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COLLEGE OF PHYSICIANS & SURGEONS OF BRITISH COLUMBIA | |||||||||||||||||||||||||||||||||||||||||||||||
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February 15, 1993
Re: Policy or policies pertaining to male and female circumcision I note from the article by Rebecca Wigod published recently in the Vancouver Sun that the College has established a policy which prohibits any form of female “circumcision.” I would very much like to have a copy of that policy statement, and also an answer to a question that troubles me. If the parent of a female child should approach a physician with a request for the surgical removal of that child’s clitoral hood—the foreskin only, nothing else—I presume that the physician must refuse, and furthermore that he could be charged under the Criminal Code of Canada should he comply with the request. If the parent of a male child should approach a physician with a request for the surgical removal of that child’s prepuce—the foreskin only, no other part of the penis—would the physician likewise be required to refuse? And could he be charged with a criminal offence should he comply with the request? If there is a difference in policy or application of law based solely on gender—and we’re assuming here that there is no demonstrable medical need to perform the procedure on either child—what exactly justifies that difference? It seems to me that the male and female foreskins are equal in terms of function and hygiene, and also with respect to their involvement in the creation and enjoyment of sexual pleasure. If that is indeed the case, we should expect the consequences of removal to be very much the same, which suggests that their functional importance and integrity should be regarded equally. I know that the procedure is far more likely to be requested for a male child than for a female child, thus the question may seem hypothetical. I think it is relevant, nonetheless, and look forward to your response.
[signed]
February 25, 1993
Dear Dr. Anderson: I am replying to your letter of February 15, 1993 regarding male and female circumcision. I enclose a copy of the Council’s resolution of March 1992 which is self-explanatory. I will try to reply factually to some of the issues and questions you raise in your letter. First of all, as enclosed, the Council resolution covers female circumcision, excision and infibulation as being unacceptable medical procedures. In fact, this procedure as performed traditionally very often involves severe damage, if not total excision of the clitoris. I note that your question specifies removal of the clitoral hood only, and furthermore, I note that you compare this to performance of male circumcision, or removal of the prepuce. While embryologically the origin of these two organs is similar, anatomically and functionally they are quite different. Your statement that the male and female foreskins are equal in terms of function and hygiene and also with respect to function, in terms of creation and enjoyment of sexual pleasure, demonstrates a misunderstanding of both the physiology of sexual function and of human anatomy. The clitoral hood plays no role in the maintenance or the lack of maintenance of personal hygiene, and serves as a protection barrier for an extremely sensitive organ, the clitoris, during normal daily, non-sexual behaviour. Furthermore, female circumcision and the removal of the clitoral hood is designed in those cultures promoting it, to limit sexual function and prevent sexual enjoyment. Circumcision in the male does not seem to affect sexual function or sexual enjoyment. Furthermore, historically and traditionally, it has promoted personal male hygiene, but in general, in Western society, poor hygiene has become less of a problem. Therefore, this is no longer considered a medically valid reason for doing circumcisions. Male circumcision has therefore become much less common recently but is still requested occasionally because of tradition or other reasons such as potential infection or phimosis. Male circumcision in no way has the negative impact on sexual function and procreation that female circumcision has. For your information, male circumcision is no longer covered as a medical procedure under the Medical Services Plan of B.C., unless medically indicated. Therefore in spite of continued striving for gender equality, and equal treatment of the sexes, basic functional and anatomical differences between man and woman continue to be present and are likely to remain so. I hope this addresses your concerns.
Yours sincerely,
June 7, 1999
Dr. M. VanAndel
Dear Dr. VanAndel: Does the College have formal guidelines dealing specifically with female and/or male circumcision? If so, would you be kind enough to provide me with copies?
Yours sincerely,
August 23, 1999
Dear Dr. Anderson: I am replying to your letter of August 11, 1999, addressed to Dr. T. F. Handley, the Registrar of the College of Physicians and Surgeons of B.C. You are asking a number of questions about infant male circumcision. In reviewing this matter I note you have written previously in 1993 on the same subject. The College has also had correspondence with a Mr. D ennis H arrison in Vancouver, with a Mr. Sawkey of Yorkton, Saskatchewan and with others who like yourself are strongly opposed to infant male circumcision. The College has received copies of correspondence between Mr. H arrison and others who have corresponded with various paediatricians and others deemed to have expertise in this field. I have become aware that correspondence about this issue is widely disseminated and letters written to one individual frequently lead to rebuttals and further questions from others. However, for your ease of reference, I am providing you with copies of letters that have been written and that have been responded to. I believe the content of these letters fully outlines the position of the College of Physicians and Surgeons in this matter. College Council has not deemed it necessary to establish a strong or autocratic position on male circumcision. As outlined in the attached correspondence, there are many other issues where similar controversy exists and where unilateral statements by the College supporting one side or the other, are unlikely to resolve anything. The legal questions as to the rights of children and the right of choice of parents, are matters for the courts to decide, as are interpretations of the Charter of Rights and Freedoms and its application to newborn infants. I note that Mr. D ennis H arrison of Vancouver recently wrote to the Honourable Ujjal Dosanjh, the Attorney General of B.C., raising some of the legal questions. I also note that this letter was widely disseminated. I have not seen the Attorney General’s answer. I hope you find the information that I have provided helpful. The incidence of routine neonatal circumcision is decreasing through educational efforts and through better informed choice on the part of parents. The College’s position is that this process is likely to continue without needless interference by unilateral edicts or over-regulation.
