and unsubstantiated claim that there "are no medical indications for circumcision in the newborn period" (Fadel 2003, W-1). Our paper examined the evidence and we concluded that there was some evidence of modest medical benefit.

"Benefit" is not the same as "indications". Removing any part of the body will eliminate the possibility of any disorder of that body part - the same kind of benefit as is claimed for circumcision - but these are not claimed as "indications" for removing those body parts.

Ms. Fadel's claim would be more plausible if it were that there are no decisive medical indications for circumcision in the newborn period. Notice again, however, that one cannot infer from this that circumcision is morally impermissible. Just as there are no decisive medical indications for neonatal circumcision there are also no decisive medical indications against this practice.

Armand Antommaria (2003) suggests that if routine neonatal male circumcision is performed for cultural rather than medical reasons then it should not be characterized as a medical procedure and that it might therefore be better for doctors not to be involved. But insofar as a cultural practice has medical value, its being performed for cultural reasons is not incompatible with its being a medical procedure.

This hopelessly blurs two unrelated reasons for doing it. "Insofar as a cultural practice has medical value" is an open-ended clause, that begs the question whether circumcision has any medical or cultural value.

Thus Professor Antommaria's suggestion presupposes that there are not medical benefits to circumcision, and this presupposition is a point of contention. Notice also, that even if circumcision were thought not to have any medical benefit, it would not follow that there is no sense in which it is a medical procedure. The term "medical procedure" is ambiguous between (a) a procedure performed for medical purposes, and (b) a procedure employing medical means. Even if circumcision were not a medical procedure in the former sense, it could still be a medical procedure in the second sense.

Paul Ford also questions the involvement of doctors in circumcision. He says that even if parents may permissibly have their children circumcised "it does not mean that the medical profession should be involved in the practice" (Ford 2003, 58). Indeed, parental preferences do not commit doctors to being involved. Nor can one infer, however, that doctors should not be involved. Paul Ford is correct that the involvement of doctors in a procedure that is exclusively cultural is less easily justified than their involvement in a procedure that also has medical benefits. However, this is not to say that doctors may not be involved in procedures that have only cultural and no medical goals. One possible justification is that doctors will be more expertly equipped to employ the medical means to the cultural end, thereby minimizing the health risks. More would obviously need to be said about this, but we should not lose sight of the fact that circumcision is not clearly an exclusively cultural practice. We argued that there is some evidence for a modest medical benefit. Accordingly it seems reasonable for those doctors willing to perform the procedure to facilitate the preferences of those parents who do wish to have their sons circumcised for its possible medical benefits. Paul Ford says that "physicians should actively discourage the practice and not simply leave it as an unproblematic decision for parents" (Ford 2003, 58) The evidence we presented suggested that there are no grounds for actively discouraging circumcision, just as there are not grounds for actively encouraging it. Our respondents would do well not to draw conclusions that are stronger than the evidence supports.

Parental decision making
Armand Antommaria (2003) and Sarah Waldeck (2003) refer to evidence that non-medical considerations are paramount in parents' decisions to circumcise their children. They take this to reflect negatively on these decisions to circumcise sons. Indeed, it is regrettable that the decision to circumcise (as well as just about every other kind of decision people make) is not informed by all the relevant information and is influenced by inappropriate considerations. This shows that decisions are not made in the right way, but it does not follow from this that the wrong decision is made. Sometimes the right decision can be made for the wrong reason

This is very sloppy thinking. The Benetars seem to be claiming some God-like power to know what is the "right" decision (to circumcise) other than the reasons adduced for it.

and sometimes there may be more than one acceptable decision. We have suggested that circumcision falls into the latter category.

How can it be both right to cut part of a baby's genitals off and right not to? This is not "crumbed versus battered" we are choosing (for someone else) here.

Notice too, that the very factors that are said to influence parents' decisions to circumcise their sons - to resemble their fathers and peers, for example - will influence parents not to circumcise their sons in those societies where circumcision is uncommon.

