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Correspondent: DIRECTOR OF ETHICS March 4, 1992 Dear Dr. Anderson: I have been asked to reply to your letter of February 14, 1992 to the President of the Canadian Medical Association regarding circumcision. The CMA does not have a policy on this issue. However, we have consulted with the Canadian Council on Multicultural Health in order to determine what other health care organizations are doing about this problem, and the CMA Committee on Ethics is being asked to study the issue. Given our heavy agenda, I cannot promise that the CMA will issue a statement on circumcision in the near future. However, you can be assured that the matter is being given serious consideration. Thank your for bringing this issue to our attention. Sincerely yours, [signed] John R. Williams, Ph.D.
cc: Dr. Carole Guzmán, MD, President, CMA
le 8 août 1997 Monsieur, Je donne suite à votre lettre du 3 juillet dernier, addressé au Dr Léo-Paul Landry, au sujet de la circoncision des enfants en bas âge. L'Association médicale canadienne n'a pas de politique officielle sur cette question et ne compte pas en produire dans un proche avenir, étant donné ses priorités actuelles. Cette question a cependant été étudiée en profondeur par une de nos affiliées, la Société canadienne de pédiatrie. On peut obtenir la politique de la SCP auprès du secrétariat national de la Société, au 401, rue Smyth, Ottawa (Ontario) K1H 8L1. Étant donné les énormes différences de point de vue qui ont cours en ce qui a trait aux aspects medicaux, sociaux et religieux de la circoncision des enfants de sexe masculin, l'Association médicale canadienne ne peut affirmer que la circoncision des enfants en bas âge serait contraire à son Code de déontologie. De même, le Comité d'éthique médicale de l'Association médicale mondiale a récemment étudié cette pratique et a décidé de ne pas la condamner. Nous conserverons toutefois votre lettre dans nos dossiers, au cas où nous déciderions de nous pencher à nouveau sur cette question. Veuillez agréer, Monsieur, l'expression de mes sentiments les meilleurs. Le directeur de l'Éthique, [signature] John R. Williams, PhD cc : Léo-Paul Landry, MD, secrétaire général
December 27, 1997 Dr. John R. Williams
Dear Dr. Williams: We had some correspondence a few months ago, when you responded to a letter concerning infant male circumcision which I had written to Dr. Léo-Paul Landry, Secretary-General of the Canadian Medical Association. In response to my question as to why the Canadian Medical Association was continuing to tolerate a practice which appeared to violate the CMA Code of Ethics, you replied that enormous differences in point of view prevented the CMA from taking a stand on the issue. Since I am not an expert in the field of ethics, I have had difficulty interpreting your response. I would appreciate it if you could assist me in understanding precisely what you mean. If I am not mistaken, you are asserting that from the perspective of ethics, there exist valid rationales both for and against routine infant circumcision. While I had little trouble identifying arguments supporting the view that routine infant circumcision is unethical, I have been unable to conceive of any circumstance under which a coercive, non-therapeutic form of surgery would be ethical. Could you assist me in identifying the arguments in favour of the proposition that routine infant circumcision is ethical? I am providing copies of my letter to other individuals who are interested in this issue. Yours sincerely, [signed] D ennis H arrison Copies to:
January 12, 1998 Dear Mr. H arrison: Thank you for your letter of December 27, 1997 on the subject of infant male circumcision. In the third paragraph you state: "If I am not mistaken, you are asserting that from the perspective of ethics, there exist valid rationales both for and against routine infant circumcision." Your inclusion of the word "routine" here makes all the difference. In my letter of August 8, 1997 I was referring to infant circumcision in general, not to routine infant circumcision. I understand the latter term to exclude circumcision for religious or medical reasons. There may well be an emerging consensus that routine infant circumcision should not be performed, but as far as I can tell, there is widespread disagreement about whether circumcision should be performed for other reasons. Sincerely yours, [signed] John R. Williams, Ph.D.
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March 3, 1999 Dear Dr. Williams: I would like to raise further questions in regard to routine infant circumcision, a subject on which we had some correspondence a while ago. I understand "routine infant circumcision" to mean infant circumcision that has neither medical indication nor religious significance. Several important developments have occurred over the past couple of years:
Does the Canadian Medical Association plan to take any action in response to the above developments? When evidence came to light suggesting that silicone breast implants could cause local complications, these prostheses were withdrawn from the market pending further investigation. Circumcision can cause a wide range of complications, including death, and as a routine procedure is no more essential than breast augmentation. Will the Canadian Medical Association call for a moratorium on routine infant circumcision? According to Statistics Canada, about 25 percent of Canadian newborn males were circumcised in 1996. The vast majority of these circumcisions had no religious significance. To raise awareness of this issue and stimulate further discussion, I am providing copies of my letter to a number of ethicists and physicians via email. Sincerely, [signed] D ennis H arrison References:
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July 14, 1999 Dear Dr. Williams: I wrote you last March in connection with routine infant circumcision. I listed several developments that have occurred on the circumcision front over the past couple of years, and asked what action the Canadian Medical Association (CMA) planned to take in response to these developments. So far I have received no reply. I visited the CMA Web site the other day. I was surprised to find that the CMA's mission is "to provide leadership for physicians and to promote the highest standard of health and health care for Canadians." I can see little in the way of either leadership for physicians, or promotion of the highest standard of health and health care for Canadians, in past correspondence we have had on the subject of neonatal circumcision. The Canadian Paediatric Society has advised that circumcision is of no net medical benefit to an infant. Dr. Douglas McMillan, Chair of the Fetus and Newborn Committee, has stated that "there is no need for a routine circumcision." It follows that infant male circumcision is performed to meet the needs of someone other than the patient. When a physician performs surgery to meet the needs of someone other than the patient, is that physician violating the Hippocratic Oath? If not, please explain why. The Code of Ethics of the Canadian Medical Association calls on practitioners to "treat all patients with respect." In your view, does treating all patients with respect involve protecting incompetent persons from nonessential surgery? If not, please explain. The CMA Code of Ethics also enjoins physicians to "provide appropriate care for your patient." In your opinion, does providing appropriate care for a patient entail obtaining the patient's personal consent for invasive non-therapeutic surgical interventions? If not, please explain. I would appreciate answers to the above questions. Sincerely, [signed] D ennis H arrison
