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Correspondent: BRITISH COLUMBIA MINISTRY OF HEALTH August 14, 1998 Dear D ennis H arrison: The Honourable Ujjal Dosanjh, Attorney General, has recently provided the Minister of Health and Minister Responsible for Seniors with a copy of your letter dated December 12, 1997, regarding the legality of routine infant circumcision. At this time, the Honourable Penny Priddy is away from Victoria and has asked me to respond on her behalf. Amendments to the Criminal Code of Canada were given Royal Assent on April 25, 1997, to clarify specifically that the practice of female genital mutilation is criminal conduct. Further, the College of Physicians & Surgeons of British Columbia, the body responsible for setting standards of medical care in the province, considers female circumcision to be an unacceptable medical procedure. Physicians here must decline to perform these procedures and must refuse to refer the surgery to anyone. With regard to male circumcision, the province of British Columbia does not pay for this procedure as a matter of course but only in a small number of cases when deemed medically necessary. Male circumcisions done on a basis other than medical necessity are outside the jurisdiction of the Ministry of Health and are considered to be a matter between the parents and the physician. You have raised a number of important ethical issues in respect of the practice of circumcision. I understand that male circumcision continues to be a matter of contention within the medical profession and thus, you may wish to make your views known to the College of Physicians & Surgeons in respect of the ethical issues involved. For your information, I have enclosed a photocopy of an article that appeared in the Globe and Mail on August 6, 1998. Thank you for sharing your views on this important matter. Yours truly, [signed] Janet E. McGregor
November 29, 1999 The Honourable Penny Priddy
Dear Minister: I seek your assistance in obtaining responses to questions I have asked of the College of Physicians and Surgeons. I have received no reply to two letters I sent recently to Dr. Mary J. Donlevy, Chair of the College's Ethical Standards and Conduct Review Committee, concerning the ethics of neonatal circumcision. The letters, dated October 7, 1999, and November 8, 1999, were sent via registered mail. Specifically, I would like the College to answer the following question: Is it ethical for a physician to perform an invasive non-therapeutic surgical procedure on a person incapable of giving informed consent?I would appreciate any assistance you could offer in obtaining an answer to the above query. I believe the College is obliged to answer questions from the public under the provisions of the Medical Practitioners Act. 1,2 For your information, I enclose a copy of a letter from Dr. Margaret A. Somerville to Dr. M. VanAndel, Deputy Registrar of the College. Dr. VanAndel recently stated that neonatal circumcision is "not an ethical issue." Dr. Somerville, a Fellow of the Royal Society, is the founding director of the McGill Centre for Medicine, Ethics and Law. I also enclose copies of the two letters I sent to Dr. Donlevy. References:
Sincerely,
December 17, 1999 Dear Mr. H arrison: Thank you for your letter dated November 29, 1999 seeking assistance in obtaining a response from the College of Physician & Surgeons of British Columbia to your correspondence dated October 7, 1999 and November 8, 1999. A member of my staff reached the College offices by telephone and was advised that a response to your correspondence was posted on December 6, 1999. I trust that this is satisfactory. Yours sincerely,
March 10, 2000 The Honourable Mike Farnworth
Dear Minister: RE: INFANT MALE CIRCUMCISION Infant male circumcision is becoming the focus of increasing public debate. In order to draw attention to the issues surrounding this practice, I enclose copies of correspondence I have had recently on this subject with the B.C. College of Physicians and Surgeons. I also 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 circumcision of boys for non-medical reasons as a violation of the United Nations Convention on the Rights of the Child. I hope you will find this material to be of value as the issue of infant male circumcision continues to develop. Sincerely,
May 1, 2000 Mr. Alan Moyes, Director
Dear Mr. Moyes, I am seeking your help one more time in obtaining a satisfactory response from the College of Physicians and Surgeons. The College has repeatedly declined to answer specific questions related to the ethics of male circumcision. The questions are quite straightforward, and I believe the College has a duty to answer them.1 Below is some background information on infant male circumcision:
In short, there does not appear to be a sound basis for the performance of infant male circumcision in this day and age. It seems to me, therefore, that the College has a moral and statutory obligation to explain why members of the College are continuing to circumcise male infants. I have been asking the College to answer the following two questions:
I believe that to fulfill its obligation to protect the public and regulate the practice of medicine, the College must provide comprehensive and detailed replies to the above inquiries. For your information, I enclose a copy of a letter I sent to the College on March 29, 2000. I have received no reply to that letter. I also enclose copies of two recent news items from Sweden. These items give an indication of the steps that country is taking to regulate the practice of male circumcision. Once again, I request that you write to the College and direct them to provide candid and complete responses to the questions I have posed. (I would very much appreciate copies of any correspondence you might decide to send to the College). Sincerely,
June 21, 2000 Dear D ennis H arrison: Thank you for your letter dated May 1, 2000, requesting assistance to ensure that the College of Physicians and Surgeons of British Columbia responds to your most recent queries concerning the ethics and practice of infant male circumcision. As you are aware, the College is an extremely busy organization with many duties and responsibilities to fulfill. Consequently, I expect the delay you have experienced in receiving a response to your letter to the College dated March 29, 2000 does not imply an unwillingness on the part of the College to respond. By way of copy of this letter, I will ask that the College endeavour to expedite its response to you on this important issue. I trust that this is satisfactory. Yours sincerely,
June 29, 2000 Dear Mr. Moyes: Thank you for sending me a copy of your letter to D ennis H arrison dated June 21, 2000. Enclosed for your information is a copy of my letter to Mr. H arrison, dated March 6, 2000. As you can see, the College has an extensive correspondence with Mr. H arrison and the decision was made to bring it to a halt. I will not burden you with all the correspondence we have on file, unless you would like to receive it. I hope that this information will assist you in responding to any further correspondence from Mr. H arrison. Thank you for bringing the matter to my attention. Yours truly,
September 21, 2000 Dear Mr. Moyes, I have received a copy of a letter sent to you on June 29, 2000 by Dr. Thomas F. Handley, Registrar of the College of Physicians & Surgeons of British Columbia. Dr. Handley paints a picture of a long-suffering College weighted down by a protracted correspondence with an unreasonable member of the public. All I seek from the College is straightforward answers. I think the College should be able to explain on what basis physicians are circumcising male infants today. It has been recognized for over a quarter of a century that newborn circumcision is not medically justified, and medical ethics forbid operating on non-consenting persons without medical justification. After giving a series of evasive answers, the College is now trying to cut off communications altogether. Other B.C. residents besides myself have been trying to obtain satisfactory answers from the College. Our efforts have been supported by one of Canada's top medical ethicists—Dr. Margaret Somerville, Director of the Centre for Medicine, Ethics and Law at McGill University. Dr. Somerville wrote a letter of concern to the College on November 9, 1999 after reviewing some of the College's correspondence with Dr. Tom Anderson and myself. The College has not replied to Dr. Somerville's letter. I must once again turn to you for assistance in obtaining satisfactory responses to the two questions I asked the College in my letter of March 29, 2000. I believe that these questions are reasonable, and that the College, as the professional body responsible for regulating the practice of medicine in British Columbia, has an obligation to answer them. I enclose a booklet containing the correspondence between the College, Dr. Margaret Somerville, Dr. Tom Anderson, and myself. I also enclose a copy of a letter dated November 5, 1998 from Dr. Shaun Peck, Deputy Provincial Health Officer, confirming that infant male circumcision has no medical indication. Thank you for your help in this matter. Sincerely,
cc: Dr. Thomas F. Handley, Registrar, College of Physicians & Surgeons of B.C.
