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Correspondent: CANADIAN PAEDIATRIC SOCIETY October 27, 1996 Dr. Douglas McMillan
I would like to comment on your position paper which appeared in the Canadian Medical Association Journal (vol. 154 no. 6). Your paper gives credit to the notion that infant circumcision is a valid procedure which may be performed at the behest of parents for personal, religious, or cultural reasons. I am writing to you because I am unable to understand the reasoning on which your paper is founded. Insofar as it uses a harm/benefit framework for its analysis, your paper bases itself on the very legitimate premise that an infant should not be harmed. But in concluding that an infant may be subjected to a painful, unnecessary, and irreversible procedure for virtually any reason which might occur to the parents, your paper not only undermines the proposition on which it is based, but also relegates the practice of surgery to a status it has not occupied since the Middle Ages, when it was engaged in by barbers and wandering quacks. It is impossible to assess the impact of a proposed amputation without knowing what is to be amputated. Yet although your paper is some nine thousand words long, and includes more than one hundred references, it devotes only a few sentences to a description of the foreskin. These sentences acknowledge that unwritten assumptions about the foreskin have been made in the past, and that recent investigations have uncovered the presence of cells whose function is unknown. It seems to me that under these circumstances, the only prudent course of action, and the only one consistent with medical ethics, is to leave well enough alone. In building its case, your paper relies on the unwritten assumption that the foreskin has no more intrinsic value than a finger-nail clipping. You presuppose that it may be seized and cut off at the earliest opportunity. You preconceive that its removal causes no impairment of any kind, and that fundamental medical, ethical, and legal principles governing the excision of healthy tissue need not even be considered, let alone applied. You offer no justification for any of these suppositions. The paper undertakes a harm/benefit analysis that excludes from consideration the loss of sensation and function which would reasonably be expected to follow amputation of a complex and unique structure. It reviews a series of quite marginal benefits which have a long history of controversy and which have been largely discredited. After assigning monetary values to benefits which are questionable, and whose measurement is subject to a wide margin of error, the paper manages somehow to arrive at the conclusion that the pros and cons of circumcision are "...evenly balanced." I do not believe that your analysis would be taken seriously if it pertained to any other part of the body. I feel certain that you yourselves would very properly reject out of hand any proposal to find out whether benefits would accrue from forcible amputation of any portion whatever of an infant's body, in the case of a female infant. I can think of no reason why the same standard of inviolability and integrity should not apply to male infants. I do not believe that the Canadian Paediatric Society should pass its time in endeavouring to determine whether excision of this or that portion of an infant's genitals would save money in the long run. I do not believe that such efforts will be highly regarded by future generations. It is deplorable that, due to a lack of leadership, small victims are still being subjected, in the name of medicine, to an unneeded mutilation. Sincerely,
cc: Dr. John R. Taylor
November 28, 1996 Your letter of October 27, 1996 to the Canadian Paediatric Society on "Neonatal Circumcision Revisited" has been sent to me for comment as Chair of the Fetus and Newborn Committee. The Committee endeavoured to review the literature predominantly published in peer reviewed English language journals and then weighed the evidence as described in the statement. In spite of some evidence indicating a benefit in terms of a potential decrease in the incidence of urinary tract infections, we did not believe that the evidence for potential benefits of circumcision of newborn boys was compelling enough to indicate that this should be routine. However, we recognize the rights of parents to make an informed decision with regard to their newborn sons and did not feel that the potential adverse effects of circumcision were such that it should be prohibited. While your letter does not provide any reference to new information about the harmful effects of neonatal circumcision, your comparison with removal of other tissue is a valid one. Such procedures are permissible when it is felt that they are in the best interest of the individual (in this case judged by his parents). While recognizing that parents in different parts of the world differ significantly in this assessment, we sought to provide information whereby physicians (and others) might help parents make their best informed decision for their baby. To address the ethical and legal principles for parents to make decisions regarding their children was beyond the scope of this guideline. We do not believe that we have trivialized the potential importance of the foreskin; we endeavoured to indicate that the function of this specialized sensory tissue was not clear and that its removal could be painful without appropriate attention paid to anesthesia and analgesia. We would disagree that individuals who performed neonatal circumcision are no different than "barbers and wandering quacks," but would hope to promote consideration of the need for anesthesia and/or analgesia. As new information becomes available, the Canadian Peaediatric Society endeavours to keep its statements "up to date" in this and other areas which affect Canadian children. Your letter will be made available to all the members of the Fetus and Newborn Committee for their consideration. We recognize that clinical practice guidelines do not always meet everyone's approval, especially in controversial areas. However, we welcome the thoughts of all, as the Canadian Paediatric Society endeavours to provide guidance related to care of Canada's children. Yours sincerely,
February 17, 1999 Dear Dr. McMillan: Forgive me for revisiting terrain we have gone over in previous correspondence, but the more I ponder over comments you made in the press a while ago the more troubled I become. You stated in the National Post on December 4, 1998 that “there is no need for a routine circumcision, but we would respect the rights of parents to make an informed decision.” The notion that parents can authorize invasive pædiatric surgery for which there is no medical indication is at variance with well-established ethical and legal principles. The Canadian Pædiatric Society’s own practice guideline entitled Treatment Decisions for Infants and Children, which deals with the care of children who are critically ill or severely handicapped, stipulates that No other interests can override those of the child whether they be family stability or well-being, or the well-being of other caretakers. Although the burdens placed on the family must be included in making decisions, neither these burdens nor those placed on caretaking staff or on the community can be the primary reason for withholding treatment.If respect for the family cannot be the primary reason for withholding treatment, then can respect for the family be the primary reason for initiating treatment? Little more than a century ago, children were regarded as property to be treated or mistreated as parents saw fit. Since then, we have advanced to the point where we view children as persons in their own right. Why is the CPS throwing its weight behind those who would block further progress in this direction? The mission of the CPS encompasses service to children and service to members, not service to third parties. Pædiatricians are not like chauffeurs, who must go where they are told. The CPS does not make a practice of sacrificing principle for expediency. As a representative of the CPS, you would not have made statements concerning the rights of parents unless those statements rested on a firm theoretical foundation. Can you explain what ethical or legal principles form the basis for your belief that parents have a right to decide in favour of routine circumcision for a child? It is my understanding that an invasive, non-therapeutic surgical intervention such as routine circumcision cannot be undertaken without the informed consent of the person undergoing the intervention. Sincerely,
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March 16, 1999 Dear Dr. McMillan: I would like to comment on statements attributed to you last Friday, March 12, in the Toronto Star. You were quoted in an article entitled “Is circumcision really necessary?” as having said that the Fetus and Newborn Committee “will focus on educational programs to help parents make an informed decision, but we won’t take away their capacity to make an informed decision.” I enclose some material that you might wish to include in your educational programs. The material consists of an article by Dr. Eike-Henner Kluge which appeared in the Canadian Medical Association Journal (January 15, 1993) and four letters by Dr. Margaret Somerville. Two of Dr. Somerville’s letters are to Dr. Robin Walker, while the remaining two are to former Ministers of Justice.
