Dr. Larry Ohlhauser, Registrar
College of Physicians and Surgeons of Alberta

Dear Dr. Ohlhauser:

On December 27, 1997, I wrote to the Honourable Jon Havelock, Minister of Justice and Attorney General of Alberta, in connection with a circumcision pain study that was carried out recently at the University of Alberta. I inquired whether or not it was legal to circumcise a healthy person on the basis of a third-party authorization, and whether or not it was legal to use human beings or other animals as subjects in experiments involving amputations of normal body parts.

My letter was forwarded for consideration and reply to Ms. Peggy M. Hartman, Director of Civil and Family Legal Services. Ms. Hartman declined to answer my questions, but suggested that I contact you if I wished to pursue the matter further.

I was wondering, therefore, if you would be kind enough to comment on the questions that I put to the Honourable Mr. Havelock.

I was also wondering whether the performance of infant circumcision was consistent with the strategic goals of the College of Physicians and Surgeons of Alberta. It is my understanding that the College has espoused the principle that "[e]ffective medical services are: patient-focused, respecting the autonomy and privacy of the individual, provided in a caring manner, evidence-based, and respectful of society's values and resources."

Infant male circumcision appears to violate every part of this principle. It is a form of surgery that focuses not on the objective needs of the patient, but on the wishes of third parties. It is neither requested by the patient, nor performed in response to any medical condition exhibited by him. It ignores the autonomy and privacy of the patient as a person distinct from his parents. The adjective most commonly used to describe the manner of its provision is not "caring," but "barbaric." It is not based on any compelling scientific evidence. It shows no respect for one of society's most basic values, namely, the need to protect the weak and the vulnerable from bodily harm. Finally, it does not seem to be respectful of society's resources, as the Canadian Pædiatric Society has determined that neonatal circumcision is not cost effective.

Consequently I am unable to see how this procedure can be reconciled with the stated objectives of the College.

I would appreciate hearing your views. I am providing copies of my letter to other individuals who have expressed an interest in the issue of infant male circumcision as well as to the Alberta Medical Association and the World Health Organization.

I enclose a copy of the correspondence I had with the Honourable Mr. Havelock.

Yours sincerely,
 
[signed]
 
D ennis H arrison

Copies to:

• Ms. Barbara Brady-Fryer, Project Director, Faculty of Nursing, University of Alberta
• Dr. Margaret A. Somerville, Founding Director, McGill Centre for Medicine, Ethics and Law
• Dr. John R. Williams, Director of Ethics, Canadian Medical Association
• Dr. Douglas D. McMillan, Chair, Fetus and Newborn Committee, Canadian Paediatric Society
• Dr. W. W. Anderson, President, Alberta Medical Association
• Dr. Hiroshi Nakajima, Director-General, World Health Organization

Dear Dr. Ohlhauser:

I wrote you last February in connection with a medical study undertaken by researchers at the University of Alberta for the purpose of measuring pain responses in infants undergoing circumcision. I have not received a response so far, though I'm sure you will be replying in due course. In the meantime, I am sending additional material that may be of interest to you.

I enclose the following:

• a recent media report entitled "Anesthesia Complications Killed Baby" as evidence of the fact that pain control does not render circumcision harmless;
   
• copies of medical studies documenting the nature and extent of the tissue ablated in a circumcision;
   
• a collection of statements on circumcision made by professionals over the past century;
   
• a copy of a letter I have received from Dr. Shaun Peck, Deputy Provincial Health Officer, British Columbia.

Dr. Peck states that there is no medical indication for infant male circumcision, a position which is in agreement with the clinical practice guideline issued by the Canadian Paediatric Society and with statements made by the researchers at the University of Alberta. If infant male circumcision is not medically indicated, then what is the ethical or legal basis for performing it?

There is no doubt that all the infants enrolled in the study suffered pain; some were traumatized to the point of danger. These facts are documented in the December 24/31, 1997 issue of the Journal of the American Medical Association. By exposing children to unnecessary risk, did the physicians involved in the study not fail in their duty of care to the children? Before subjecting a child to an invasive surgical intervention, should a physician not establish that the surgical intervention is medically indicated?

