when is prophylactic surgery on children justified?

[andrewJ]

http://jme.bmj.com/cgi/content/full/28/1/10

ABSTRACT:
Bioethics committees have issued guidelines that medical interventions should be permissible only in cases of clinically verifiable disease, deformity, or injury. Furthermore, once the existence of one or more of these requirements has been proven, the proposed therapeutic procedure must reasonably be expected to result in a net benefit to the patient. As an exception to this rule, some prophylactic interventions might be performed on individuals "in their best interests" or with the aim of averting an urgent and potentially calamitous public health danger. In order to invoke these exceptions, a stringent set of criteria must first be satisfied. Additionally, where the proposed prophylactic intervention is intended for children, who are unlikely to be able to provide a meaningfully informed consent, a heightened scrutiny of any such measures is required. We argue that children should not be subjected to prophylactic interventions "in their best interests" or for public health reasons when there exist effective and conservative alternative interventions, such as behavioural modification, that individuals could employ as competent adolescents or adults to avoid adverse health outcomes. Applying these criteria, we consider the specific examples of prophylactic mastectomy, immunisations, cosmetic ear surgery, and circumcision.

[andrewJ]

Application 4: Neonatal circumcision Another example of an allegedly prophylactic medical procedure is routine neonatal male circumcision. Despite the obvious ethical problems they pose, the ritual circumcision practices of Muslims, Jews, and various indigenous African tribes are not under consideration here, as these rituals neither have medical objectives nor usually take place within the provenance of the health care system. Where medical involvement does take place in these rites, or where medical justifications are proffered as an additional defence for religious blood rites, the following discussion must necessarily apply.

Despite its ubiquity in the US, routine neonatal circumcision is a highly controversial procedure that has drawn sharp criticism from ethicists and medicolegal experts.21–28 Advocates of neonatal circumcision have claimed that the amputation of the healthy foreskin from male neonates is a legitimate prophylactic procedure that is akin to immunisation and is performed on public health grounds.29 It is similarly claimed that circumcision is in the best interest of the individual affected. As a procedure whose supporting rhetoric bridges both categories of prophylactic intervention, it deserves special analysis. It also deserves special consideration because of its ubiquity in the US and because of the unbelievably long list of diseases it has traditionally been claimed to prevent.


Prophylactic circumcision: The `best interest' of the individual argument
Since its introduction as a medical procedure in the 19th century, the orthodox medical profession has most frequently employed male circumcision as a cure and preventive for such "diseases" as masturbation, epilepsy, insanity, hip-joint disease, enuresis, involuntary nocturnal seminal emissions, phimosis, redundant prepuce, prolapse of the rectum, tuberculosis, feeble-mindedness, strabismus, convulsions, prostate cancer, and night terrors, to name just a few.30 On these and similarly questionable grounds, it was introduced as a routine and quasi-compulsory procedure during the Cold War era. The allegedly medical rationale for mass circumcision are continuously shifting, and, as a reflection of this, the 1999 American Academy of Pediatrics policy report on circumcision lists urinary tract infection (UTI), penile cancer, and phimosis as being among the diseases for which circumcision is supposed to be preventive.31 Advocates of mass circumcision claim that the supposed decrease in the rate of these diseases among circumcised males renders circumcision as being in the best interest in the individual, irrespective of all other medical and ethical considerations.


1. Presence of clinically verifiable disease, deformity, or injury
Routine circumcision is, by definition, performed on a healthy organ in the absence of disease, deformity or injury. It is not in the best interest of the individual to undergo surgery for a disease he does not have and is not likely to develop. Therefore, routine circumcision fails to meet the primary requirement for intervention.


2. Least invasive and most conservative treatment option
Circumcision is attended by risks, disadvantages, dangers, and drawbacks. Although the complication rate from routine circumcision is low,32 the potential for these complications to be catastrophic, mutilatory, infective or haemorrhagic is very high.33 The tragedy of death, gangrene, or total and partial amputation of the penis are some of the possible complications of routine circumcision that cannot be justified on any grounds, either in terms of public health gains or the best interest of the child.


3. Net benefit to the patient and minimal negative impact on the patient's health
Cost-utility analyses have determined that neonatal circumcision results in an overall negative impact on health.34,35 Also, circumcision advocacy has traditionally been based on ambiguous and unimpressive data, opinions, and the exclusion of contrary evidence. It ignores the large literature demonstrating the unique anatomical and physiological benefits offered by the prepuce and intact penis. For instance, anatomical investigations have confirmed the rich erogenous innervation and concomitant sexological functions of the prepuce.36–38 Thus, because of the loss of a protective, sensory, and functional structure, the impact on the individual's health and human rights is significantly negative.


