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Correspondent: COLLEGE OF PHYSICIANS & SURGEONS March 3, 1996 Dr. Michael Dixon, Registrar
I am writing in reference to a doctor who circumcised my nephew at the request of his parents in August of last year. The Canadian Paediatric Society, in their publication Circumcision in the Newborn Period, state in paragraph 2: There is no medical indication for circumcision during the neonatal period.and in paragraph 12: ...a decision to circumcise in the newborn period must be ascribed to social rather than medical reasons...In paragraph 15, the Society calls circumcision a "mutilative...and obsolete operation." It is my contention that if this operation cannot be considered to be therapeutic, then the consent of the parents is not valid, and the doctor should not have performed the surgery. In light of this, I would like to pursue disciplinary action against the doctor who performed the surgery. I would also like to inquire about the College's position on neonatal circumcision in general. I look forward to your response. Thank you for your time. Sincerely,
April 10, 1996 Dear Mr. Barichello: Thank you for your letter of March 3rd to Dr. Michael Dixon expressing concerns with respect to the circumcision of your nephew in August of last year. I apologize for the delay in response but felt it important to first consult with Dr. Dempsey, College Medical Advisor, about the issues and questions you have raised. You are correct that within the medical community there remains controversy with respect to the medical necessity for circumcision. Dr. Dempsey has provided me with a copy of a recent publication of the Canadian Medical Association Journal (March 15, 1996) where the Canadian Paediatric Society guidelines are revisited by an expert panel. In reviewing the literature, Dr. Dempsey advises me that the experts have been unable to take a definitive position with respect to the debate around circumcision. Rather, they have formulated a number of conclusions, many of which are based on the need for further information. A copy of this article is enclosed for your information. The College of Physicians & Surgeons of Ontario does not have an official policy with respect to circumcision but leaves the decision up to members in consultation with the parents of infants who request circumcision. There are, of course, many reasons why a family would choose circumcision after reviewing the indications and contraindications with their medical advisors. Therefore, the College believes it would be inappropriate to interfere in this family/health care advisor decision-making process. I trust this information is helpful. Nevertheless, should you wish to pursue your complaint, the College would require the consent of your nephew's parents before it can proceed with the investigation. If you have any questions, please feel free to contact either Dr. Dempsey at extension 248 or myself at extension 441. Yours sincerely, [signed] Sandra McCullough
cc: Dr. Laurel Dempsey
May 24, 1996 Dear Dr. Dempsey: Regarding Sandra McCulloch's letter to me regarding my complaint about my nephew's circumcision. In Ms McCulloch's letter she paraphrases you as saying that "the experts have been unable to take a definitive position with respect to...circumcision. Rather, they have formed a number of conclusions, many of which are based on the need for further information." This is not entirely accurate. The experts have concluded that "the evidence... does not support recommending circumcision as a routine procedure for newborns." In any case, since the medical evidence would seem to be incomplete, and the surgery non-therapeutic, the College does not need to have "a specific policy with respect to circumcision" only a policy on the rights of the patient to be free from unnecessary surgical interventions or amputations. The removal of the healthy foreskin violates the patient's rights. The College must remember that the patient in these cases is not the parents BUT THE INFANT. Why should the College leave the decision regarding circumcision up to its members and the parents of the baby? "There are, of course, many reasons why a family would choose circumcision after reviewing the indications and contraindications with their medical advisors." My point is that the patient is not in a position to review this material, and it is his penis that is being cut. This is clearly surgery that should be left up to the patient to decide at his age of consent. The College's position not to interfere with the family and their health care provider in this circumstance constitutes a lack of protection for the baby which does not want to be interfered with by his parents and their doctor. Ms McCulloch, and the sources that she quotes in her enclosure to me ignore completely the issue of penile sensitivity. It seems obvious that the removal of skin from an organ as sensitive as the penis must be presupposed to detract from its sensitivity, unless it can be shown otherwise, which it has not. Quite the contrary, new research concludes that: "Circumcision ... ablates junctional mucosa that appears to be an important component of the overall sensory mechanism of the human penis." The article also states that "Meissner's corpuscles of the prepuce may be compared with similar nerve-endings in the finger-tips and lips," and refers to parts of the foreskin as "primary sensory tissue." I enclose a copy of The prepuce: specialized mucosa of the penis and its loss to circumcision, published recently in the British Journal of Urology by Taylor, Taylor and Lockwood. I apologize for the quality of the copy, but I am sure that you can easily find it in the original. Finally, Ms McCulloch's statement that should I wish to pursue my complaint, the College would require the consent of my nephew's parents before it could proceed is absurd. How can parents be expected to agree to investigate themselves and their doctor for something that they have had done to their baby? Is it the College's position to require the consent of the parents of babies in order to pursue a case of female genital mutilation? Under a failure of the College to pursue this issue, who is left to speak for the rights of the infant? I await your reply.