I would like to draw your attention to statements made by psychologist Ron Goldman in his book, Circumcision: The Hidden Trauma (Boston: Vanguard Publications, 1997). Dr. Goldman writes: "To defend themselves 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." (p. 192)

I'm troubled by the apparent readiness of some physicians to jeopardize the health of vulnerable persons when neither medical necessity, nor religious observance, nor any other reasonable grounds can be invoked as justification. I'm sure you agree that injuring a defenceless person without justification is a grave matter.

I hope you will have time to respond to my concerns. I look forward to your reply.

Sincerely,
 
[signed]
 
D ennis H arrison
 
Enclosures:
 
(1) NewsNet5 report: Anesthesia Complications Killed Baby
(2) The prepuce: specialized mucosa of the penis and its loss to circumcision
(3) Immunological functions of the human prepuce
(4) Circumcision in the physicians' own words
(5) Letter from Dr. Shaun Peck dated November 5, 1998

Copies to:

• Dr. Emmett Francoeur, President, Canadian Paediatric Society
• Dr. Roderick Fraser, President and Vice-Chancellor, University of Alberta
• The Honourable Halvar C. Jonson, Minister of Health
• Dr. Rowland T. Nichol, President, Alberta Medical Association
• Mr. Ian Potter, Assistant Deputy Minister, Health Promotion and Programs
• Dr. Margaret A. Somerville, Founding Director, McGill Centre for Medicine, Ethics and Law
• Dr. D. Lorne Tyrrell, Dean, Faculty of Medicine, University of Alberta
• Dr. John Waters, Chief Medical Officer of Health, Province of Alberta
• Dr. John R. Williams, Director of Ethics, Canadian Medical Association
• Dr. Marilynn J. Wood, Dean, Faculty of Nursing, University of Alberta

Dear Mr. Falk:

The following comments are in response to yours of August 11th:

1. The College does not have an official policy on male circumcision because we believe it is unnecessary. I indicated to you previously that, in the absence of medical reasons for circumcision, the procedure is not medically necessary and is, therefore, cosmetic. The decision to undergo circumcision then rests with the patient and/or parent(s). Our position cannot be stated any plainer.
    
2. The College does not plan on introducing a policy on male circumcision.
    
3. The position of the Canadian Paediatric Society is not unreasonable but carries no weight.
    
4. The answers to questions 4 through 8 are addressed by the above comment having to do with an elective procedure for cosmetic reasons.
    
5. Physicians who perform any procedure on individuals without appropriate consent could be seen as engaging in unprofessional conduct.

Sincerely,
 
[signed]
 
L. R. Ohlhauser, M.D.
Registrar
 

Dear Dr. Bhimji:

The Executive Committee of the Council of the College of Physicians and Surgeons directed that you be advised of the following information:

1. The College does not have an official policy on male circumcision because we believe it is unnecessary. In the absence of medical reasons for circumcision, the procedure is not medically necessary and is, therefore, cosmetic. The decision to undergo circumcision then rests with the patient and/or parent(s).
    
2. The College does not plan on introducing a policy on male circumcision for the reason noted above.
    
3. The position of the Canadian Paediatric Society is not unreasonable but is not a standard of practice.
    
4. Physicians who perform any procedure on individuals without appropriate consent could be seen as engaging in unprofessional conduct.

Sincerely,
 
[signed]
 
L. R. Ohlhauser, M.D.
Registrar
 

Dear Dr. Ohlhauser:

Thank you for your letter of September 1, 1999, outlining the College's position on infant male circumcision. You say that when circumcision is not medically necessary, the decision to undergo this procedure rests with the patient and/or parent(s).

Although there seems little doubt that a competent adult has the legal authority to consent to non-therapeutic circumcision being performed on himself, the idea that parents can consent to non-therapeutic circumcision being performed on their children is more problematic. In a free and democratic society, no one—least of all a child or other vulnerable person—can be forced to undergo a surgical intervention that is not medically necessary. Dr. Margaret Somerville, Founding Director of the McGill Centre for Medicine, Ethics and Law, has put it this way:

A non-therapeutic surgical intervention such as cosmetic surgery is only legally justified with the voluntary and informed consent of the person who undergoes the intervention.¹

I enclose a copy of the letter that contains the above quotation, as well as an article by Dr. Somerville entitled "Medical Interventions and the Criminal Law: Lawful or Excusable Wounding?" This article, published in 1980 in the McGill Law Journal, analyzes the status of medical interventions under Canadian criminal law.