Yours sincerely,
September 7, 1999
Dear Dr. VanAndel: Thank you for sending me a copy of the College’s policy on female circumcision. I would like to inquire about the choice of words in this document. I assume the College has no policy on male circumcision, since none was sent. The College characterizes female circumcision as a “mutilating procedure” that has no place in the practice of medicine. I presume the College is relying on some definition of “mutilation” that is independent of cultural values, since female circumcision is by no means universally regarded as a disfigurement. In some cultures, female circumcision is viewed more as a beauty treatment, essential for any girl’s well-being. I found the following definition of “mutilation” in Stedman’s Medical Dictionary: Disfigurement or injury by removal or destruction of any conspicuous or essential part of the body.[1] It seems to me that this definition, or any other objective definition of “mutilation” I can think of, fits female circumcision and male circumcision equally well. The prepuce is among the most conspicuous features of the male anatomy. It has been present in all primates for at least 65 million years,[2] and has been described in the scientific literature as a complex anatomical structure essential for normal sexual function.[3-11] Does the College consider excision of the normal male prepuce to be a mutilating procedure? If not, please explain why.
Sincerely,
cc: Dr. T. F. Handley References:
September 15, 1999
Dear Mr. H arrison: The College’s view on male circumcision has been well explained to you in previous correspondence. I have also received copies of correspondence involving you and Mr. Ujjal Dosanjh, Attorney General of British Columbia, Dr. Margaret A. Somerville, Dr. Tom Anderson of Summerland, and many others. Further correspondence and discussion about this subject is unlikely to be productive. The College’s position on infant male circumcision has been made abundantly clear to you and to a few others who share your strong opinions. In answer to your specific question, “mutilation” is a term, the application of which is dependent on the existing norms in a society. Placing a bone through one’s nostrils and deliberately stretching the ear lobes or making the lower lip larger, is considered a sign of beauty in some societies, yet would be considered a form of mutilation by many in our society. Aborting a developing fetus is considered the ultimate form of mutilation by many, yet in our society, is currently considered to be acceptable. You have every right to have your opinion that male circumcision is a form of mutilation. However, that opinion is not widely shared and male circumcision is not considered a form of mutilation by this College.
Yours sincerely,
September 22, 1999
Dear Dr. VanAndel: Thank you for your letter of August 23rd. You state that the lawfulness of neonatal circumcision is a matter to be decided by the courts. Be that as it may, the ethics of neonatal circumcision are a matter to be decided by the College. Under existing statutes, the College must establish, monitor and enforce standards of professional ethics amongst members. In your letter, you have characterized neonatal circumcision as a controversial issue. However, the basic facts relating to neonatal circumcision are simple, straightforward, and irrefutable:
I believe the College has a statutory responsibility to weigh the above facts and determine whether or not neonatal circumcision is an ethical procedure. Does the College believe that neonatal circumcision conforms to the standards of professional ethics established, monitored, and enforced by the College?
Sincerely,
September 24, 1999
Dear Dr. VanAndel: Thank you for your letter of September 15th. You say that “mutilation” is a term, the application of which is dependent on the existing norms in a society. You also say the College does not view male circumcision as a form of mutilation because “that opinion is not widely shared.” I take it the College’s characterization of female circumcision as a mutilation is dependent on the fact that female circumcision is uncommon in our society. I suppose that if female circumcision ever became as prevalent here as it has become in certain other regions, then the College would cease to regard it as a mutilation. In other words, the more protection the public needs, the less protection the College offers. That, at least, is where your chain of reasoning seems to lead. Has the guiding principle of medicine been changed from “First, do no harm” to “When in Rome, do as the Romans do?” I looked up “mutilation” in about a dozen different dictionaries. (See appendix). I found no support for the idea that a mutilation is not a mutilation once it becomes established in practice or custom. In any case, how does the College know that male circumcision is not widely regarded as a mutilation? Has the College commissioned any opinion polls on this subject? If a simple majority of B.C. residents agreed that male circumcision was a mutilating procedure, would the College change its current policy? Or would a two-thirds majority be required? Where are the goalposts? You say I have strong opinions. However, there is no doubt that neonatal circumcision is an invasive non-therapeutic surgical operation. That is a simple fact, not an opinion. The question that remains is whether it is ethical and legal for a physician to perform an operation of this kind on any person incapable of giving voluntary and informed consent. I believe the College has an obligation under existing legislation [1,2] to answer this question. To sum up, I have attempted to analyze the College’s position on male and female circumcision. My information has come from medical studies, dictionaries of the English language, and the College’s own statements. I am concerned that if my analysis is correct, the College is failing in its duty to protect the public and is practising discrimination on the basis of sex.