November 23, 2000 Dear Mr. Moyes, I wrote you on September 21st to ask your assistance in getting the College of Physicians & Surgeons to give straightforward answers to two questions. I am sure you will be responding in due course. The purpose of the questions was to find out exactly what the rules are in regard to performing non-essential surgery on non-consenting persons at the request of third parties. In the meantime, I would like to provide you with additional information on the subject of infant male circumcision. I enclose the following material:
Dr. Somerville touches on this issue in her book. She writes: ...it seems clear to me that, certainly outside the religious context, recent medical research on routine infant male circumcision shows that this operation cannot be ethically or legally justified on the basis of its medical benefits. There has been some confusion in this regard, particularly on the part of medical associations who seem to be concerned not to speak out against routine infant male circumcision. For instance, the American Academy of Pediatrics recognizes that the medical benefits of this procedure do not outweigh its risks to a degree that it can be recommended to parents as a routine procedure. But they then conclude that the decision about circumcision should be left to the parents in consultation with their physician. In my opinion, this conclusion is wrong both ethically and legally. Unless the medical benefits of a surgical intervention on a child unable to consent for himself clearly outweigh its risks (and the academy finds that in the case of routine circumcision they do not), then it cannot be ethically or legally justified on the basis of the parents' consent and, therefore, the physician must not undertake it unless he or she has some other justification for doing so.Dr. Somerville also writes: A common error made by those who want to justify infant male circumcision on the basis of medical benefits is that they believe that as long as some such benefits are present, circumcision can be justified as therapeutic, in the sense of preventive healthcare. This is not correct. A medical benefits or "therapeutic" justification requires that overall the medical benefits sought outweigh the risks and harms of the procedure required to obtain them, that this procedure is the only reasonable way to obtain these benefits, and that these benefits are necessary to the well-being of the child. None of these conditions is fulfilled for routine infant male circumcision. If we view a child's foreskin as having a valid function, we are no more justified in amputating it than any other part of the child's body unless the operation is medically required treatment and the least harmful way to provide that treatment.And: Physicians who undertake infant male circumcision could be legally liable for medical malpractice (civil liability in battery or negligence), which can result in an award of damages simply for carrying out the circumcision even if it was competently performed. They could also, as explained, be charged with criminal liability for assault. In both ethics and law, a physician has a primary obligation of personal care to the patient. This obligation requires the physician both to place the patient first and to "first do no harm." Physicians who undertake surgery on patients must prove that it is justified.I hope the enclosed information is of value to you. I look forward to your reply. Sincerely,
March 23, 2001 Dear Mr. Moyes, I would like to reopen the line of correspondence we had last year in regard to the College of Physicians & Surgeons. You wrote to the College on June 21, 2000, requesting that they expedite a response to my questions concerning infant male circumcision. The College replied to you on June 29th with a letter to the effect that they had found my correspondence burdensome and had decided to bring it to a halt. I have sent the College a total of eleven letters since November 15, 1996. Three of these letters were addressed to the Chairperson of the Ethical Standards and Review Committee, the remaining eight were to the Registrar or Deputy Registrar of the College. I have not contacted the College by telephone, email or any other way. I do not see how eleven letters sent over a period of more than four years could have imposed an undue hardship on the College, especially since the letters concerned an important ethical issue that comes directly within the College’s purview. In any case, I was forced to write that often because the College and its ethics committee kept refusing to answer certain key questions. There are still several questions outstanding, the two most important being the following:
Sincerely,
May 23, 2001 Dear D ennis H arrison: I am writing in response to your letter dated March 23, 2001, and to follow-up our subsequent discussion by telephone respecting circumcision. I indicated in the course of our discussion that I would be writing to you and proposing the office of the Ombudsman as an option for you to consider. However, upon review of the file of our correspondence, I note that my letter to you dated December 27, 2000 expressly referred to that option and provided you with contact information to reach that office. On that basis, I regret that I have no further information to provide to you and no further suggestions as to alternative courses of action except as previously recommended to you. Thank you for advising me of your continuing concerns in relation to this issue. Yours sincerely,
