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Correspondent: COLLEGE OF PHYSICIANS & SURGEONS August 12, 2003 Attention: Complaints Department
I am writing to express my concern and to register my complaint about Pollock Clinics advertisements for infant male circumcision. The advertisements have appeared in BC Parent and WestCoast Families. A sample is enclosed. Pollock Clinics also advertises infant male circumcision on a Web site: http://www.circumcisionvancouver.com. I am concerned that these advertisements present a very one-sided view of circumcision. They do not mention the position of the governing specialty college, the Canadian Paediatric Society. The Canadian Paedatric Society recommends that circumcision of newborns should not be routinely performed. Pollock Clinics provides only one source of medical information about circumcision, and this source is a Web site operated by a US physician with strong personal opinions favouring circumcision. The address of this Web site is http://www.medicirc.com. I have read the College’s Advertising Guidelines, which say that physicians "must not exaggerate, be false, inaccurate, misleading or be reasonably capable of being misinterpreted." I have also read Article 34 of the Code of Ethics, which says "Recognize a responsibility to give the generally held opinions of the profession when interpreting scientific knowledge to the public; when presenting an opinion that is contrary to the generally held opinion of the profession, so indicate." It seems to me that by presenting an extremely one-sided view of circumcision in their advertising, Pollock Clinics is violating the Code of Ethics and the Advertising Guidelines. Circumcision can cause many different complications, occasionally catastrophic. A baby boy died last year after he was circumcised at a hospital in Penticton. The procedure is not medically recommended. Should B.C. parents be exposed to advertising for such a procedure? My request is that the College investigate the activities of Pollock Clinics. [signed] James Loewen
August 14, 2003 Attention: Complaints Department
The subject of my complaint is the following promotional material prepared by Pollock Clinics:
Responsibility to reflect generally held opinion of the profession On its Web site and in the BC Parent advertisement, Pollock Clinics refers readers to only one source of medical information on circumcision: a Web site called www.medicirc.com. This Web site turns out to be maintained by Dr. Edgar Schoen, an outspoken American circumcision advocate, whose views on circumcision do not reflect the consensus of opinion in the medical community. To be more specific, Dr. Schoen's Web site describes the potential medical benefits of infant male circumcision as "compelling," though no pediatric society in the world has this opinion. The American Academy of Pediatrics (AAP), for instance, advises that "existing scientific evidence of potential medical benefits is not sufficient to recommend routine neonatal circumcision." Dr. Schoen dismisses the position of the AAP as "misleading." In short, Pollock Clinics is referring the public to a source of information that does not reflect the generally held opinion of the medical profession. Article 34 of the Code of Ethics of the Canadian Medical Association (1996), endorsed by the College of Physicians & Surgeons of British Columbia, enjoins physicians to Recognize a responsibility to give the generally held opinions of the profession when interpreting scientific knowledge to the public; when presenting an opinion that is contrary to the generally held opinion of the profession, so indicate.By referring the public to only one source of information on the medical effects of circumcision, and failing to disclose that this source does not reflect the generally held opinion of the profession, Pollock Clinics appears to be violating the Code of Ethics. Standard of disclosure According to the Pollock Clinics Web site, "circumcision is regarded as one of the safest routine operations in practice today." No reference is given for this statement. It is by no means universally accepted; in a memo to physicians issued on February 20, 2002, the College of Physicians and Surgeons of Saskatchewan assesses circumcision risk as follows: Infant male circumcision is often treated as a very minor procedure with virtually no risk of significant complications. That is frankly not true.It is alarming when a clinic in B.C. declares a procedure to be safe, and the medical licensing authority in another province says "that is frankly not true." The College has a statutory obligation to protect the public from unsubstantiated or misleading claims. It should be noted that last year a Penticton infant actually died from circumcision complications at B.C. Children's and Women's Health Centre. Though the published rates for circumcision complications vary widely, Williams and Kapila have suggested that a realistic figure is between 2% and 10%[1]. The commonest complication of circumcision is meatal stenosis[2]. In one prospective study of 140 elective circumcisions, 4 (2.8%) of the patients developed meatal stenosis requiring formal meatotomy[3]. In another study, involving 117 circumcisions, 13 (11.1%) of the boys developed meatal stenosis necessitating meatotomy[4]. Meatal stenosis is not even mentioned as a potential complication of circumcision on the Pollock Clinics Web site, though it is an inherent risk of the procedure. Perhaps Pollock Clinics is failing to follow up patients on a long-term basis. In the case of meatal stenosis, the median age at presentation of symptoms is 48 months after circumcision[5]. By failing to substantiate the claim that circumcision is "one of the safest routine operations in practice today," and by omitting to mention the commonest long-term complication of circumcision, Pollock Clinics appears to be in breach of the Rules under the Medical Practitioners Act, specifically Rule 98, which stipulates that doctors "must not exaggerate, be false, inaccurate, misleading or be reasonably capable of being misinterpreted." It should also be noted that the standard of informed consent, which was set out by the Supreme Court in Reibl v. Hughes and Hopp v. Lepp, requires physicians to disclose—without being asked—all material risks of treatment, including risks that are special or unusual. Standard of practice In the Fall, 2002 issue of the College Quarterly, the College of Physicians and Surgeons of B.C. advised physicians that infant male circumcision should be approached as a cosmetic procedure. In the words of the College, "the issue of perceived medical necessity is, in the opinion of most experts, no longer pertinent." If that is the case, why do potential medical benefits figure so prominently in the Pollock Clinics promotional material on circumcision? The College also advised all physicians to include the following information in discussions with parents re infant male circumcision:
Another potential area of concern may be patient follow-up. As noted earlier, common complications of circumcision can take a while—sometimes years—to develop. If Pollock Clinics is reporting a negligible complication rate from circumcision, that could be due to the absence of late follow-up. Once again, I am requesting an investigation into the conduct of medical practitioners who have ownership in Pollock Clinics, or who work there. [signed] D ennis H arrison References
August 26, 2003 Dear Mr. H arrison:
Re: Complaint concerning Dr. N. Pollock I am writing to acknowledge receipt of your recent letter of concern regarding Dr. Pollock. To enable the College to respond to your concern properly, we require comment from the doctor regarding it. I note that you have given your consent for a copy of your letter to be sent to Dr. Pollock and I shall obtain his comment regarding your letter. Having obtained such comment, and such records deemed necessary, I may then be in a position to respond with an explanation. It may be necessary to refer the matter to a Committee of the College. College committees usually meet every second month, so there will be some delay in obtaining an opinion if we proceed this way. I want to assure you, however, that your concerns will be carefully considered, and I will respond as quickly thereafter as possible. Thank you for bringing this matter to our attention. Yours sincerely, [signed] T. Peter Seland, MD, FRCPC
August 29, 2003 Dear Dr. Seland: Thank you for your letter of August 26th, in which you indicate that my complaint regarding Pollock Clinics' advertising for neonatal circumcision will be sent to Dr. Pollock for comment. I feel I should perhaps clarify the purpose of my complaint. I am asking the College to investigate my contention that promotional material from Pollock Clinics is violating the Code of Ethics and the Medical Practitioners Act. I realize that obtaining comment from the doctor(s) involved is a normal part of the complaint process; but in this particular case, the immediate object of concern is some promotional material. Since this material is being disseminated publicly, I think the College can proceed to check it for compliance with ethical guidelines and government regulations, with or without comment from the medical practitioner(s) responsible. I have consented to having my complaint forwarded to Dr. Pollock as a matter of courtesy, though I do not think it really necessary to get a doctor's feedback before evaluating his public advertisements. It is the College's evaluation of these advertisements that I am requesting. Thank you for considering this matter. Sincerely, [signed] D ennis H arrison
September 9, 2003 Attention: Complaints Department
This is a complaint regarding Dr. Neil Pollock, specifically the deceptive methods he uses to convince parents that their infant sons would benefit from being circumcised. I refer to the ads he has running in several Vancouver area magazines—one of which is attached—and the information found on his website which quite clearly promotes the procedure itself, not just his "bloodless and painless" technique. Of particular concern is the American website he refers parents to for "all the latest medical studies about circumcision." This site is the creation of the notorious Edgar Schoen of Oakland, California, probably the world's strongest defender of routine infant circumcision. Schoen's arguments in favour of circumcision—e.g. prevention of UTIs, HIV and penile cancer—are outdated to say the least, and in fact have been discredited even in the U.S. where circumcision has long enjoyed popularity among "for profit" physicians (obstetricians in particular) as a lucrative add-on. I don't think Dr. Pollock would be allowed to "sell" any other non-indicated procedure in this manner, especially one to be performed on an infant or young child, and especially one which has only cosmetic value. I see little difference between what Dr. Pollock is doing and, for example, the advertising of Caesarian sections as preferable to natural births for a variety of reasons which could be backed up by a careful selection of scientific studies. It's one thing to offer an improved surgical technique, but quite another to tell a prospective patient that the surgery itself is necessary or may have certain benefits when such claims cannot be substantiated. [signed] Thomas Anderson, Ph.D.
September 10, 2003 College of Physicians & Surgeons of British Columbia
I am writing to bring a matter to the College's attention. "Pollock Clinics", a medical facility associated with college member Dr. Neil Pollock, has been advertising its infant circumcision procedure in local publications including "BC Parent" and "West Coast Families". The advertisements refer the reader to two web sites: "circumcisionvancouver.com", Dr. Pollock's own site, and "medicirc.com", a site operated by Dr. Edgar Schoen of the United States. These advertisements and both web sites present routine infant circumcision in a manner that is, in my opinion, biased. Routine circumcision of infants is not recommended by any pediatric society, yet these materials present the procedure as if it were supported by the medical community. The "medicirc" web site even states that the medical benefits of circumcision are "compelling" (!). It seems to me that Dr. Pollock, as a member of the College, should be abiding by the Code of Ethics of the Canadian Medical Association (1996), which asks physicians to "recognize a responsibility to give the generally held opinions of the profession when interpreting scientific knowledge to the public; when presenting an opinion that is contrary to the generally held opinion of the profession, so indicate." On Dr. Pollock's website, readers are told that "circumcision is regarded as one of the safest routine operations in practice today". They are not told by whom this procedure is so regarded; certainly it would not be the College of Physicians and Surgeons of Saskatchewan, which advised its members in a memo last year that the notion of circumcision as "a very minor procedure with virtually no risk of significant complications" is "frankly not true". This appears to be just the notion Dr. Pollock is presenting to prospective clients. This would, it seems to me, constitute a violation of the Medical Practitioners Act, which states that physicians "must not exaggerate, be false, inaccurate, misleading or be reasonably capable of being misinterpreted", in addressing actual or prospective patients. Here in British Columbia, the college of Physicians and Surgeons advises members in dialogue with parents about infant circumcision to put forth the following information: that infant male circumcision is not a medical necessity; that the procedure is not recommended by national paediatric associations; that risks can be significant in rare instances; and that currently most male infants are not circumcised. None of this information is presented on Dr. Pollock's website, in the advertisements mentioned, or on the "medicirc" web site. This would appear to show that Dr. Pollock is in contravention of the College's recommended practice. Because of this, I am requesting an investigation into the conduct of any and all medical practitioners who are associated with Pollock Clinics. Thank you very much for your attention to this matter. Sincerely, [signed] Greg Dickey.
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