APPENDIX: Definitions of "mutilation"
Sincerely,
September 28, 1999
Dear Dr. Anderson: The position of the College of Physicians and Surgeons of BC with respect to infant male circumcision has been adequately explained to you. The College does not consider this an “ethical” matter, as was likewise explained in some detail. The ultimate responsibility for College policy lies with College Council and its various sub-committees including the Ethical Standards and Conduct Review Committee. I have tried to summarize what I perceive to be the College’s current position. Thank you for providing the College with the reference to the Medical Practitioners Act. I assure you that the College is quite aware of the content of the Act. However, up to now, the College has not accepted your contention that this is an ethical issue.
Yours sincerely,
October 4, 1999
Dear Mr. H arrison: On September 28th of this year, I wrote to T. Anderson, PhD, of Summerland, B.C. about concerns similar to yours. As I am sure you are aware, Dr. Anderson, like yourself, objects to infant male circumcision and feels that this is an “unethical” practice. The position of the College of Physicians and Surgeons of BC with respect to infant male circumcision has been adequately explained to you. The College does not consider this an “ethical matter” nor an issue of “mutilation.” The ultimate responsibility for College policy lies with College Council and its various sub-committees, including the Ethical Standards and Conduct Review Committee. I have tried to summarize what I perceive to be the College’s current position. In my view, the details of that position and its basis have been adequately explained to both you and Dr. Anderson. You of course have every right to disagree with that position, however, the concerns that you have raised and the conclusions that you have reached are not shared by many.
Yours sincerely,
October 7, 1999
Dr. Mary J. Donlevy
Dear Dr. Donlevy: I have received a copy of a letter from Dr. VanAndel, Deputy Registrar of the College, to Dr. Tom Anderson on the subject of neonatal circumcision. Dr. VanAndel implies in his letter that neonatal circumcision does not present ethical difficulties. I seek another opinion on this matter, as I believe Dr. VanAndel may have been in error. There is no doubt that neonatal circumcision is an invasive non-therapeutic surgical intervention. It removes healthy tissue. My research has led me to believe that parents do not have the legal authority to consent to such procedures being performed on their children. It is my belief, based on the literature and case law I have reviewed, that an invasive non-therapeutic surgical intervention requires the voluntary and informed consent of the person undergoing the intervention. I enclose a copy of Dr. VanAndel’s letter. I would like to ask two questions: First, is Dr. VanAndel correct in stating that the College does not regard neonatal circumcision as an ethical issue? Second, is it ethical for a physician to perform an invasive non-therapeutic surgical procedure on a person incapable of giving informed consent?
Sincerely,
November 8, 1999
REGISTERED MAIL Dr. Mary J. Donlevy
Dear Dr. Donlevy: I wrote to you on October 7, 1999 in connection with neonatal circumcision. I am sure you will be responding to my questions in due course, though so far I have received no reply. I enclose a reprint of my letter of October 7th. I would appreciate a reply at the earliest opportunity. For your information, I enclose a copy of an article entitled Anti-circumcision lawsuit says ‘no detail is too small’ which appeared recently on the front page of the National Post.
Sincerely,
December 6, 1999
Dear Mr. H arrison: Thank you for your letters of October 7th and November 8th stating your opinion on infant male circumcision. The Ethical Standards & Conduct Review Committee reviewed these letters at its most recent meeting held on November 24th. In addition, we reviewed your enclosures, the correspondence between yourself and Dr. M. VanAndel, Deputy Registrar, and various other information on the subject which considered both the medical and possible ethical questions at our most recent meeting held on November 24th. For your information, the Committee consists of four elected physician members of the Council of the College and two members of Council who are public representatives appointed by government. In all there are four men and two women on the Committee as it is presently constituted. Generally, these are more senior members of Council. After due consideration of these issues, the Committee had nothing to add to the letters of Dr. VanAndel. Thank you for your opinion on this matter.