Does the College agree with Dr. Somerville's premise that a non-therapeutic surgical intervention requires the voluntary and informed consent of the person on the receiving end? If not, please explain.

Notes:

¹ Dr. Margaret A Somerville. Letter dated January 28, 1998 to Dr. C. Robin Walker, member of the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS), and co-author of the 1996 CPS position paper on neonatal circumcision.

Yours sincerely,
 
[signed]
 
Geoffrey T. Falk
 

Dear Dr. Ohlhauser:

Thank you for your letter of September 13, 1999 in response to my inquiry regarding circumcision. I appreciate the Executive Committee's response on what is obviously a very difficult issue to address. While the letter provided responses to some of the questions posed, it failed to address the most relevant and important ones. As such I respectfully resubmit some of the questions for the Committee's response.

1. The Executive Committee's response of September 13, 1999 implies that procedures that are not medically necessary are considered cosmetic and that parents have an unfettered right to consent to those procedures. Should this statement be interpreted to mean the Executive Committee takes the position that it has no jurisdiction over physicians performing cosmetic procedures?
    
2. The issue of consent for non-therapeutic interventions on children appears to remain problematic. In the response provided by the Committee, it states that "physicians who perform any procedure on individuals without appropriate consent could be seen as engaging in unprofessional conduct." Dr. Margaret Somerville, one of Canada's leading lawyers and ethicist states:
   
   

   A non-therapeutic surgical intervention such as cosmetic surgery is only legally justified with the voluntary and informed consent of the person who undergoes the intervention.

   A similar position has clearly been taken by the courts and is easily reviewed in current case law as per my previous letter. Could the Committee please confirm that it believes that, currently, physicians are appropriately and legally accepting the consent provided by parents with respect to non-therapeutic infant circumcision?
    
3. Why would the College not consider the statements of leading Canadian paediatricians to form the basis of a standard of practice? If professional organizations such as the Canadian Paediatric Society are not to establish the standards of practice, then who does the College suggest should set these standards?
    
4. Does the College believe that non-therapeutic infant circumcision raises ethical issues?
    
5. Does the College believe that non-therapeutic infant circumcision is ethical?
    
6. Given the concerns raised by prominent Canadian ethicists, does the College believe that physicians performing "routine" or non-therapeutic infant circumcision are violating the basic principles of human rights?
    
7. Can the College provide assurances that it would not conduct disciplinary hearings into a physician's practice if the physician's practice were alleged to violate human rights?

The standards of practice and the ethical issues raised by medical treatments and procedures are clearly within the purview and jurisdiction of the College. I trust that in order to guide my fellow physicians and myself, the College will provide detailed responses to the questions posed regarding the ethics of non-therapeutic infant circumcision. I have enclosed letters and a scholarly paper by Dr. Margaret Somerville from McGill University to assist the College in its deliberation.

Please contact me at the address and telephone number provided should you require further information about my request.

Sincerely yours,
 
[signed]
 
Arif Bhimji
 

Dear Dr. Bhimji:

I acknowledge receipt of your further letter on the subject of infant male circumcision.

This College's position was stated clearly in my previous correspondence and I have no intention of debating the merits of that position further with you or anyone else for that matter. Any challenge to the legality of our position would be for the Courts to decide.

We respect your differing view on the matter and trust that you will afford us the same consideration.

This letter ends the correspondence that we are prepared to engage in with you.

Sincerely,
 
[signed]
 
L. R. Ohlhauser, M.D.
Registrar
 

REGISTERED MAIL

Dr. Larry Ohlhauser, Registrar
College of Physicians & Surgeons of Alberta

Dear Dr. Ohlhauser:

I wrote to you on February 12, 1998, and November 13, 1998 in regard to a medical study conducted at the University of Alberta for the purpose of measuring pain responses in male infants undergoing circumcision. I have received no response to either letter.

