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Circumcision, Ethics, and Medicine


 

Like all professions, medicine has its own ethical code and principles of conduct. One rule of conduct is "First, do no harm." Removing a normal, healthy body part and causing unnecessary pain is doing harm. Some doctors who circumcise acknowledge the associated pain and then dismiss it by saying, "It only lasts for a minute," implying that it is acceptable to subject an infant to unnecessary pain as long as it is temporary. (In one study, the time required for the procedure ranged from six to forty minutes.(1)) However, there is strong evidence that the pain has lasting effects. Even if it did not, this careless attitude about inflicting pain violates the ethical principles of the medical profession. It also violates general moral principles to subject anyone, particularly a defenseless infant, to any unnecessary pain for any period of time. As recently reported in the New England Journal of Medicine, "Failure to provide adequate control of pain amounts to substandard and unethical medical practice."(2) Furthermore, circumcision without anesthesia is inconsistent with ethical guidelines that prohibit performing surgical procedures on laboratory animals without anesthesia.(3) Based on these standards and given that there is no effective and safe anesthetic that will eliminate circumcision pain, all circumcisions would be prohibited.

According to the Hippocratic oath, another important principle of medical practice is that the patient’s welfare shall be the doctor’s first consideration.(4) In the case of circumcision, doctors generally tend to ignore this rule, while parents falsely believe they are following it. One physician defended circumcision by saying that "within the community at large, at the present time, there is not a tremendous amount of support for saying to parents you shouldn’t do this." For this physician, regarding the issue of circumcision, community attitude seems to supersede the patient’s welfare. Isn’t it the medical profession’s responsibility to lead rather than follow regarding community health care standards?

STAGES OF MORAL DEVELOPMENT

Lawrence Kohlberg’s writing on moral development can be applied to thinking about social attitudes surrounding circumcision. According to Kohlberg’s stages of moral development, someone who acts based on what is expected by others is exhibiting a conventional level of morality.(5) This is the level of moral reasoning that is most common in our society. A person acting at this level primarily values social approval and adheres to the moral rules and conventions of society. Physicians receive social approval by taking a safe, neutral position on circumcision and doing the surgery if requested. Circumcising an infant is an example of conventional, socially acceptable behavior that is in conflict with universal moral principles.

A person who acts according to universal moral principles would exhibit what Kohlberg calls a postconventional morality, the highest level of moral reasoning. Few people choose to follow self-chosen universal ethical principles rather than the conventional principles accepted by their society. To do so puts one at risk of being ridiculed, ostracized, or worse. Most people would rather condemn the whistle-blower instead of examining their own behavior. Nevertheless, a growing number of doctors and nurses refuse to participate in circumcisions because the procedure conflicts with their ethical principles. After performing circumcisions for ten years, one day pediatrician Paul Fleiss finally heard the "agonizing cry" of an infant he was circumcising. He realized what he was doing and stopped performing circumcisions. "You just should not be cruel to babies."(6)

AGREEING TO INFLICT PAIN

A physician who agrees to circumcise is complying with a request to inflict pain on another human being. Professor Stanley Milgram conducted a series of experiments at Yale University to find out how far people would go in obeying a command to inflict pain on another person.(7) Most subjects obeyed the command to continue shocking a confederate, who really received no shocks, up to the danger level. In a subsequent experiment, Milgram found that a subject could be induced through group pressure to inflict greater harm on an innocent person than the subject did when he or she acted alone.(8) Since physicians recognize that peers generally agree to circumcise, that awareness probably contributes to physicians’ willingness to comply with the request.

Similar to the arrangement in Milgram’s experiments, when physicians perform their first circumcision, they are directed by a superior. Given the past and current cultural and professional environment, only an exceptional doctor would refuse to comply with the senior doctor’s instructions. There is no cruel intent, only denial and self-deception. Once a physician does a circumcision, he or she has crossed an emotional line from which it is exceedingly difficult to retreat.

DENYING RESPONSIBILITY

To defend against moral culpability and guilt, physicians have convinced themselves that they are not responsible for circumcision. They claim that they simply defer to parental requests and act as if they have no choice in the matter. George Denniston, a physician specializing in preventive medicine who has served with many medical and professional organizations, asks, "Since when does a trained surgeon take the advice of uninformed laypeople as to whether or not he should operate?"(9) Circumcision is the exception. However, the same doctors would refuse to perform other types of unnecessary surgery on infants. For example, if a parent requested that the infant’s toes or ears be cut off for no apparent reason, the physician would decline. An exception to fundamental principles and practice signifies danger.

Most physicians do not consider circumcision to be an ethical issue. With enough social support and tacit agreement, people can be incredibly blind to their own ethical violations. Rudolph Hess, a German officer who participated in the mass killing of Jews during the Holocaust, did not think what he did was an ethical issue. At the Nuremberg trials he said, "I really never gave much thought to whether it was wrong. It just seemed a necessity. We just never heard anything else."

MEDICAL ETHICS ARTICLES

A medical journal article that examines the ethics of male infant circumcision concludes that circumcision violates all seven Principles of Medical Ethics (AMA 1992).(10) "Female circumcision" is the subject of two opinion articles. In one article the writer comments, "No ethical defense can be made for preserving a cultural practice that damages women’s health and interferes with their sexuality."(11) Because of the complication risks, in addition to potential psychological and sexual impact, a similar statement would apply to male infant circumcision.

In the other article, a philosophy professor argues that the physician has a duty only to provide "medically appropriate and necessary services," not all possible requested medical services.(12) According to this writer, the physician is not a "moral eunuch" and may refuse to provide services for ethical reasons. This would also apply to a woman requesting circumcision for herself. On the matter of a woman requesting circumcision for her daughter, the writer believes that the physician should refuse for ethical reasons, regardless of related cultural values and traditions. The writer concludes by expressing the same views on male circumcision. "To argue differently is to be guilty of discrimination on the basis of sex. . . . Both involve what in other contexts would be called nonconsensual mutilation of a minor for nonmedical reasons."(13)

See also Ethical Questions for the AAP Task Force on CIrcumcision.


NOTES

  1. Benini, F. et al., “Topical Anesthesia during Circumcision in Newborn Infants,” Journal of the American Medical Association 270 (1993): 850-3.
  2. Walco, G., Cassidy, R., & Schechter, N., “Pain, Hurt, and Harm: The Ethics of Pain Control in Infants and Children,” New England Journal of Medicine 331 (1994): 543.
  3. DHHS, Publication NIH 85-23, Guide for the Care and Use of Laboratory Animals, 1985.
  4. Academic American Encyclopedia, s.v. “Hippocratic Oath,” 1993.
  5. Kohlberg, L., The Psychology of Moral Development (San Francisco: Harper & Row, 1984), 174.
  6. Romberg, Circumcision: The Painful Dilemma (South Hadley, MA: Bergin & Garvey, 1985), 353.
  7. Milgram, S., “Behavior Study of Obedience,” Journal of Abnormal and Social Psychology 67 (1963): 371-8.
  8. Milgram, S., “Group Pressure and Action against a Person,” Journal of Abnormal and Social Psychology 69 (1964): 137-43.
  9. Denniston, G., letter to the editor, The Female Patient 17 (1992): 10.
  10. Denniston, G., "Circumcision and the Code of Ethics," Humane Health Care International 12 (1996): 78-80.
  11. Toubia, N. “Female Circumcision as a Public Health Issue,” New England Journal of Medicine 331 (1994): 712-6.
  12. Kluge, E., “Female Circumcision: When Medical Ethics Confronts Cultural Values,” Canadian Medical Association Journal 148 (1993): 288-9.
  13. Ibid., 289.




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