Yours truly,
December 10, 1999
Dear Dr. Donlevy: Thank you for your letter of December 6th. You describe my letters of October 7th and November 8th as statements of my opinion on infant male circumcision. However, my reason for writing those letters was to ask the Committee’s opinion on neonatal circumcision, not to give my own. You mention that the Committee reviewed my letters and other material related to neonatal circumcision at a meeting held on November 24th. I would appreciate it if you could provide me with the minutes of that meeting. Two leading medical ethicists, Drs. Margaret Somerville and Eike-Henner Kluge, have stated that circumcision of a child presents serious ethical difficulties if the circumcision is not medically indicated. I would like to know whether or not the Ethical Standards & Conduct Review Committee agrees with Drs. Somerville and Kluge on this point. I believe the College of Physicians & Surgeons of British Columbia has a responsibility under the provisions of the Medical Practitioners Act to respond to my question in an appropriate manner. To ensure there is no misunderstanding, I will repeat the question: Does the Ethical Standards & Conduct Review Committee agree with statements made by top medical ethicists to the effect that non-therapeutic circumcision of children presents serious ethical difficulties? If not, please explain why. For your information, I enclose a copy of a letter dated November 9, 1999, from Dr. Somerville to Dr. VanAndel.
Sincerely,
February 28, 2000
Dear Dr. Handley: RE: INFANT MALE CIRCUMCISION I am writing to you as an individual who is concerned about the practice of infant male circumcision. Recent medical studies have shown that the inner surface of the prepuce is made up of specialized sensory tissue. I wish to know if any ethical difficulties are presented when such tissue is removed without medical indication from a person incapable of giving informed consent. I asked this question of Dr. Mary J. Donlevy, Chair of the Ethical Standards and Conduct Review Committee, in a letter dated December 10, 1999. I have received no response to that letter. I enclose a reprint of the letter for your information. I believe that as the body responsible for establishing and monitoring standards of professional medical ethics, the College of Physicians & Surgeons should be able to answer the following question: Is it ethical for physicians to remove normal genital anatomy from persons who are in good health and who are incapable of giving informed consent? If I have not received a response to this question by March 31, 2000, I intend to pursue this matter further with the minister responsible for administration of the Medical Practitioners Act, [1996] RSBC Chapter 285. For your information, I enclose a news item from the Radio Sweden Web site referring to a report on circumcision prepared for the Swedish National Board of Health. The report characterizes the circumcision of boys for non-medical reasons as a violation of the United Nations Convention on the Rights of the Child.
Sincerely,
March 6, 2000
Dear Mr. H arrison: RE: INFANT MALE CIRCUMCISION I have reviewed the previous extensive correspondence between you and Dr. VanAndel of this office, and I have little to add. I note that you have been informed on a number of occasions that many physicians no longer perform infant circumcision in the absence of a medical indication. However, it does not necessarily follow that the procedure should be branded as unethical, or that it needs to be formally restricted. There are many health issues on which ethical opinions are divided, e.g. termination of pregnancy for non-medical reasons, reproductive technologies, end of life decisions, withdrawal of treatment, and so on. Within our own society, circumcision of male infants has a long history of acceptance, and there remains a substantial body of parents and others who feel strongly, for a variety of reasons, that they should have access to having their male infants circumcised. Prevailing opinion, both within the medical profession and amongst the general public, will no doubt continue to evolve through debate. Complex issues, especially those of a social or religious nature, would not be resolved by any inflexible edict from a medical regulatory body to its members at this time. Such action would inevitably have to withstand legal challenge and scrutiny by the courts. It cannot be justified by evidence of acute, newly emerged evidence of significantly increased risk to the public. Furthermore, with respect to the Radio Sweden report enclosed with your letter, it would do nothing about circumcisions performed by non-physicians, except, perhaps, to increase their number. Control of the practices of individuals who are not licensed members of a regulated health profession rests with law enforcement authorities and the Attorney General’s office. Furthermore, Section 84 of the Medical Practitioners Act specifically states that the Act does not apply to, or affect those who practise the religious tenets of their church without pretending a knowledge of medicine or surgery. If you wish to achieve a complete ban on the circumcision of infant males, I encourage you to redirect your endeavours to the Attorney General’s office, with a request for the necessary legislative changes. You have now received detailed replies from this College on the subject of male infant circumcision, to the extent that we shall not feel obliged to respond to further correspondence from you on the subject.