Nor have I received satisfactory responses to questions I asked of Dr. Donald Morrish, Chair of the Health Research Ethics Board at the University of Alberta. Dr. Morrish has not replied to letters I sent on June 17, 1999, and September 27, 1999.

It is my understanding that the College of Physicians and Surgeons of Alberta is responsible for monitoring standards of professional ethics amongst Alberta practitioners. I respectfully ask the College to answer the following question:

Is it ethical for a physician to circumcise any person incapable of giving informed consent, if the procedure is not medically necessary?

For your ease of reference, I enclose copies of my letters

• to the College dated February 12, 1998, and November 13, 1998;
• to Dr. Donald Morrish dated June 17, 1999, and September 27, 1999.

Sincerely,
 
[signed]
 
D ennis H arrison
 

Dear Mr. H arrison:

Re: Infant male circumcision
Your enquiry of January 24, 2000

It is this College's position that, in the absence of medical reasons for circumcision, the procedure is not medically necessary and is, therefore, cosmetic. In the case of an infant, it is only proper and logical that the decision to undergo circumcision rests with the parent(s).

Sincerely,
 
[signed]
 
L. R. Ohlhauser, M.D.
Registrar
 

Dear Dr. Ohlhauser:

Thank you for your letter of January 26th. You state that it is "only proper and logical" for the parent(s) to decide whether or not a newborn son should undergo circumcision, even in the absence of medical reasons for the procedure.

With all respect, it seems to me that in essence the College is defending the right of physicians to perform unnecessary surgery on incompetent patients. I seek clarification of the following point:

Can the College's reasoning be generalized and extended beyond the specific issue of circumcision to other analogous situations? In other words, is it the College's position that a physician may operate on a child or incompetent adult for no medical reason, if requested to do so by the next of kin?

Sincerely,
 
[signed]
 
D ennis H arrison
 
cc: Dr. David Bond, President, Alberta Medical Association
 

Dear Mr. H arrison:

Re: Infant male circumcision
Your letter of February 3, 2000

Quite obviously, there is a difference between patients who are minors and adult patients who are mentally incompetent; but with your subjective view that cosmetic surgery is unnecessary, it is unlikely that you will see how preposterous your analogy is.

Our position was stated clearly in my previous correspondence and I have no intention of debating its merits with you or anyone else.

It is apparent that you hold a differing view on the matter and we respect that, just as we expect that you will afford us the same courtesy.

Sincerely,
 
[signed]
 
L. R. Ohlhauser, M.D.
Registrar
 

Dear Dr. Ohlhauser:

I have received your letter of February 15th. With all respect, I still have some difficulty understanding the College's position on infant male circumcision.

The thrust of your letters seems to be that since parents have moral and legal responsibilities for the well-being of their children, it follows that the "circumcision decision" properly rests with parents. The problem with this way of looking at things is that it ignores the moral and legal responsibilities of physicians. In the vast majority of cases, circumcision of a newborn does not involve treatment of a disease or deformity. Is it ethical and legal for a physician to remove normal, well-formed anatomy from any person incapable of giving informed consent? I am troubled by the College's apparent reluctance to admit that this all-important question even exists.

For your information, I enclose a copy of a Radio Sweden news item referring to a report on circumcision prepared for Socialstyrelsen, the Swedish National Board of Health. The report characterizes circumcision of boys for non-medical reasons as a violation of the United Nations Convention on the Rights of the Child, and proposes a complete ban on this practice.

You state that "there is a difference between patients who are minors and adult patients who are mentally incompetent." I would appreciate it if you could explain briefly what this statement means, in relation to consent for procedures.

Sincerely,
 
[signed]
 
D ennis H arrison
 

Dear Dr. Burns:

I have been reviewing previous correspondence I have had with the College on the subject of infant male circumcision. I would like clarification of a point made by Dr. Larry Ohlhauser, past Registrar of the College, in a letter dated February 15, 2000.

I had asked the College whether Alberta physicians could operate on incompetent patients who had no medical need for surgery. Dr. Ohlhauser replied as follows:

Quite obviously, there is a difference between patients who are minors and adult patients who are mentally incompetent.

