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Correspondent: COLLEGE OF PHYSICIANS & SURGEONS October 5, 1999 Dear Ms. Taylor: Thank you for your letter of August 16, 1999 which was received in the College's office on September 15, 1999. Dr. Little has asked that I respond to your letter. The College of Physicians and Surgeons of Nova Scotia does not have a policy prohibiting infant male circumcision and there is no other regulatory body in Canada to our knowledge that has such a policy. It is the College's view that this is a personal issue and that those interested in prohibiting infant male circumcision should endeavour to change societal views by the usual means. Sincerely yours,
October 29, 1999 Dear Dr. Pearce: Thank you for your letter of October 5th, in which you write that the College views neonatal circumcision as a "personal issue." I believe the College's stance raises important questions in regard to consent for procedures. There is no doubt that neonatal circumcision is an invasive non-therapeutic surgical intervention. As I indicated in my letter of August 16th, it seems doubtful that parents have the legal authority to consent to such procedures being performed on their children. The courts have set strict limits on proxy decision-making. I am surprised that the College of Physicians and Surgeons, a body responsible for protecting the public interest, does not seem to share the Supreme Court's concerns about safeguarding the physical integrity of incompetent persons. Removing one testicle from a newborn male will reduce his chances of getting testicular cancer by 50 percent. Removing his breasts will eliminate the possibility that he will develop male breast cancer. If prevention of disease is insufficient justification for removing testicles or breasts, then it is insufficient justification for removing the prepuce. The latter structure has been present in primates for at least 65 million years, and has been described in the medical literature as specialized, specific erogenous tissue necessary for normal sexual function. In my letter of August 16th, I asked specific questions relating to the ethical, legal, and human rights implications of neonatal circumcision. These questions have been left unanswered, though they concern matters that come well within the purview of the College. I feel my queries are important because they go to the heart of the ethical practice of medicine. As a citizen and a consumer of medical services, I wish to assure myself that medical services delivered in Nova Scotia conform to the highest ethical standards. I believe the College has a duty to respond to my concerns in an appropriate manner. Accordingly, I would like to put the following questions to the College once again:
Yours sincerely,
November 22, 1999 Dear Ms. Taylor: Re: Male circumcision This acknowledges receipt of your letter of October 29, 1999. The College of Physicians and Surgeons of Nova Scotia does not feel it constitutes professional misconduct for a physician licensed in Nova Scotia to perform a legal medical act such as a male circumcision. I have said all I can say regarding this matter. Sincerely yours,
December 7, 1999 Dear Dr. Pearce: Thank you for your letter of November 22nd. I am disappointed that once again you have not answered the specific questions I asked regarding the ethical, legal, and human rights implications of neonatal circumcision. You refer to male circumcision as a "legal medical act." I believe, however, that since the object of the College is to serve and protect the public,1 the College has the burden of proving neonatal circumcision is a legal act. The College cannot simply presume that this is the case. One of our country's leading medical ethicists, Dr. Margaret Somerville, has argued that infant male circumcision contravenes current provisions of the Criminal Code. Dr. Somerville is the founding director of the McGill Centre for Medicine, Ethics and Law, a professor in the faculties of law and medicine at McGill University, and a Fellow of the Royal Society. The gist of Dr. Somerville's argument is that the law prohibits a physician from performing any invasive surgical operation on an incompetent person unless the physician can show that the operation is medically required. For your information, I enclose a copy of an article entitled "Circumcision is assault, ethicist says," which appeared in the Montreal Gazette on October 18, 1997. I also enclose a copy of a letter dated November 10, 1997 from Dr. Somerville to Dr. Robin Walker, a member of the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS) and co-author of the 1996 CPS position paper on neonatal circumcision. Note the following statement, which appears on page 2 of the letter: The present law would prohibit circumcision on a child unless the persons consenting to this and the person carrying it out can show that it is justified.As the guardian of the public interest in matters related to the practice of medicine, the College of Physicians & Surgeons of Nova Scotia must take reasonable care to ensure medical practitioners in this province are acting ethically and legally. I have presented evidence suggesting neonatal circumcision is unethical and illegal. I request that the College address my concerns in an appropriate and timely manner. Notes: 1 Chapter 10 of the Acts of 1995-96, s. 4(3). Yours sincerely,