Sincerely,
March 10, 2000
Dear Dr. Handley: RE: INFANT MALE CIRCUMCISION Thank you for your letter of March 6, 2000. With all respect, I think you may be missing an important point. I believe that as the professional body responsible for regulating the practice of medicine in British Columbia, the College must take reasonable steps to ensure that physicians in this province are acting ethically and legally. Two of Canada’s top medical ethicists—namely, Drs. Margaret Somerville and Eike-Henner Kluge—have concluded that neonatal circumcision presents serious ethical and legal difficulties. It seems to me that if the College intends to pursue a policy of unrestricted infant male circumcision, then the College has the burden of proving Drs. Somerville and Kluge wrong. The College has been provided on several recent occasions with evidence that circumcision of healthy boys is unethical and illegal. For your ease of reference, I enclose herewith three pieces of such evidence:
Note the following statements: The present law would prohibit circumcision on a child unless the persons consenting to this and the physician carrying it out can show that it is justified.
A non-therapeutic intervention ... is only legally justified with the voluntary and informed consent of the person who undergoes the intervention.
Both [female circumcision and male circumcision] involve what in other contexts would be called nonconsensual mutilation of a minor for nonmedical reasons.
I trust the College will, at the earliest opportunity, furnish evidence that College members who circumcise minors for nonmedical reasons are acting ethically and legally. The College has a statutory obligation to maintain ethical standards. Simply asserting that “ethical opinions are divided” does not, in my view, go very far towards maintaining ethical standards. Isn’t the need to grasp the nettle and resolve divisive issues one of the main reasons for the College’s existence? The College of Physicians and Surgeons of British Columbia also has an obligation to serve the public. In my estimation, declining to answer questions that come directly within the College’s purview and advising that the College does not feel obliged to respond to further correspondence is inconsistent with serving the public. I would appreciate answers to the following questions:
If you have any questions or would like to speak to me about this request, please contact me at [phone number].
Sincerely,
March 29, 2000
REGISTERED MAIL Dear Dr. Handley: I would appreciate answers to two questions I asked in a letter of March 10, 2000:
I think these questions are important. I believe the College has an obligation to answer them. If I have received no response by April 30, 2000, then I intend to pursue the matter further with the minister responsible for administration of the Medical Practitioners Act, [RSBC 1996] Chapter 285.
Sincerely,
September 11, 2000
Dear Dr. Handley: Towards the end of June you should have received a letter dated June 21st from Mr. Alan Moyes, Director of Legislation and Professional Regulation at the B.C. Ministry of Health, requesting that the College of Physicians and Surgeons of British Columbia “endeavour to expedite its response” to questions I had asked in a letter dated March 29th. The questions were in regard to the ethical and legal problems posed by non-therapeutic circumcision of children. So far I have received no response of any kind from the College. To assist the College in its deliberations, I enclose a copy of a paper entitled Infant Male Circumcision: A Violation of the Canadian Charter of Rights and Freedoms by Dr. Arif Bhimji. This paper, which was published recently in a new electronic journal called HealthcareLaw, looks at neonatal circumcision from the perspectives of medicine, ethics, law and human rights. I trust that the College will respond to my letter of March 29th at the earliest opportunity. For your ease of reference I enclose copies of Mr. Moyes’ letter of June 21st and my letter of March 29th.
Sincerely,
cc: Mr. Alan Moyes
September 14, 2000
Dear Mr. H arrison: I am responding to your letter of September 11th, 2000 to Dr. Thomas Handley of this office. Dr. Handley is not available for a response and I am replying on his behalf. Please find enclosed a copy of Dr. Handley’s letter of June 29th to Mr. Alan Moyes of the Ministry of Health. You will note that Mr. Moyes has been made aware of the College’s previous correspondence with you, including the College’s decision to cease its involvement in further correspondence. The College’s position on your concerns has been made abundantly clear to you. Thank you for providing the College with a copy of the paper by Dr. Arif Bhimji. The College will retain this information on file for potential future reference.
Sincerely,
January 16, 2002
Dear Dr. VanAndel, I am writing to request further clarification of the College’s position re the case of Dr. Eric Michael Oxley, who was disciplined by the College for castrating a 20-year old mentally handicapped patient at the request of the patient’s mother. In your email of January 14th, you stated that "Dr. Oxley mistakenly accepted the mother’s consent as valid." To assist me in understanding why it was a mistake to accept the validity of the mother’s consent, I would appreciate answers to the following questions:
I would appreciate answers to the above questions at your earliest convenience. Thank you for your time.