June 10, 1996 Dear Mr. Barichello: Thank you for your further correspondence of May 24, 1996, received here on May 29. The College understands that you continue to be concerned about the circumcision of your nephew and I read with interest the further information you have supplied. Notwithstanding all of the above, it remains the case that your fundamental issue is with the parents of the infant and it is with them that the appropriate starting point for your concerns must be. Yours sincerely,
July 26, 1999 Dr. John M. Bonn, Registrar
Dear Dr. Bonn: I would like to express my concerns in regard to comments made in the media by Dr. Aaron Jesin, a Toronto physician. Dr. Jesin is quoted as follows in the July 15, 1999 edition of eye magazine: "Maybe there isn't anything bad about being much more sensitive to pain." Dr. Jesin was referring to the fact that infants circumcised at birth are more sensitive to pain months later. Circumcision was the topic of discussion on the "Jane Hawtin Live" television program on October 21, 1997. Dr. Jesin was one of the guests on this program. He played down the need for pain control during neonatal circumcision, making the following comments: ...whether to use anaesthetic is still up for discussion... Dr. Jesin joked about the whole issue of pain control in newborns by suggesting that if circumcision was traumatic enough to make Jewish males more sensitive throughout life, then circumcision wasn't such a bad thing. Unfortunately, every society is blind to its own worst practices. If the topic under discussion had been female circumcision, and a medical study had just found that female circumcision left girls more sensitive to pain six months later, would it have occurred to anyone on the show to turn this finding into a joke? As a member of the public, I wish to know whether Dr. Jesin's views on pain management are consistent with policies governing the practice of medicine in Ontario. Sincerely,
August 5, 1999 Dear Dr. Bhimji: Your comprehensive and impressive review of the concerns surrounding the issue of routine infant circumcision has been carefully reviewed. We respect your views on this issue and acknowledge the legitimate opinion that you have formed. However, there are others within our profession and without who do not share these views and have an equally strongly held opinion that male circumcision is an accepted medical procedure. This College will not formally endorse either position. The series of inquiries you have made seeking assurances as to the outcome of potential regulatory actions at the College over this issue are not amenable to a definitive answer. Any allegation brought before the College's regulatory processes is fully investigated and a decision made based upon the unique circumstances of that allegation. There is no way that we could give you an assurance or guarantee as to the outcome of any such proceeding. Thanking you for providing this information to your College, I remain Yours sincerely,
August 6, 1999 Dear Mr. H arrison: Re: Dr. A. Jesin Thank you for your letter of July 26, 1999 regarding the above-noted physician. You have raised concerns about comments Dr. Jesin has made in various media regarding the issue of pain as it relates to circumcision of infants. You have asked whether Dr. Jesin's views are consistent with policies governing the practice of medicine in Ontario. The College of Physicians & Surgeons of Ontario receives its authority as a regulatory body from the Regulated Health Professions Act. The Act does not address issues as specific as pain management. The College does not have any public statement or policy regarding the issue of pain management generally or the experience of pain in the infant during circumcision. This area is a highly contentious one, with heated debate on both sides. The College recognizes that physicians will have different opinions on a variety of issues and generally feels that physicians are entitled to express those opinions. I trust this information is of assistance to you. Yours very truly,
August 16, 1999 Dear Ms. Boon: Thank you for your letter of August 6th in response to my concerns about Dr. Aaron Jesin's public comments on neonatal circumcision. You characterized the issue of neonatal circumcision as "a highly contentious one, with heated debate on both sides." However, the basic facts relating to neonatal circumcision are not contentious at all. On the contrary, they are simple, straightforward and irrefutable:
I believe the College has an obligation to form an opinion of neonatal circumcision based on the simple facts. The smoke from the "heated debate" to which you refer can obscure these facts, but it cannot change them. Sincerely,
cc: Dr. John Bonn, Registrar
January 6, 2000 Dear Dr. Bonn: Thank you for your letter of August 5, 1999 in response to my inquiry regarding circumcision. I can well appreciate your position on what may amount to "advance rulings" on events that are not actually before the College and therefore shall not pursue further responses regarding abstract issues. However, there are a number of questions that were not responded to in your letter that were neither abstract nor asking for a form of advanced ruling. As such I am resubmitting them to you for response.