4. Competence to consent to the procedure
An infant is unable to provide informed consent. Proxy consent is invalid because of the lack of medical necessity. Also, the US Department of Health has stated that a competent "patient has a fundamental right to grant or withhold consent prior to examination or treatment" and "refusal must be respected".39 As an infant's state of incompetence is temporary, it is unethical to take advantage of his inability to refuse and to submit him to a medically unnecessary surgery that a competent adult might refuse.

Parental anxieties that a genitally intact son may be teased by his peers in school are illegitimate grounds for overriding the individual's right to autonomy. Parents are usually projecting onto their children their own remembered traumas suffered as a result of obsolete institutionalised humiliations, such as compulsory communal showering in school—a practice that has largely been abandoned, even though parents may be unaware of this change. Parents have responsibilities towards, not rights over, their children.6 Thus, in the absence of urgent medical necessity, they have no right to arrange the amputation of a healthy part of their child's body. As the one who must live with the consequences of the surgery, the child must be accorded the dignity of a choice over the appearance and function of such an intimate part of his body. Also, since there is no guarantee that an individual would be glad that his foreskin had been amputated during infancy or childhood, the ethical default position must be to protect him from circumcision until he reaches adulthood, when he can make an informed and uncoerced decision for himself. A genitally intact adult can always elect to be circumcised: a circumcised individual, however, has had his autonomy and sovereignty violated in this respect and has been left without any options.


5. Standard practice
Routine neonatal circumcision may be common practice in the US, but it is not a standard practice, as it is highly controversial, and has been rejected by the health care systems of all other Western countries. It is not a standard of practice to subject healthy patients to surgeries for diseases they do not have or cannot be reasonably expected to contract. The standard of optimal health goals must be derived from the natural and intact human body and not from a body that has been artificially reconfigured, surgically diminished, or structurally altered in any way.


6. Individual at high risk of developing the disease
Failure to obtain individual consent cannot be warranted because an individual who has been protected from circumcision is at extremely low risk of developing the diseases in question. Even according to the controversial studies used to rationalise neonatal circumcision as a means of reducing the incidence of UTI, the rate of UTI for intact infants is only 0.154% as opposed to 0.034% for circumcised infants.40 Although the difference in rates is only 0.12 percentage points, it has been made to appear significant by being stated in terms of a 3.7% increase. Objective studies, however, have established causative links between UTI and poor perineal hygiene,41 lack of breast feeding,42 forced retraction of the immature foreskin,43 and use of soap in the preputial pouch.44 Thus, UTI can be more conservatively prevented by improvements in parenting skills. The standard of care is to treat UTI with readily available antibiotics. Allegedly prophylactic surgery cannot be justified.

Phimosis, defined as a juvenile prepuce that is not yet developmentally ready to retract, is not a disease at all, and its effect on health has been greatly exaggerated, deriving from 19th century phobias about masturbation.45 Genuine cases of balanitis xerotica obliterans (BXO) that cause non-retractability due to cicatricial preputial stenosis are exceedingly rare, affecting only 0.6% of boys by their 15th birthday.46 Most importantly, these can be pharmacologically treated with a high rate of success.47 Circumcision, thus, is an inappropriate treatment for BXO/phimosis.

Penile cancer is one of the rarest male cancers and is strongly associated with lifestyle choices, such as smoking, poor hygiene, a history of STD infection, human papilloma virus, and multiple sex partners.48 Furthermore, the lifetime risk of a US male, who is likely to be circumcised, ever being diagnosed with penile cancer is 1 in 1,437,49 yet the rate is even lower in Denmark (1 in 1,694),50 where neonatal circumcision is not practised. These risks are strikingly smaller than the 1 in 8 lifetime risk for breast cancer among US females. Thus, only an insignificant fraction of adult males are at risk of developing the diseases for which circumcision is either supposed to be preventive (penile cancer) or for which circumcision is wrongly considered to be the best means of treatment (BXO/phimosis). Finally, the proven behavioural factors involved in the aetiology of penile cancer indicate that this disease can be reasonably avoided by cultivating healthful behaviours, such as avoiding smoking, multiple sex partners, poor hygiene, and STD infections.


Prophylactic circumcision as a public health measure
Here, we will only consider those infectious and contagious diseases associated with circumcision that concern public health, such as HIV and other STDs, listed by the AAP policy report.31


1. The danger to public health must be substantial
The danger to public health posed by the STDs for which circumcision is supposed to be useful is insubstantial. Because the sexual transmission of HIV and other STDs is usually dependent upon adult lifestyle choices, a programme of amputating a healthy part of the penis from an unconsenting minor as a means of reducing the incidence of STDs is unethical. In marked contrast, the contraction of the diseases for which children are routinely immunised, such as polio and measles, is independent of lifestyle choices and is determined by such accidental, unforeseeable, and casual situations as unknowingly breathing the same air as an infected person.