I enclose copies of relevant earlier correspondence with the College. Thank you for your time.

Sincerely,
 
[signed]
 
D ennis H arrison
 

Dear Mr. H arrison:

I received your letter requesting clarification of previous correspondence.

I do not wish to extend a debate on which it is clear there is a fundamental disagreement about the necessity for cosmetic surgery.

Accordingly, I reiterate Dr. Ohlhauser's observations that it is preferable to respect that difference of opinion.

Yours truly,
 
[signed]
 
Robert A. Burns, B.Sc., M.D.
Registrar
 

Dear Dr. Burns:

I am seeking clarification of two points. The first point relates to the limits of proxy consent. In Re Eve, the Supreme Court ruled that parents do not have the legal authority to consent to an invasive, irreversible non-therapeutic surgical operation being performed on their child. Although the immediate focus of the Eve case was the proposed sterilization of a young woman with a mental disability, the reasoning of this case can be generalized and applied to any non-therapeutic procedure having permanent and irreversible effects. Does the College accept the Supreme Court's decision in Re Eve, effectively prohibiting invasive, irreversible surgical operations being performed on incompetent patients for non-therapeutic reasons?

The second point relates to Dr. Ohlhauser's statement that "quite obviously, there is a difference between patients who are minors and adult patients who are mentally incompetent." I do not understand what this statement means. In the context of obtaining substituted consent for a medical intervention on an incompetent patient, are there any practical differences between (a) a patient who is incompetent because of a mental disability, (b) a patient who is incompetent by reason of age, (c) a patient who is unable to give consent due to medical status (say a coma), or (d) a person who is unable to provide consent for any other reason?

I would be grateful if the College could clarify the above points.

Sincerely,
 
[signed]
 
D ennis H arrison
 

Dear Mr. Falk:

Thank you for your recent letter regarding the issue of infant male circumcision.

I am aware of the changed advice given in the Province of Saskatchewan, and appreciate your relaying of the background material.

At the moment, the actions in Saskatchewan have prompted us to seek an updated opinion from an ethicist, and potentially, therefore, to review a position statement that was issued a decade or so ago.

When that process has been completed, I may be in a position to answer your questions specifically; until then, please accept this interim acknowledgment and the undertaking to follow-up as our process is completed.

Sincerely,
 
[signed]
 
Robert A. Burns, B.Sc., M.D.
Registrar
 

Dear Dr. Burns:

Re: Infant male circumcision

Earlier this year, the College of Physicians & Surgeons of British Columbia issued a formal policy on the above procedure. The policy clearly states that circumcision is not medically necessary for infants. It identifies in detail the various ethical problems associated with performing a medically unnecessary surgical operation on an incapable patient. Similar guidance has been provided by the Colleges in Saskatchewan and Manitoba.

A few years ago, the University of Alberta made headlines around the world when a study aimed at measuring pain responses in male infants undergoing circumcision was stopped prematurely. The reason for the early termination was that two of 11 newborns in the study had potentially dangerous episodes within minutes of the procedure. One of the infants lost muscle tone and stopped breathing for 25 seconds.

Here in B.C., a Penticton infant died after undergoing circumcision in 2002.

Given that (a) the operation is not risk-free, (b) it is carried out on extremely vulnerable patients, (c) it has been condemned by leading ethicists, and (d) policies on the procedure have been released by the Colleges in all the other Western provinces, there appears to be ample reason for the CPSA to address the issue. Could you tell me if the College has any plans to draft a policy on infant male circumcision? If not, could you please explain why?

Thank you for your time.

Sincerely,
 
[signed]
 
D ennis H arrison
 

Dear Mr. H arrison:

I write in belated response to your letter regarding infant male circumcision.

The College of Physicians and Surgeons of Alberta continues to expect physicians to exercise professional judgement in the face of evolving evidence and standard of care in all matters, including infant male circumcision.

The College will, therefore, not be providing any formal guidance on this particular issue as distinct from others.

Sincerely,
 
[signed]
 
Robert A. Burns, BSc, MD
Registrar

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