The ethical issues raised by medical practices and procedures are clearly within the purview and jurisdiction of the College. I trust that in order to guide my fellow physicians and myself, the College will provide detailed responses to the questions posed regarding the ethics of non-therapeutic infant circumcision. I have enclosed letters and a scholarly paper by Dr. Margaret Somerville from McGill University to assist the College in its deliberation. Please contact me at the address and telephone number provided should you require further information about my request. Sincerely yours,
January 13, 2000 Dear Dr. Bhimji: Once again I respond to your correspondence with regards to this issue. As indicated in our last correspondence dated August 5, 1999, we respect your views on this issue and acknowledge the legitimate opinion that you have formed. However, there are others within our profession and without who do not share these views and have an opinion that male circumcision is an acceptable surgical procedure. This College will not formally endorse either position. Trusting that I have your understanding on this issue and advising that we will not engage in further correspondence on it, I remain Yours sincerely,
May 1, 2000 Dear Mr. Barichello: Thank you for your letter of April 11, 2000 to the College of Physicians and Surgeons of Ontario which has been forwarded to me for response.
You have asked whether physicians providing male circumcision are engaging in professional misconduct. Any complaint brought before the College's regulatory processes is fully investigated and a decision made based upon the unique circumstances of the allegation. I trust this information is of assistance to you. Yours very truly,
June 14, 2000 Dear Ms. Boon: Thank you for your letter of May 1, 2000, in response to my questions of April 11, 2000. I assure you that you are wrong about my reason for writing—I am not asking the College to endorse my views on neonatal circumcision. Rather, I am asking the College to clarify its own views on this issue. With all respect, your letter has not assisted me to understand the College's position. In fact, it has drawn attention to further problems. Regarding the question of whether or not routine circumcision is appropriate, you state that the College "will not formally endorse either position." Be that as it may, the College does not currently discipline member physicians for circumcising healthy boys. This may not amount to a formal endorsement of routine circumcision, but it certainly amounts to tacit acceptance of the procedure by the College. I am writing to find out what medical, ethical and legal principles underpin this tacit acceptance. You state that some people feel "circumcision is an accepted medical procedure." Can you name an authoritative body that recommends infant male circumcision on medical grounds? You write that "the College has not endorsed the position of the Canadian Paediatric Society." Could you identify the professional body or bodies that the College considers to be authorities on circumcision? You feel I was asking the College to answer leading questions. I do not necessarily agree with your assessment, but to address your concerns I have pared the list of questions down to four and changed the wording. The revised questions are as follows:
I would appreciate a detailed response at your earliest convenience. I look forward to your reply. Sincerely,
cc: Dr. John Bonn, Registrar
June 21, 2000 Dear Mr. Barichello: This will confirm receipt of your most recent letter of June 14, 2000 at the College of Physicians and Surgeons of Ontario. I apologize if my previous letter was not of more assistance to you. However, there is little I can add to what I have previously stated. As you know, there are varying societal opinions about both the necessity and the value of male circumcision. As such, the College of Physicians does not have a position on this issue. I trust this information is clear. Yours very truly,
June 23, 2000 Dear Dr. Bonn: I am writing to inquire about the ethical and legal aspects of a medical study carried out recently at the Hospital for Sick Children. The study involved measuring pain responses in male infants undergoing circumcision.1 Circumcision removes specialized sexual tissue that "provides a large and important platform for several nerves and nerve endings."2 The operation is not required for an infant's mental or physical health. It is not recommended by the Canadian Paediatric Society, and is not an insured service under the Ontario Health Insurance Plan (OHIP). Clearly, the study in question involved performing non-essential surgery on non-consenting persons. The subjects suffered pain during and after the procedure. Adverse events such as skin reactions, bleeding and infection were noted in follow-up telephone interviews with the parents. Except in a medical emergency or with statutory authorization, no one can intrude on another person's body without that person's consent. Since children are not legally capable of giving consent, "substituted consent" is given on their behalf by parents or, if necessary, by a court. However, a 1986 Supreme Court of Canada decision called E. (Mrs.) v. Eve [1986] 2 S.C.R. 388 created an important precedent in Canadian law which limits parents' and courts' abilities to give medical consent on behalf of children. In Eve, the court dismissed an application by a mother for the legal authority to have her retarded daughter sterilized. The court found that the proposed sterilization was not necessary for the daughter's mental or physical health. The reasoning of this case can be extended beyond the specific issue of sterilization to other analogous situations. If circumcision is not necessary for a baby's mental or physical health, then it is arguable (on the basis of Eve) that a parent and/or court cannot legally give the consent necessary to perform it. I would be grateful if you would clarify the following issues:
As you are aware, s.3(2) of the Procedural Code of the Regulated Health Professions Act stipulates that the College, in carrying out its objects, has a duty to serve and protect the public interest.S.3(1) of the Code sets out those objects, which include:
Thank you for your assistance. I look forward to your reply. References:
Sincerely,
July 7, 2000 Dear Mr. H arrison: This will confirm receipt of your letter of June 23, 2000 to the Registrar of the College of Physicians and Surgeons of Ontario, which has been forwarded to me for response. As noted in my previous response of August 6, 1999, the College of Physicians does not have a position on the issue of male circumcision. With respect to the two views on the value of circumcision, the Registrar has indicated that this College will not endorse either position. I trust this information is clear. Yours very truly,
July 14, 2000 Dear Ms. Boon: Thank you for your letter of July 7. I'm uncertain as to what you mean by "the two views on the value of circumcision." There has been a high level of consensus in the medical community for at least a quarter of a century that neonatal circumcision is not medically required. The Canadian Paediatric Society, the American Academy of Pediatrics, the British Medical Association, and the Australian College of Paediatrics all agree that neonatal circumcision is not required for an infant's physical or mental health. The procedure is not an insured service under the Ontario Health Insurance Plan (OHIP). I'm at a loss to understand how any reasonable person could maintain in the face of these facts that the medical community is divided over the need for neonatal circumcision. Even conceding (for the sake of argument) that credible medical experts do disagree on the need for circumcision, what are the implications of this for clinical practice? Can a physician ethically and legally perform an invasive, irreversible surgical operation on a non-consenting person if there is equal doubt as to whether or not the proposed operation is medically required? I am disturbed by the College's apparent unwillingness to address these very basic issues. I request once again that you respond in a reasonable fashion to my letter of June 23. If I have received no reply by September 30, then I intend to pursue this matter further with the Honourable Elizabeth Witmer, minister responsible for administration of the Regulated Health Professions Act. Sincerely,
cc: Dr. John Bonn, Registrar
July 24, 2000 Dear Ms. Boon: I have received your letter of June 21, 2000. You reiterate that the College of Physicians and Surgeons of Ontario does not have a position on infant male circumcision, and decline once again to answer specific questions concerning the ethics of this practice. The College is the professional body responsible for regulating medical practice in Ontario. As such, the College should be able to answer questions related to infant male circumcision, regardless of whether or not the College has a position on the issue. Section 3(1) of the Procedural Code of the Regulated Health Professions Act stipulates that "the College, in carrying out its objects, has a duty to serve and protect the public interest." I find it difficult to see how the public interest can be protected if the College refuses to account for the conduct of its members. Infant male circumcision cannot be justified on the grounds of medical necessity. It is not recommended by the Canadian Paediatric Society, and is not an insured service under the Ontario Health Insurance Plan (OHIP). I believe the College has an obligation to explain the ethical and legal principles that allow physicians to perform this operation on non-consenting minors. In general, non-therapeutic surgical interventions cannot be carried out on persons incapable of giving informed consent for themselves. I request once again that you respond fully to my letter of June 14, 2000. I enclose a copy of it for your ease of reference. If I have not received a comprehensive reply by September 30, 2000, then I intend to pursue this matter further with the Honourable Elizabeth Witmer, Minister of Health and Long Term Care. Section 3 of the Regulated Health Professions Act imposes a duty on the Minister to ensure that "the health professions are regulated...in the public interest," and "appropriate standards of practice are developed and maintained." Sincerely,