Sincerely,
February 25, 2002
Dear Mr. H arrison: In answer to your letter of January 16, 2002, please find enclosed copies of the e-mails received from you and the answers that I provided. I believe my e-mail of January 16th provides the answers to most of your questions. I note that your e-mail and your letter were sent on the same day. For further clarification, it must be noted that representation of Dr. Oxley’s patient’s interests were assigned to the Public Trustee. Therefore, the patient’s mother did not have the authority to make decisions on behalf of her adult son. Dr. Oxley erred in assuming that the mother’s consent on behalf of her son was valid. Furthermore, since this was a sterilization procedure, the Courts have determined that consent by the Guardian or the Public Trustee is insufficient to allow for sterilization procedures. Second opinions and other professional opinions should have been sought before performing the sterilization procedure. This was described in the College’s press release. The College is advised that for sterilization procedures, it would be prudent to have the Courts determine the validity of opinions before the procedure is done to confirm that the patient’s rights have been fully considered, and so that the potential of subsequent civil action by the patient himself or herself, or by alternate decision-makers, can be minimized. The details of your fourth question are contained in the various aspects of guardianship legislation which has been recently enacted by the Provincial government and which is difficult to understand, even for lawyers. Please find enclosed, a copy of the current edition of the College Quarterly Newsletter which tries to make some sense out of this legislation. Please note that this refers to general consent and that consent for sterilization procedures has been identified by the Courts as deserving of special attention.
Sincerely,
August 15, 2002
Dear Mr. H arrison: Thank you for your letter of August 7, 2002 and the enclosed document from the College of Physicians & Surgeons of Saskatchewan. I was not aware of the position that the Saskatchewan College had adopted on this matter. I do not know what the routine infant circumcision rate is in British Columbia, but I would suspect that it is significantly lower than in Saskatchewan. It would be difficult to determine the circumcision rate in BC since as in Saskatchewan, it is an uninsured service here, and since infant circumcisions may be carried out in private physicians’ offices without formal recording of the procedure, other than the patient record. As you are aware from our previous correspondence, the BC College has not taken a position on infant circumcision, except that this is left to parental and physician discretion. As you are also aware, current recommendations from paediatric experts and various medical societies do not include routine circumcision of infants. Your previous requests that the College place significant restrictions on the performance of infant circumcisions and in effect, ban them as an unprofessional or unethical procedure, remains a policy that is unlikely to be adopted by College Council. However, a reminder of required consent and a reminder of the need for discussion between the physician and parent, which is the core of the Saskatchewan document, may be appropriate. It would appear that the low circumcision rates in Nova Scotia and Newfoundland were achieved without restrictive edicts by the College in those provinces and are the natural result of changes in medical training and thinking and are changes in culture and public perception. I will place your letter and the document from Saskatchewan on the agenda for the Council meeting this fall. I will write you again following the Council’s review of this matter.
Sincerely,
August 30, 2002
Dear Dr. VanAndel: Re: Death of Penticton infant I’m disturbed and saddened by the death of a Penticton baby from circumcision complications. I’m sure the College feels the same way. I would like to give my general opinion on this matter and comment on some statements attributed to you in the press. First of all, since you were quoted in today’s Globe and Mail as saying you had never heard of a death from circumcision, I’m taking the liberty of enclosing some reports of deaths and serious complications from this procedure. At least two Canadian infants have lost their penises to circumcision. Doctors “reassigned” them as girls. One of them, David Reimer, was the subject of a book called As Nature Made Him. He lives in Winnipeg. The other individual lives anonymously in Toronto as a “lesbian.” I would also like to comment on a statement attributed to you by the National Post. You were reported to have said, “Every time somebody dies in a car accident, should we outlaw driving?” The problem with this analogy, at least in my opinion, is that routine infant circumcision is not a recommended procedure, and outlawing unadvised procedures on infants is not like prohibiting people from driving. To my way of thinking, it’s more like prohibiting vehicle owners from going through red lights or driving down city streets at 120 kilometres per hour. Even the College’s counterpart in Saskatchewan has characterized routine infant circumcision as “imprudent if not improper.” Medical ethicists seem to be unanimous in their opinion that routine infant circumcision is unethical. I don’t see how restricting such a questionable procedure can be compared to prohibiting people from driving. You said in a radio interview that although paediatric organizations do not recommend routine circumcision, some members of the medical profession, notably in the field of urology, favour the procedure because they see a lot of foreskin problems. This is like arguing that if you cut off a baby’s little finger, then it won’t get caught in a car door. Today we know that the foreskin is a normal body part having specialized functions. As such, it can’t be ethically or legally cut off just to prevent future problems any more than any other normal body part can be cut off just to prevent future problems. Another important issue, as I see it, is the burden of proof. Ethically and legally, any physician who performs surgery on a patient has the burden of proving it is justified. As the Supreme Court noted in the landmark Eve case, Since, barring emergency situations, a surgical procedure without consent ordinarily constitutes battery, it would be obvious that the onus of proving the need for the procedure is on those who seek to have it performed. I trust the above point of law will be made clear in any document the College issues to its members on the subject of male circumcision. There is no doubt that routine infant male circumcision is an unrecommended, irreversible, potentially lethal surgical operation. By definition it is performed on incompetent patients. As I see it, the College must decide whether a procedure of this kind is ethically acceptable in the twenty-first century, especially in view of the recent fatality. I trust that in keeping with its statutory obligation to protect the public, the College will do the reasonable thing and follow the lead of the Saskatchewan College in cautioning doctors against performing this procedure.