In his article, Dr. Kluge explains why physicians must turn down requests to tamper with children’s sex organs for non-medical reasons. In her letters, Dr. Somerville explains why neonatal circumcision is technically criminal assault. Dr. Somerville indicates in her letter of January 28, 1998 to Dr. Walker that invasive non-therapeutic surgical interventions cannot be legally undertaken in this country without the informed consent of the person undergoing the intervention. If the Fetus and Newborn Committee rejects Dr. Somerville’s analysis, then the onus falls on the Committee to make a rebuttal. As far as I know, the Committee has never made such a rebuttal. In fact, I am not aware of a single theoretical argument the Committee has ever advanced in support of the notion that circumcision is an appropriate medical procedure for newborns. Sincerely,
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May 21, 1999 Dear Dr. McMillan: I've been reviewing earlier correspondence we have had on the subject of neonatal circumcision. I came across some problematic statements in a letter dated November 28, 1996. You wrote: “...we [the Fetus and Newborn Committee] did not feel that the potential adverse effects of circumcision were such that it should be prohibited.” In the same letter, you wrote: “...we endeavoured to indicate that the function of this specialized sensory tissue [the preputial mucosa] was not clear.” It seems to me that if the function of a body part isn't clear, then the consequences of removing that body part can't be clear either. How did the Fetus and Newborn Committee manage to determine that the potential adverse effects of neonatal circumcision were "not such that it should be prohibited," if circumcision removes tissue whose function is not clear? I am also troubled by comments you have made in the media, to the extent that you have placed parental preferences ahead of children’s rights (“There is no need for a routine circumcision, but we would respect the rights of parents to make an informed decision.” National Post, December 4, 1998, p. A4). In your letters you have portrayed the Fetus and Newborn Committee as a forward-looking body, dedicated to staying abreast of scientific research and devoted to protecting the interests of Canada’s children. I’m surprised to see an organization with such progressive views clinging to nineteenth-century conceptions of science and children’s rights. Is the Fetus and Newborn Committee aware of an article on the prepuce1 published recently in the British Journal of Urology? Is the committee aware of work in progress by Dr. John Taylor in Winnipeg? Sincerely,
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June 10, 1999 Dear Mr. H arrison: I know that your letter of May 21, 1999 was sent to several members of the CPS Fetus and Newborn Committee. I will bring it to the attention of others for their information when we next meet. Yours sincerely,
July 8, 1999 Dear Dr. McMillan: You stated in the press earlier this year that you and your colleagues would be focusing on educational programs to help parents make an informed decision with respect to neonatal circumcision. Could you possibly tell me a bit more about these educational programs? When are they scheduled to begin? At whom will they be directed? What kind of information will be included? Re: the rights of parents to make an informed decision. What is the basis for your belief that parents have a legal right to circumcision of an infant who is in good health? My reading of Canadian case law is that the courts attach very great importance to protecting a person's privacy interests in his or her own body. Re: paternalism. In earlier correspondence you rejected a "paternalistic" role for physicians in the provision of health care. However, safeguarding the basic human right of a child to physical integrity is not paternalism. Paternalism is the subjection of a child to an invasive, irreversible non-therapeutic surgical intervention such as routine circumcision. For your information I enclose copies of two articles that appeared recently in the British Journal of Urology. The articles, entitled "Involuntary circumcision: the legal issues" and "The psychological impact of circumcision" deal with two critical areas of concern that were not passed under review (to state the truth they were not even mentioned) in the 1996 CPS position statement on neonatal circumcision. Sincerely,
enclosures
July 16, 1999 Dear Mr. H arrison: In response to your letter of July 8, 1999, please be advised that I am no longer Chair of the Fetus and Newborn Committee of the Canadian Paediatric Society. Any future correspondence may be directed to the Canadian Paediatric Society, Suite 100, 2204 Walkley Road, Ottawa, Ontario K1G 4G8. Yours sincerely,
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