2. The condition must have serious consequences if transmitted
With the current exception of HIV, the STDs whose incidence circumcision is supposed to reduce have few serious consequences if transmitted. Antibiotics are very effective at treating most STDs. Genital herpes, may be incurable, but its morbidity is negligible at best, and it is more common among circumcised than genitally intact US males.51


3. Effectiveness of the intervention
The effectiveness of circumcision in safeguarding public health is either negligible or non-existent. The routine circumcision experiment, which has been conducted since the 1950s in the US has failed to prevent the US from achieving the dubious distinction as the developed country with the highest rates of STDs52 and HIV.53 The allegations of efficacy are based on poorly designed and poorly executed ad hoc studies performed by circumcision advocates whose bias and conflict of interest alone should disqualify such "studies" from serious consideration. Moreover, objective scientists have also cast serious doubts upon the genuineness of the surgery's alleged medical benefits.54–58


4. Invasiveness of the intervention
Amputating part of the penis is the most invasive method of attempting to achieve the desired public health objective. Circumcision desensitises the penis and immobilises whatever shaft skin remains, thereby destroying the natural and normal means of erotic stimulation.59 The stated public health objectives could be achieved by more conservative means, such as improved sex education, making condoms freely available, or regulating prostitution.


5. Appreciable benefit and speculation about hypothetical future behaviours
The alleged benefits of circumcision are not appreciable to the individual because to reap the alleged benefits of the procedure, the individual would have to disregard safe sex warnings and deliberately engage in unsafe sexual practices with infected individuals. Even then, because the claimed benefit of circumcision under these circumstances is not statistically significant,60 there is no meaningful way to calculate the alleged benefits from circumcision to an irresponsible individual. Most importantly, the public health rational for neonatal circumcision is rooted in the unjustifiable speculation that the child will grow up to be sexually irresponsible.


6. Benefit to society must outweigh the individual's human rights burden
No substantial benefit to public health has been demonstrated for neonatal circumcision. Also, the human rights burden to the individual posed by circumcision is severe because it violates the human right to autonomy and bodily integrity, entails the loss of a normal part of the body, alters the appearance of the penis, and impairs sexual, protective, and immunological functions.


Assessment
Routine circumcision fails to satisfy the criteria necessary to justify it either as a public health measure or a procedure performed in the best interest of the individual. The human rights burden posed to the individual is severe and is not outweighed by any appreciable public health gain

[serendipity22]

The guy who repeated Wiswells work and found the only intact boys who got UTIs had congenital abnormalities was asked how many UTIs would a boy have to get to justify circumcision said,

as many UTIs that would justify a girl getting circumcised.

[Fellow Traveler]

The guy who repeated Wiswells work and found the only intact boys who got UTIs had congenital abnormalities was asked how many UTIs would a boy have to get to justify circumcision said,

as many UTIs that would justify a girl getting circumcised.

Do you have that reference Serendipity?

[serendipity22]

Do you have that reference Serendipity?

its from
http://www.cirp.org/library/disease/UTI/altschul/

Its interesting that he tried to replicate the Wiswell studies but did not find a single intact male (who didn't have a urinary tract birth defect) who had a UTI in the study.

(Circumcision doesn't correct urinary tract birth defects)

[serendipity22]

There are other articles by this guy

e.g.

http://www.cirp.org/library/disease/UTI/altschul1990/

[firsttimemumvmr]

its from
http://www.cirp.org/library/disease/UTI/altschul/

Its interesting that he tried to replicate the Wiswell studies but did not find a single intact male (who didn't have a urinary tract birth defect) who had a UTI in the study.

(Circumcision doesn't correct urinary tract birth defects)

We all know about studies and statistics! I could carry out a very bias study today and get the results I want, but merely discarding dissident opinions.

I came here to clarify my views but all I have seen so far everywhere (this site being one of the best and less offensive) is that both sides manipulate statistics. That leaves parents with only a 'go by your gut' choice.

Each side of the spectrum is massively bias, people like Dan and I don't know what to do. However, I must say that the anti lobby is hell more vocal and more aggressive (you weren't by the way). I just want more proper information and less propaganda. I must say that some of the propganda on the 'anti' lobby I find ridicoulous, what a circ'ed man is a rubbish lover! Since when??? I have multiples with my husband about every night! Much better than before but then again, yes, we love each other, fancy each other madly... is that not what's important? I found O'Hara's book completely unscientific and hugely inaccurate!

I'm still deciding on my baby boy and I consider myself unbias here. OK, DH is theoretically Jewish but religion was never a consideration with us for our baby. In fact in real terms I'm Wiccan and he's agnostic. I respect his tradition totally but we want to make this decision for DS on medical grounds.