Sincerely,
September 10, 2002
Dear Dr. VanAndel: Re: Death of Penticton infant Thank you for your letter of September 4th. I have corresponded with the College on the subject of infant male circumcision on a number of occasions, and I don’t want to go over the same terrain; however, your most recent letter contains a point to which I feel obliged to respond. You express concern that a “ban on this procedure would raise valid objections from within the medical profession and would also raise valid objections from members of the public.” I have little doubt that a ban on routine infant male circumcision would raise objections from some quarters, though whether these objections would be valid is an entirely different matter. Certainly nothing I have come across in my years of research on this issue has led me to believe that a physician is entitled to permanently alter the body of an incompetent patient who has no medical need for surgery. In any case, I’m not sure the present situation calls for an outright ban. What it does call for, at least in my opinion, is clarification of some important points. These points include:
These points all rest on a firm foundation, and they have been included in documents issued to physicians in Saskatchewan. It seems reasonable to provide similar information to physicians in British Columbia, especially in light of the recent death. One often hears the argument that though infant male circumcision is not medically indicated, it is not contraindicated either, and therefore the procedure should be a matter of parental choice. I believe this argument contains a fundamental contradiction. For if circumcision really is a matter of choice, rather than of therapeutic necessity, then it falls in the same category as rhinoplasty, breast reduction, and other procedures that cannot be performed on the basis of substitute consent. Such procedures require the personal informed consent of the individual undergoing the procedure. It is, at the very least, inconsistent to require the personal consent of the patient for all irreversible non-therapeutic body modifications except male circumcision. In the absence of compelling medical need, there is no legitimate reason for adults to make irrevocable decisions about any part of a child’s body. The only logical endpoint of the “parental choice” argument is a rejection of the core principles of medical ethics and human rights. Many people believe that the child’s parents or guardians have the authority or “right” to give consent by proxy. However, proxy consent is subject to limitations. The Supreme Court ruled in the landmark Eve case that a surgical intervention on an incompetent patient can only be undertaken for therapeutic reasons. The courts have consistently ruled that the right to bodily integrity is deserving of the highest order of protection. A competent patient has the right to refuse treatment, even when there is an urgent need for a medical intervention. Conversely, an incompetent patient has the right to be left in peace, unless an intrusion is medically justified. For your information, I enclose a copy of an article in the current issue of the Canadian Medical Association Journal. According to this article, the Saskatchewan College of Physicians & Surgeons is now advising its members to consider the legal risk to the physician, as well as the physical risk to the patient, before becoming involved in the routine circumcision of infants. If there is in fact legal uncertainty associated with performing routine infant circumcision, then surely it would be a disservice both to B.C. physicians and to the public not to tell them about it. I also enclose an ethical analysis of infant male circumcision that appeared in the National Post on August 30th.
Sincerely,
November 2, 2002
Dear Dr. VanAndel, I’m writing to provide the College with a second memo issued by the College of Physicians and Surgeons of Saskatchewan on the subject of infant male circumcision. I became aware of this second memo just recently. Perhaps it will be of value to the College in its current deliberations regarding infant male circumcision. I also wish to make a suggestion regarding the resolution of this contentious issue. Since ethics are at the centre of the debate, perhaps the College could obtain an opinion from a panel of distinguished independent ethicists. Candidates for such a panel might include Dr. Eike-Henner Kluge, founding director of the Canadian Medical Association’s Department of Ethics and Legal Affairs; Dr. Margaret Somerville, founding director of McGill University’s Centre for Medicine, Ethics and Law; Dr. Christine Harrison, President of the Canadian Bioethics Society; Dr. Michael Burgess, Chair, Biomedical Ethics, University of British Columbia; Dr. Michael McDonald, founding director of the University of British Columbia’s Centre for Applied Ethics; or any other ethicists of the College’s choosing. Turning a divisive issue over to a panel of independent experts is a well-recognized and effective method of conflict resolution.