Enclosures
January 7, 2000 Dear Ms. Taylor: Re: Male circumcision Your letter of December 7, 1999 to Dr. Patricia Pearce, President, College of Physicians and Surgeons of Nova Scotia was referred to me. Dr. Pearce indicated in her letter of November 22, 1999 that she had said all she can say regarding this matter. Your correspondence will be kept on file. Sincerely yours,
January 7, 2000 Dear Dr. Bhimji: Re: Male circumcision Thank you for your letter of December 16, 1999. We received a similar letter from Ms. Mary C. Taylor in October/November 1999. Her questions were identical to yours and I have included for your information a copy of two letters to Ms. Taylor from Dr. P. A. Pearce, President, College of Physicians and Surgeons of Nova Scotia, in response to Ms. Taylor's letters. These make clear this College's position and I can add nothing further. Sincerely yours,
February 3, 2000 Dear Dr. Little: Thank you for your letter of January 7th. I am disappointed that the College has not addressed the specific questions I asked regarding neonatal circumcision. I believe these questions are important, as they deal with standards of professional ethics. Under Section 4(3)(d) of the Medical Act, the College must "establish, maintain and develop standards of professional ethics among its members." Therefore I believe my questions lie squarely within the College's jurisdiction. I respectfully request that the College respond to the questions I posed in my letter of August 16, 1999, and repeated in my letter of October 29, 1999. If I have received no response by March 31, 2000, I will pursue this matter further with the Minister responsible for administration of the Medical Act. For your ease of reference, I enclose copies of my letters dated August 16, 1999, and October 29, 1999. Yours sincerely,
February 25, 2000 Dear Ms. Taylor: Re: Male circumcision This acknowledges receipt of your letter of February 3, 2000. Our previous correspondence stated that the College of Physicians and Surgeons of Nova Scotia does not feel it is unethical for a medical practitioner to circumcise a minor at the request of and with the informed consent of the parent or legal guardian. Dr. Pearce indicated in her letter of November 22, 1999, and I indicated in my letter of January 7, 2000, that we had said all we can say regarding this matter. You are certainly within your rights to pursue this matter with government officials or anyone else you wish to. Sincerely yours,
cc: The Honourable Jamie A. Muir, Minister of Health
June 2, 2000 Dear Dr. Little: I have received copies of correspondence between the College and Ms. Mary Taylor on the subject of neonatal circumcision, and I seek clarification of a couple of points. I have been researching circumcision for three years. My letters on this subject have been published in a number of peer-reviewed journals, including the Journal of the American Medical Association,1 the Journal of Law and Medicine,2 the Lancet,3 and Paediatrics and Child Health.4 The points on which I seek clarification are as follows:
Sincerely,
June 20, 2000 Dear Mr. H arrison: Thank you for your letter of June 2, 2000. I think the College's position can best be defined by combining the two quotes from our correspondence with Mrs. Mary C. Taylor. That is: The College of Physicians and Surgeons of Nova Scotia does not feel it constitutes professional misconduct nor does it feel it is unethical for a medical practitioner to perform a legal medical act such as circumcision of a male neonate at the request of and with the informed consent of the parent or legal guardian.The physician always requires consent and this consent is legally provided by the parent of legal guardian. There is nothing further I can add to this. Sincerely yours,
July 6, 2000 Dr. Cameron D. Little, Registrar