September 18, 2000 Dear Dr. Bonn: I have acquired a copy of a position statement entitled "Female Circumcision, Excision and Infibulation" issued by the College on January 27, 1992. I seek your assistance in coming to grips with some of the issues raised by this statement. The position statement identifies three different types of procedures performed on females: circumcision, excision, and infibulation. The first of these, circumcision, is described as "the mildest type of procedure." It involves "cutting the prepuce or hood of the clitoris." The statement warns that the performance of circumcision, excision, or infibulation by any physician licensed in Ontario will be regarded as professional misconduct. I have some difficulty understanding how the College can regard the cutting of the female prepuce as professional misconduct while simultaneously viewing the total ablation of the male prepuce as an acceptable standard of practice. The latter procedure is more invasive than the former. Please help me understand the logic behind the College's policy by answering the following questions:
Sincerely,
October 22, 2000 Dear Dr. Bonn: I wrote to you on September 18th in connection with a position statement entitled "Female Circumcision, Excision and Infibulation" issued by the College on January 27, 1992. I am sure you will be responding in due course, though to date I have received no reply. My reason for writing today has to do with the comments you made this morning on the national CBC radio network. You were being asked to account for the College's actions in suspending Dr. Frank Adams, a recognized authority on pain management who allowed patients to self-administer narcotic medication. You emphasized the need to protect the public, and divulged that the exposure of patients to unnecessary risk was the deciding factor in tipping the scales against Dr. Adams. "We cannot put patients at risk," you said. You noted that certain basic requirements had to be met before treating a patient. Apparently the discipline panel found that Dr. Adams had failed to meet these basic requirements by (for example) neglecting to perform a proper diagnosis in eight cases. You also indicated that decision-making in medicine should be evidence-based. In light of the above, I have some difficulty understanding the College's posture on infant male circumcision. The College has said it "does not have a policy" on this issue. If the College's primary objective is to protect the public, then why does the College not have a policy on a painful,1,2,3 dangerous,4,5,6,7,8,9 potentially even lethal10,11,12 surgical intervention performed without diagnosis and without medical justification13,14,15 on thousands of vulnerable persons in Ontario every year? Does the College plan to formulate a policy on infant male circumcision? If not, please explain why. I would appreciate a reply at your earliest convenience. Sincerely,
October 23, 2000 Dear Ms. Boon: I seek your assistance in understanding the College's position on management of severe chronic pain. When I raised questions last year in regard to pain control for infant male circumcision, you informed me in a letter dated August 6, 1999 that "the College does not have any public statement or policy regarding the issue of pain management generally." You also advised that "the College recognizes that physicians will have different opinions on a variety of issues and generally feels that physicians are entitled to express those opinions." If the College does not have a policy on pain management generally, and if the College keeps an open mind on contentious issues, then on what basis has the College disciplined Dr. Frank Adams, a recognized authority on pain management? For your ease of reference, I enclose a copy of your letter dated August 6, 1999. I would appreciate a reply at your earliest convenience. Sincerely,
October 24, 2000 Dear Dr. Bonn, This letter is further to my letter of October 22nd. In the course of the interview on CBC radio, you used the "red light" analogy. Going through a red light does not always have an adverse outcome, you said, but drivers who go through red lights must be penalized. You told listeners that the College had imposed a penalty on Dr. Frank Adams because he had broken certain rules, not because there was any evidence he had harmed a patient. If we look at infant male circumcision, we see that it involves performing an invasive, irreversible surgical operation on a person incapable of giving informed consent. The operation is not required for the person's mental or physical health and is performed without the benefit of a diagnosis. What colour is the traffic signal that governs infant male circumcision? If it is red, then why don't physicians who perform this operation receive the same penalty as Dr. Adams? The College has repeatedly refused to address basic issues in the context of neonatal circumcision, though evidently the College considers such issues to be of paramount importance in other contexts. I have received no responses to letters I sent the College on July 14, 2000 and September 18, 2000 seeking clarification of the fundamental rules of medical practice in the context of neonatal circumcision. I request once again that the College explain the basis on which physicians in Ontario are circumcising healthy boys. I would appreciate a reply at your earliest convenience. Sincerely,
June 27, 2001 Dr. Rocco Gerace