August 17, 1999 Dear Mr. H arrison: Thank you for your letters of March 3, 1999 and July 14, 1999 and enclosures on the subject of infant male circumcision. The information you have provided will contribute to the Canadian Medical Association's work on this issue if and when our Board of Directors determines that it should be given priority among all the issues we are being asked to address. Sincerely, [signed] John R. Williams, PhD
August 23, 1999 Dear Dr. Williams: Thank you for your letter of August 17th. Since recent medical evidence suggests neonatal circumcision is harmful, and the lawfulness of neonatal circumcision has been questioned by leading Canadian ethicists, I have no doubt the Board of Directors of the Canadian Medical Association will assign top priority to reviewing the status of this procedure. For your information, I enclose a copy of an article that was published in The Globe and Mail on June 10th. The article is accompanied by an image that may contain an important subliminal message. Note the following features:
I wonder if this image does not signal where the Canadian medical profession is headed if it does not soon come to grips with the simple truth -- that neonatal circumcision is a serious invasion of the body, effected without medical need and without patient consent. Sincerely, [signed] D ennis H arrison June 22, 2000 Dear Dr. Williams: The National Post reported today that a Toronto-based company is using the foreskins of healthy newborn boys to develop a replacement skin product.1 This product will be used to treat burns, diabetic ulcers, and other conditions requiring skin grafts. The foreskin is a normal body part. Like the clitoral hood, of which it is the homologue, the prepuce is made of specialized sexual tissue. The anatomical structure of the foreskin has been described in detail in the medical literature by Canadian researchers.2 I would appreciate an answer to the following question: Is it ethical for caregivers to donate a healthy human body part taken without medical need from a non-consenting person in their custody?Thank you for considering the above question. I look forward to your reply.
Sincerely, [signed] D ennis H arrison
August 29, 2000 Dear Dr. Williams: You indicated in a letter dated May 23rd that you would shortly be responding to concerns I had expressed in regard to a circumcision pain study undertaken at the University of Alberta. I assume your response has been delayed by a heavy workload and will arrive in due course. My reason for writing at this time is to draw your attention to a paper by Dr. Arif Bhimji entitled Infant Male Circumcision: A Violation of the Canadian Charter of Rights and Freedoms which was published recently in a new online journal called HealthcareLaw. After examining newborn circumcision from the perspectives of medicine, ethics, law, and human rights, Dr. Bhimji concludes that the practice violates fundamental principles enshrined in our constitution. I would be interested in hearing your opinion of Dr. Bhimji's paper. A copy is enclosed. Sincerely, [signed] D ennis H arrison
November 17, 2000 Dear Mr. H arrison: At its 9 - 11 November meeting the CMA Committee on Ethics discussed the following correspondence related to infant male circumcision:
The Committee asked me to inform you that its mandate does not include the review of decisions made by research ethics committees and that it has confidence in the CMA affiliated societies, such as the Canadian Paediatric Society and the College of Family Physicians of Canada, that have dealt with the issue of infant male circumcision at the policy level. Please accept this letter as a definitive response to your correspondence with the Canadian Medical Association and its employees on infant male circumcision. Sincerely, [signed] John R. Williams, Ph.D.
November 28, 2000 Dear Dr. Williams, Thank you for your letter of November 17, 2000. In the course of a protracted correspondence with the Canadian Medical Association on the subject of infant male circumcision, I have gained the impression that the CMA's posture on this issue is informed not so much by principle as by political expediency. For example, in a letter dated August 8, 1997 you justified the CMA's do-nothing policy by citing "enormous differences of opinion that currently exist in regard to the medical, social and religious aspects" of this procedure. Not once have you addressed the ethical issues per se. I would like to draw your attention to a new book by Dr. Margaret Somerville entitled The Ethical Canary: Science, Society, and the Human Spirit. In a chapter entitled "Altering Baby Boys' Bodies: The Ethics of Infant Male Circumcision," Dr. Somerville writes: It is very difficult to believe that a person, especially a physician, could understand the new knowledge about circumcision and believe that it did little or no harm to the baby boys on whom it is carried out. And yet my experience has been that many physicians, especially those who are older and have performed very large numbers of circumcisions, are unwilling to accept this evidence or, it seems, even to give it open-minded consideration. In by far the majority of cases, this resistance is not connected with physicians' own religious beliefs, although it could, of course, be connected with concern that recognizing the harms involved in infant male circumcision could interfere with others' religious beliefs or traditional or cultural practices. This concern probably influences politicians and leaders of medical professional societies. When approached about the ethics and legality of infant male circumcision, they frequently fail to respond. If they do respond, either they state that the practice does not raise any ethical or legal issues or, if they recognize that it does raise these issues, they often justify the practice with statements that are ethically and legally wrong. I have spent many hours replying to letters signed by ministers of justice or of health, or presidents of colleges of physicians and surgeons. In these letters, I give the same arguments that I discuss in this chapter to explain why, in my opinion, they are ethically and legally wrong. Sometimes, I do not receive any reply, but I have found that when I do receive a response, it rarely addresses the ethical and legal issues I have raised and often simply repeats the same statements as those in the letter to which I replied that I argued were wrong.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.Further: 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 trust this information is of value. Sincerely, [signed] D ennis H arrison
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