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October 7, 2002
Kathryn
Moseley, M.D.
Henry
Ford Health System
One
Ford PL5A
Detroit,
MI 48202
Dear
Dr. Moseley:
According to the literature, you served on the AAP Committee on
Bioethics, which issued a 1995 statement “Informed Consent, Parental
Permission, and Assent in Pediatric Practice.” (1) This Committee
approved the 1999 Circumcision Policy Statement.(2) There appear
to be conflicts between these documents, and I request your assistance
in clarifying some ethical concerns. Given the importance of the
circumcision issue to many people, clarification of these points would
help us to accurately educate others about the AAP recommendations.
Citing the Bioethics Policy, the Circumcision Policy states that
parents must make choices about health care for infants and young
children because infants and young children are not capable of making
their own decisions.(3) However, these decisions are related to
diagnosis and treatment for an ailment.(4) Non-therapeutic
circumcision is genital surgery performed on a child with no ailment,
and circumcision is not treatment.
Question 1: Should parents
make health care decisions for infants and young children that do not
relate to an ailment or treatment? Please explain.
According to the Principles of Medical Ethics, a physician shall
provide medical care and “regard responsibility to the patient as
paramount.”(5) The Bioethics Policy says “Pediatric health care
providers . . . have legal and ethical duties to their child patients
to render competent medical care based on what the patient needs, not
what someone else expresses . . . [T]he pediatrician’s responsibilities
to his or her patient exist independent of parental desires or proxy
consent” (p. 315).
Question 2: Is a
physician’s compliance with a parental request for non-therapeutic
circumcision consistent with rendering “competent medical care based on
what the patient needs?” Please explain how you reconcile these
statements with the position of the Circumcision Policy that parents
“should” make the decision about non-therapeutic circumcision, implying
that doctors should comply with parental decisions.
According to the AAP Circumcision Policy, pain medication is “safe and
effective in reducing the procedural pain associated with circumcision”
(emphasis added, p. 689). The AAP policy on neonatal anesthesia states
that the use of medication should be based on the same medical criteria
used for older patients. (6)
Question 3: Can any pain be justified in a
surgical procedure that the Circumcision Policy acknowledges is not
essential to a child’s well-being? Please explain.
The Bioethics Policy says “A patient’s reluctance or refusal to assent
should also carry considerable weight when the proposed intervention is
not essential to his or her welfare and/or
can be deferred without substantial risk . . . Coercion in diagnosis or
treatment is a last resort” (p. 316).
Question 4: Since infants
are forcefully restrained and clearly protest being circumcised, and
circumcision is not essential to a child’s well-being and can be
deferred without substantial risk, is circumcision of an infant done by
“coercion” and if yes, is this coercion justified? Please
explain.
The Circumcision Statement takes the position that “it is legitimate
for the parents to take into account cultural, religious, and ethnic
traditions” (p. 691) when making a decision about circumcision. The
reference for this statement is an article titled, “Caring for Gravely
Ill Children.” (7)
Question 5: How does this
reference apply to the situation of cutting off the foreskin when no
ailment is present and no treatment is required?
I also notice that you served on the committee that authored the Female
Genital Mutilation (FGM) Policy Statement.(8) In that statement
the AAP “recommends that its members decline to perform any medically
unnecessary procedure that alters the genitalia of female infants,
girls, and adolescents” (p. 155).
The parallels between cutting female genitals and cutting male genitals
are notable. The FGM statement reports, “Some women have no
recollection of the event, particularly if it was performed in infancy,
while others deny that the procedure has had any negative effect on
their health or sexual life” (p. 154). Similar claims made by
circumcised men can be explained by psychological theory and
principles.(9) The FGM Policy also states,
Parents
are often unaware of the harmful physical consequences of the custom,
because the complications of FGM are attributed to other causes and
rarely discussed outside of the family. Furthermore, parents may feel
obligated to request the procedure because they believe their religion
requires female genital alteration (p. 155).
These statements may also be said for cutting male genitals.(10)
Noting the position of the AAP against FGM, a letter to the editor of
Pediatrics called on the Circumcision Task Force to “afford the same
protection to our male patients . . . . and refuse to perform
unnecessary mutilating procedures on our patients simply because of
their parents’ desires.”(11) In response chair Carole Lannon defended
the Task Force’s position. “The critical distinction between female
genital mutilation and male circumcision is the potential medical
benefits of male circumcision.”(12)
As recently as 1973, female circumcision was suggested in a medical
journal as a treatment for frigidity.(13) Another author
suggested female circumcision to treat a non-retractable clitoral
hood.(14) The surgical procedure was covered by Blue Shield until
1977.(15) Some have suggested that if there were as much research
seeking potential medical benefits for FGM as there is for male
circumcision, more potential medical benefits for FGM would be reported.
Question 6: Would you
approve of female genital mutilation at the request of parents in its
most minor form (excision of the clitoral prepuce, similar to excision
of the penile prepuce) if such a procedure were reported to have
“potential medical benefits?” If no, please clarify the apparent
conflict between these two Policies. Specifically, the Circumcision
Policy implies complying with parental requests for cutting male
genitals, but the FGM Policy recommends declining requests for cutting
female genitals.
I would appreciate a prompt reply letting me know that you received
this letter and providing an estimate of when you can respond in full.
For your convenience, please use my email at crc@circumcision.org.
Thank you very much for your attention to this request, and I look
forward to your response.
Very truly yours,
Ronald Goldman, Ph.D.
Executive Director
DELIVERY WAS VERIFIED WITH A RETURN RECEIPT. NO RESPONSE WAS RECEIVED.
1. American Academy of Pediatrics, Committee on Bioethics. Informed
consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;93:314-317.
2. Lannon C. Circumcision—The debate goes on. Pediatrics. 2000;105:685.
3. American Academy of Pediatrics, Task Force on Circumcision.
Circumcision policy statement. Pediatrics.
1999;103:686-693.
4. American Academy of Pediatrics, Committee on Bioethics. Informed
consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;93:314-317.
5. American Medical Association. Principles of medical ethics. 2001.
URL: http://www.ama-assn.org/ama/pub/category/2512.html.
6. American Academy of Pediatrics. Neonatal anesthesia. Pediatrics. 1987;80:446
7. Fleischman A, Nolan K, Dubler N, et al. Caring for gravely ill
children. Pediatrics.
1994;94:433-439.
8. American Academy of Pediatrics, Committee on Bioethics. Female
genital mutilation. Pediatrics.
1998;102:153-156.
9. Goldman R. Circumcision: The hidden trauma. 1997. Vanguard
Publications, Boston.
10. Goldman R. The psychological impact of circumcision. BJU
International. 1999; 83 (Suppl. 1):93-102.
11. Bartman T. Circumcision—The debate goes on. Pediatrics. 2000;105:681.
12. Lannon C. Circumcision—The debate goes on. Pediatrics. 2000;105:685.
13. Wollman L. Female circumcision. Journal
of the American Society of Psychosomatic Dentistry and Medicine 1973;20:130-131.
14. McLintock D. Phimosis of the prepuce of the clitoris: Indication
for female circumcision. Journal of
the Royal Society of Medicine. 1985;78:257-258.
15. Wallerstein E. Circumcision: An American health fallacy. 1980.
Springer Publishing, New York.
See also Circumcision, Ethics, and Medicine.
© Circumcision Resource Center
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