May 29, 2001 Dear Mr. Moyes, Thank you for your correspondence of May 23rd, in which you refer to a letter you sent me on December 27, 2000. I would appreciate it if you could forward me a copy of that letter, as I don't seem to have it in my possession and don't recall receiving it. My request is simply that in your capacity as Director of Legislation and Professional Regulation, you send the College of Physicians & Surgeons a letter similar to the following: I have seen the College's correspondence with D ennis H arrison on the subject of infant male circumcision. Mr. H arrison asks if the College "can provide assurance that it is ethical for members of the College to remove normal tissue from non-consenting persons for non-therapeutic purposes." I note the College has not responded to this question. Sincerely,
June 15, 2001 Dear D ennis H arrison: Further to your letter of May 29, 2001. I have enclosed a copy of the letter that we previously sent to you on December 27, 2000. On review of that letter, it now appears that the letter was not correctly addressed. I regret that this letter was never received by you. The concern I have with posing the question to the College of Physicians and Surgeons using the phrasing you have proposed is that the patient is not a "non-consenting person." My information is that this procedure is invariably done with the consent of one or both parents and this constitutes a valid consent in law. As this issue seems to primarily involve medical ethics, I invite you again to consider contacting the Canadian Medical Association which is centrally involved in the development of ethical standards for the profession across the country. I trust that this is satisfactory. Yours sincerely,
June 21, 2001 Dear Mr. Moyes, Thank you for your letter of June 15, 2001, in which you suggest that parental consent for newborn circumcision "constitutes a valid consent in law." As you know, infants are not legally capable of giving consent and "substituted consent" is given on their behalf by parents, or if necessary, by a court. But a 1986 Supreme Court of Canada decision called E. (Mrs.) v. Eve, [1986] 2 S.C.R. 388, creates an important precedent in Canadian law that limits parents' ability to give medical consent on behalf of children in certain circumstances. In Eve, the court was asked whether a parent and/or court could give substituted consent to the sterilization of a young girl with an intellectual disability who was legally incapable of giving personal consent. The court decided that since the proposed sterilization was irreversible and was not necessary to protect the girl's physical or mental health, no parent and no court could legally give substituted consent. The reasoning of this case can be generalized and extended beyond the specific issue of sterilization to other analogous situations. Since circumcision is an irreversible operation that is not necessary for a baby's physical or mental health, it would seem (on the basis of Eve) that no parent and no court can legally give the consent necessary to perform it. Dr. Margaret Somerville, one of Canada's most prominent medical ethicists and the founding director of McGill University's Centre for Medicine, Ethics and Law, has addressed the issue of consent for newborn circumcision on a number of occasions. In her most recent book, The Ethical Canary, Dr. Somerville writes: In general, parents cannot authorize non-therapeutic interventions—that is, routine circumcision—on their children.I'm not aware of any recognized authority in Canada who has publicly stated that parental consent for non-therapeutic circumcision of a minor "constitutes a valid consent in law." In any event, I'm not asking you to write to the College and tell them what the correct answer is. I'm merely requesting your assistance in getting the College to respond to my question. If you are uncomfortable with the concept of an infant as a "non-consenting person," then perhaps the following wording would be more acceptable: I have seen the College's correspondence with D ennis H arrison on the subject of infant male circumcision. Mr. H arrison raises the issue of operating on an individual who is legally incapable of giving personal consent. Specifically, Mr. H arrison asks if it is ethical for a physician to remove normal tissue from such an individual for non-therapeutic purposes. I note the College has not responded to this question.Although the Canadian Medical Association (CMA) is centrally involved in developing ethical standards for the medical profession across the country, the responsibility for interpreting and enforcing those standards in B.C. rests with the College of Physicians & Surgeons, as per the Medical Practitioners Act. Therefore I believe the College of Physicians & Surgeons of B.C., not the CMA, is the body I should be approaching if I want to know whether or not a particular practice is consistent with medical ethics. I trust that the above explanation is satisfactory and that you will assist me in getting the College to answer my question concerning the ethical ramifications of removing a normal part of a healthy organ from an individual incapable of giving personal informed consent. Sincerely,
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