Dear Dr. Little: You were interviewed on CBC television a few days ago in connection with the suspension of a Nova Scotia physician from the practice of medicine. The physician had become involved in a sexual relationship with a former patient. You said that rules had been put in place to protect the public, and that physicians knew the rules. I would like to know more about the rules governing the performance of surgical operations on incompetent persons. Can a physician perform an invasive, irreversible surgical operation on an incompetent person if the operation is not required for the person's mental or physical health? Would a physician who performed such an operation be guilty of professional misconduct? Would the consent of the incompetent person's next of kin serve as a defence for the physician's actions? I would appreciate hearing your answers to the above questions. I am glad that rules have been put in place to protect the public, and that the College is committed to enforcing those rules. Sincerely,
July 13, 2000 Dear Mr. H arrison: Thank you for your letter of July 6, 2000. From the questions in your letter it appears that you have a personal reason for asking these questions. Generally a surgeon cannot operate on any person without informed consent. Where a person is deemed mentally incompetent by law then the surgeon normally requires consent of the guardian who is officially appointed to make decisions for the patient. The next of kin may or may not be the guardian. If this has to do with male circumcision, for example, the parents are the infant's guardian and must provide consent. In almost all instances the circumcision is done at the request of the parent/guardian. These are legal questions and my advice to you would be to seek advice from a lawyer in British Columbia and because rules differ from province to province. I would suggest that you address your questions to Dr. Morris VanAndel at the College of Physicians and Surgeons in Vancouver. Their address is: [address provided]. Sincerely yours,
July 19, 2000 Dear Dr. Little: Thank you for your letter of July 13, 2000. My reasons for asking questions about circumcision are not of a personal nature. Circumcision of healthy boys is an important ethical issue that has engaged the attention of many people from all walks of life. The research I have done leads me to believe that if the foreskin is a normal body part, then parents can no more consent to having it removed from a child than they can consent to having any other normal body part removed from a child. Under Canadian law, parental consent for an invasive, irreversible surgical operation on a child is valid only if the operation is therapeutically necessary. Since routine circumcision by definition is not therapeutically required, it follows that parental consent for this procedure is ineffective. Consequently physicians who undertake routine infant circumcision could be civilly liable in battery or negligence, even if the procedure is competently performed. Indeed, they could be charged with aggravated assault. You stated on national television that "physicians know the rules." Since you are not only a physician but a lawyer, I expect you know the rules well. Please correct me if my reasoning with respect to the legality of circumcision is wrong. Sincerely,
July 25, 2000 Dear Mr. H arrison: This acknowledges receipt of your letter of July 19, 2000. I have legal training but I am not a lawyer and I have never been called to the bar. Your analysis would have to be confirmed by a lawyer. I stand by my statement that informed consent can be legally provided by a parent or legal guardian for a minor. There is nothing further I can add. Sincerely yours, [signed] Cameron D. Little, MD, LLB, FRCPC
November 4, 2004 Dear Dr. Little: I am writing to inquire about the College's position on infant male circumcision. I believe this procedure raises important ethical issues. It has been condemned by two of Canada's top medical ethicists: Dr. Margaret Somerville of McGill University and Dr. Eike-Henner Kluge of the University of Victoria. Significant changes are occurring at the national level. Guidelines aimed at discouraging routine infant circumcision have been issued by the Colleges in Saskatchewan and B.C. Below are a few excerpts from the B.C. policy:
A medical study carried out by Dr. John R. Taylor at the University of Manitoba in the 1990s found that circumcision removes specialized sexual tissue. (Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-295.) Removing healthy body parts from non-consenting patients raises ethical and legal problems. Non-therapeutic surgery on female genitals is expressly prohibited by the Criminal Code. In light of the new information about circumcision, and the leadership being shown on this issue by Colleges in other parts of the country, does the College of Physicians and Surgeons of Nova Scotia plan to provide guidance on neonatal circumcision? If not, please explain why. Thank you for taking the time to consider this issue. I look forward to your reply. Sincerely, [signed] Mary C. Taylor ^Top |