This implies that parents make a decision whether to circumcise everywhere, and just make a different decision in three-quarters of the world. Parents in most of the world do not decide about circumcision at all, so looking like the father is taken for granted. (In the same way, "parents' decision not to cut off their babies' hands" is not "influenced by a wish that they look like their fathers", because there is no such decision.)

Thus Professors Antommaria and Waldeck's comments do not entail the wrongfulness of circumcision (any more than they would entail the wrongfulness of not circumcising in societies where circumcision is rare).

Again, the Benetars assume cutting part of a baby off is ethically on all fours with leaving a baby alone. It is not.

Male and Female circumcision
A number of commentators took issue with our comparison of male and female circumcision. Frances Batzer and Josh Hurwitz suggest that "to equate female circumcision with male circumcision under any guise is ludicrous" because "the ultimate outcome and purpose of each is quite different" (Batzer and Hurwitz 2003, W-1) They seek to assure us that male circumcision "is performed with no intent to inhibit or change sexual or psychological function" whereas female circumcision, they say is "meant to decrease sexual enjoyment" (Batzer and Hurwitz 2003, W-1) What these authors do not realize (but should, because it was mentioned in our paper) is that male circumcision has not infrequently been performed with the intention of curbing sexual desire - the very same justification that has often been used for female genital cutting. Now, it happens to be false that circumcision has this effect, but it is also false that the equivalent form of female genital cutting (as distinct from the more severe form, the effects of which these authors describe) has this effect. Thus we find that the analogy is immune to the criticism of these authors. We explained this carefully in our paper. These commentators have not sought to rebut our argument, but instead ignored it. Sara Webber and Toby Schonfeld make a similar mistake. They note that female circumcision, the removal of clitoral preputial tissue, has been used for two apparently conflicting purposes - sometimes to curb sexual activity, and sometimes to promote it (in married women).

And the same is true of male circumcision.

Although this may seem odd, they suggest that these two purposes are explained at a deeper level by an attempt to direct a female's sexuality toward her husband. With this aim, masturbation, premarital and extramarital sexual activity are to be curbed, and "missionary position heterosexual sex with the husband" is to be promoted. It is, these authors say, the "directing [of] women's sexuality that is objectionable" (Webber and Schonfeld 2003, 66) rather than the curbing of sexuality, to which we had referred. This argument fails in a number of ways. First, it is hard to see why it is only "directing sexuality" rather than also "curbing sexuality" that is morally troubling. Second, the explanation that circumcision has been used in an attempt to direct sexuality, could as (im)plausibly be employed to explain why males are circumcised as it can to explain why females are circumcised. Indeed, as we indicated, male circumcision has sometimes been employed in an attempt to curb male sexuality, while it has also been thought to enhance sexual pleasure. It could be argued, that the sexuality of males has been directed, even if not in exactly the same way, that the sexuality of females is alleged to be directed. The point is not that female sexuality has not been controlled and directed, but that the evidence does not suggest that the practice of circumcision (understood as the removal of preputial tissue) is any more directive of women's sexuality than it is of men's.

Huh? So the fact that it doesn't work makes it all right??

The third problem with the argument of Professors Webber and Schonfeld is that even if circumcision had been used in a bid to direct female but not male sexuality, it would not follow that different moral judgments could be made about physically analogous male and female circumcision,

This seems to mean that the Benetars have no more ethical objection to FGM than to MGM, namely, none.

particularly if two conditions were met: (a) neither the male nor female form actually had any effect on sexuality; and (b) neither male nor female circumcision, in the given instances, were employed in the hope of directing sexuality. We have suggested that condition (a) is true.

But their suggestion is probably false.

Instances of male and female circumcision performed by people recognizing the truth of condition (a) would satisfy condition (b). Professors Webber and Schonfeld might respond that it is the historical purpose of circumcision, rather than the purpose of any given circumcision that is relevant. But on this argument, currently innocuous practices are tainted for all eternity if they once had an odious foundation.

This is confused. The historical purpose, to limit sex, still taints the present purposes.