Sincerely,
November 6, 2002
Dear Mr. H arrison, Thank you for your letter of November 2nd. The College is fully aware of the second memo issued by the College of Physicians and Surgeons of Saskatchewan on the issue of infant male circumcision. In answer to your second suggestion, the College has a well established Ethical Standards and Conduct Review Committee. At the committee’s discretion it may seek or review opinions on any subject from any sources including the opinions from some of the individuals that you have suggested. In fact, Dr. Margaret Somerville has spoken at the College-sponsored Annual Ethics Conference, and Dr. Michael Burgess occupies the Chair in Biomedical Ethics which is co-funded by the College of Physicians and Surgeons. The College’s Ethics Committee has a significant number and variety of responsibilities and a scope of discussion and resolution of this particular issue is left to their discretion. Your suggestions will be provided to the Committee by copy of your letter along with the other material that you have sent.
Yours sincerely,
June 14, 2004
Dr. T. Peter Seland
Dear Dr. Seland: I would like to commend the College for its new policy on infant male circumcision. The policy finally brings into the open a number of difficult issues which the College previously avoided. I note, however, that the policy enjoins physicians to "consider the infant’s social and cultural circumstances" when deciding what might be in the infant’s best interest. By way of contrast, no reference to social or cultural circumstances appears in the College’s policy on female circumcision, though millions of people around the world regard the latter practice as an essential part of their cultural identity. Some religious leaders even believe that a mild form of female circumcision is sanctioned by Islam. As noted in previous correspondence, female circumcision encompasses a wide range of procedures, some of which are less invasive than male circumcision. In Singapore, for instance, female circumcision consists of nothing more than a one-centimetre symbolic incision on the female prepuce without any excision of tissue. My purpose, of course, is not to defend female circumcision, but to draw attention to the cultural bias still inherent in the College’s approach to the issue of non-therapeutic circumcision. If the social and cultural values of the parents are insufficient to justify medically unnecessary operations on girls, then they are insufficient to justify medically unnecessary operations on boys. To suggest otherwise is to practise discrimination based on sex. In any case, last August I filed a formal complaint in connection with circumcision advertising by Pollock Clinics. I would appreciate a response to my complaint at your earliest convenience.
Sincerely,
July 22, 2004
Dr. Peter Seland
Dear Dr. Seland: Re: infant male circumcision Once again I wish to commend the College for taking significant steps to address the above issue. My reason for writing is twofold: firstly, I would like to comment on something you said recently in the media, and secondly, I am requesting a response to a formal complaint I filed last August in regard to public advertising for infant circumcision by Pollock Clinics. In the press you described circumcision as “medically neutral.” I assume this point of view is based on the premise that the risks and alleged benefits of routine infant circumcision are evenly balanced. It seems to me, though, that there is a problem with this way of looking at things. If we simply weigh surgical risk against potential benefit, then we can make a case for removing practically any normal body part. Amputating the little finger, for instance, removes a structure that is prone to getting caught in car doors and developing arthritis later in life. The benefits of digitectomy are minor, but so is the surgical risk associated with the procedure. On that basis it could be argued that the risks and benefits of amputating a baby’s little finger cancel each other out and hence the operation is “medically neutral.” No one would take such logic seriously, because it assigns no value to a finger. But if we must assign a value to fingers, or to toes or ear lobes for that matter, then we also have to put some value on the prepuce, described in the medical literature as a “specific erogenous zone.” Once we do that, we can’t describe its ablation as “medically neutral” any more than we can describe the removal of any other normal body part in that way. Could you please advise how the College came to the conclusion that routine infant circumcision is medically neutral? I would also be interested in knowing why it is that whenever the College compares and contrasts male circumcision with female circumcision (FGM), only the most extreme forms of the latter procedure form the basis of comparison. According to Amnesty International, no more than 15 percent of female circumcisions are of the most radical type, involving clitoridectomy and infibulation. I have previously provided the College with evidence that FGM as practised by Muslims in Singapore consists of a symbolic incision without any excision of tissue. Perhaps the College could explain how it would view a request for such a procedure in British Columbia. The other issue I wish to raise is the sheer volume of circumcisions being performed in B.C. at the present time. Dr. Neil Pollock stated recently in the Vancouver Courier that he performs 2,000 newborn circumcisions annually. That figure represents about 20 percent of male infants born each year in the Lower Mainland, and according to Dr. Pollock, his volume has been going up. When the totals for other physicians are added in, Vancouver may have one of the highest rates of circumcision in the country. Like any other form of surgery, circumcision carries the risk of complications, some very serious. When non-recommended elective surgery on infants becomes as widespread as it has in Vancouver, it may be a public health issue, so I am cc’ing this letter to Dr. Perry Kendall, Provincial Health Officer. Finally, as I noted earlier, I am requesting a response to my complaint regarding public advertising for newborn circumcision by Pollock Clinics. It has been eleven months since I filed the complaint.
Sincerely,
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