A Catholic debate
John Paul Slosar and Daniel O'Brien very helpfully showed how our arguments are compatible with the best Catholic thinking about circumcision. Petrina Fadel takes them to task for looking to non-Catholics "for guidance" instead of following (her view of) Catholic teaching. While we do not wish to enter a debate around what the correct Catholic view is on circumcision, there are numerous weaknesses in Ms. Fadel's response to Drs. Slosar and O'Brien, which require no special knowledge of Catholic teachings to recognize. First, she employs the very rhetoric against which we cautioned and carefully argued. For instance, she cavalierly describes circumcision as "amputation"

And how is it not amputation? Do the Benetars demand bones?

(Fadel 2003, W-1) and "mutilation" (Fadel 2003, W-2). She liberally disburses anecdotes (Fadel 2003). She appeals to those authorities who support her view (Fadel 2003), and leaves critical readers wondering how representative these interpretations of the relevant teachings are in Catholicism. These readers will not be content with her assurance that she is "certain" that she is "interpretating the genuine sentiment of every upright conscience" (Fadel 2003, W-2). Such talk is crude rhetoric, not the sort of reasoned argument we expect to see in an academic journal.

Any Catholic judging circumcision to be immoral would have to explain how God could have once commanded (some) people to circumcise their sons, something which Catholics must surely believe given that they accept what they call the Old Testament. Even if one believes that the covenant of the circumcision has been superceded and that circumcision is no longer required, Catholics opposed to circumcision need to explain how God could have commanded what they take to be immoral. Ms. Fadel offers us no such explanation. She does note (correctly) that ancient Hebrew circumcision (which would have been performed on Jesus) involved removal of less of the foreskin than contemporary Jewish circumcision. But given Ms. Fadel's arguments about circumcision, it is hard to see how she could think that even this more limited form of circumcision is morally permissible. Thus she needs to explain how God could have commanded a form of circumcision she takes to be immoral.

A moment ago, they said, "But on this argument, currently innocuous practices are tainted for all eternity if they once had an odious foundation." But on THIS argument, currently immoral practices (such as human sacrifice) are redeemed for all eternity if they once had a sanctified foundation.

Other problems
The responses of our critics abound with other defects. We cannot list them all, but we shall provide a few examples.

Rio Cruz and colleagues offer us a non sequitur. They say that to reach our conclusion that circumcision is morally permissible, we ignore the fact that, worldwide, circumcision is relatively rare (Cruz et al. 2003). But the rarity of a practice is utterly irrelevant to determining its moral permissiblity. Worldwide, baseball is rare, but that does not make it immoral.

These same authors also offer appeals to authority. For example, they say that forced "male circumcision has been recognized as a human rights violation in at least one legal case and in two United Nations reports" (Cruz et al. 2003, W-1). But moral arguments cannot be settled by appealing to legal judgments and United Nations reports. And if one could, it would be far from clear that merely one legal case and two United Nations reports would establish the conclusion. Wayne Hampton is prone to a crude relativism. He says that we "neglect the fact that child abuse is not an objective interpretation, but a subjective one" (Hampton 2003, W-1). Now, insofar as that is true, he has no moral complaint against those who circumcise. He might take this practice to be child abuse, but if what constitutes "child abuse" is merely a matter of subjective interpretation he has no grounds for criticizing those circumcisers who deny that circumcision is child abuse. In a non-relativist moment, he assures us that there "is a whole website devoted to cataloging bad reasons for circumcision" (Hampton 2003, W-1).

Aw, shucks! It's actually only a page of this site.

Only the most naïve readers will be impressed by this. There are whole websites devoted to holocaust denial,

Should I invoke Godwin's Law? Actually, it is the circumstitions, not the listing of them, that have a lot in common with holocaust denial - they are both desperate attempts to defend the indefensible.

various conspiracy theories and dozens of other crackpot views. The mere existence of these websites and the "evidence" they list, provides us with no reason to accept their claims. There is no substitute for examining the actual evidence, as found in peer- reviewed papers.

My catalogue of bad reasons (as well documented as I can make them) has an underlying point: to illustrate that something else is going on - that there is a wish to (meddle with the genitals, specificially to) circumcise that has nothing to do with health, religion or anything but itself. And in fact the Benetars' casuistry is only circumstitionising writ large. If circumcision were not already rampant, their argumentation for it would look completely mad. As I said above, try substituting "earlobe-removal" throughout, and see how sane it is.

George Hill does not distinguish causation from relationships such as correlation and mere coincidence. In support of his claim that circumcision impedes intromission and intra-vaginal penile gliding, he notes that "the sale of sexual lubricants" in the United States "far exceeds that in countries where routine non-therapeutic circumcision is unknown" (Hill 2003, W-1).

That's very interesting. It's certainly hard to think of any other reason that it might be true. Do the Benetars think lubricant sales cause circumcision perhaps, or that both have some other underlying cause? It'd be fascinating to know what that is.

A number of our commentators employ inflammatory rhetoric. For example, Petrina Fadel compares the research use of circumcised prepuces with the Nazi use of Jewish skin to make lampshades (Fadel 2003). But there is a vast moral difference between using surgical waste

To call somebody's foreskin "surgical waste" could be called inflammatory rhetoric. The Benetars beg the question that the "surgical waste" has been obtained by ethical means. There are still ethical issues involved in the use of "surgical waste": consider the scandals involving the misuse of the hearts and brains that are "surgical waste" from autopsies.

... for research and making lampshades out of somebody one has murdered.

It might have been better to cite commercial, rather that research, use of foreskins.

Numerous of our respondents provide tendentious formulations of their arguments and beg the question. Wayne Hampton, for example, says that "conformity, anatomic incorrectness, chastity enforcement, false ideas about how men are made … conflict with real human values such as autonomy, wholeness, human dignity, and so on" (Hampton 2003, W- 2).

Loosely formulated, perhaps, but hardly wrong for that reason.

Paul Ford describes circumcision as a "type of barbarism", lumping it together with penile bifurcation (Ford 2003, 58). Rio Cruz and colleagues proclaim that we "conclude that amputating normal, natural, protective, and sexually important tissue from a non- consenting infant does not constitute abuse" (Cruz, 2003, W-1). None of these formulations are helpful. They assume the very conclusions for which the authors need to argue.

Do the Benetars believe the foreskin with which almost every male is born is abnormal, unnatural, dangerous and/or sexually unimportant? Apparently so, when they compare it to a gangrenous foot, and to malignancy.

Conclusion
While we welcome the great deal of attention our paper has received, we find it regrettable that so many of our respondents discuss the issues as emotively as they do. What is needed when engaging this and other topics about which people feel strongly, is a cool and impartial examination of the evidence and a careful analysis of the issues and arguments. There has been all too little discussion of circumcision in the bioethics literature and we sought to alter that. It is important, however, that the discussion meet rigorous quality standards.

It is highly debatable whether the Benetars' discussion does this. They seem determined to defend circumcision by hook or by crook:

• Claiming the slimmest margin of benefits as justification, but failing to do the converse for deficits
• Deeming every justification to be adequate and worthy
• Denigrating every defence of the normal, whole, intact human's right to stay that way
• Comparing the individual's right to autonomy over the possession of his own body unfavourably with obscure, rare and marginal deficits of him deciding later to have part cut off
• Claiming marginal (and as yet unacheived) pain reduction to be equivalent to the complete and universal painlessness of leaving babies alone

Circumcision, we argued, is a permissible practice, suitably subject to parental discretion.

This raises the question, if the penis's owner has no right to decide for himself what of it he may keep, why that right should be transferred only to both parents? Alternatives are: -

• The father only
• The mother only
• A grandparent or grandparents
• Siblings
• The wider family
• The local community
• The doctor
• The medical profession
• The state

However, we suggested that the way it is currently performed - namely without (appropriate) analgesia - is morally unacceptable. Opponents of current circumcision practices would be on strong ground if they restricted their opposition to this feature of the practice.

This assumes that "(appropriate) analgesia" is harmless and does provide sufficient, if not complete, pain relief, and both assumptions are unproved and probably false.

References