Dear Dr. Gerace: I'm writing to ask a question about infant male circumcision. I would like to broaden my understanding of the ethical issues surrounding this procedure. Circumcision is an invasive, irreversible surgical operation. In Ontario it is often performed on healthy infants. An infant is a person who is legally incapable of giving informed consent. My question is as follows: Can the College provide assurance that it is ethical for a physician to operate on a person who has no medical need for surgery, and who is legally incapable of giving informed consent?I would appreciate a response at your earliest convenience. Sincerely,
August 21, 2001 Dr. Rocco Gerace, President,
Dear Dr. Gerace, I am professor and chair of the ethics and gerontology programmes at Laurentian University in Sudbury, Ontario. Biomedical and elder ethics are my field, and related to this, I am the Chair of the Research Ethics Committee at the Sudbury Regional Hospital. In our hospital system, we have been trying for some time to create an updated ethical code for all hospital employees. In addition, the office of the on-staff clinical ethicist has been trying to create an effective ethics education programme for all employees and for the wider community. As a result of a survey we've done, and further discussion in our research ethics committee, a question has emerged for which we are seeking information from the College of Physicians and Surgeons. Has the college articulated any policy regarding surgery on persons who, first of all, are incapable of giving informed consent, and secondly, have no real need for surgery? An example here would be an elderly man with dementia who has prostate cancer. The medical prognosis is that prostatectomy is not needed to save his life, and would do nothing to improve the quality of his life. Another example, taken from the beginning of life rather than the end, is a healthy male infant slated to undergo routine circumcision. Medical associations advise that this procedure is not medically justified. In situations where a patient cannot give personal informed consent, and there is no real medical need for an intervention, is it ethical to proceed with surgery? I look forward to your response. Yours sincerely,
August 31, 2001 Dear Mr. Miller: Your letter dated June 27, 2001, addressed to Dr. Rocco Gerace, has been passed to the Physician Advisory Service for a response. In your letter you ask the question about the ethics of a physician operating on a child who has no medical need for surgery and who is legally incapable of giving informed consent. Under the Health Care Consent Act, if someone is not capable of making decisions for themselves then the physician would go to the person who is the substitute decision maker, in this case that would normally be the parents. In recent years there has been medical articles published on infant male circumcision. You may want to research some of these articles from the internet or the local library. Also the Ontario Medical Association, Section on Paediatrics may have some information on this subject. The address of the Ontario Medical Association is 525 University Avenue, Suite 300, Toronto MSG 2K7 I hope this is of some assistance to you. Sincerely,
September 10, 2001 Dear Ms. Janes: Thank you for your letter of August 31st. I appreciate your reference to the Health Care Consent Act, but my question pertained to the ethics of circumcision, not the operation's legal status. The body responsible for establishing and enforcing ethical standards for Ontario physicians is the College of Physicians and Surgeons of Ontario. Pursuant to section 3(1) of the Procedural Code of the Regulated Health Professions Act, the College must develop, establish and maintain standards of professional ethics for its members. Accordingly, I am resubmitting the following question for a response: Can the College provide assurance that it is ethical for a physician to operate on a person who has no medical need for surgery, and who is legally incapable of giving informed consent? Sincerely,
January 19, 2002 Beverley Janes
Dear Ms. Janes: On June 27, 2001, I wrote to the College in connection with infant male circumcision. I asked whether it was ethical for a physician to operate on an incompetent person who does not require medical treatment. Since then, I have received responses from both yourself and Ms. Jill Hefley, Associate Director of Policy and Communications. The gist of these responses is that under the Health Care Consent Act, parents have the authority to consent to medical treatment for their children. The Health Care Consent Act, however, applies only to medical treatment that is ethical and appropriate. It is not the intent of the Act to give parents the legal authority to consent to unethical, inappropriate medical interventions on their children. The responsibility for deciding what constitutes ethical and appropriate medical practice rests with the College of Physicians & Surgeons. Accordingly, I am re-submitting my question of June 27, 2001, for a response: Can the College provide assurance that it is ethical for a physician to operate on a person who has no medical need for surgery, and who is legally incapable of giving informed consent?I would appreciate a response at your earliest convenience. Sincerely,
November 12, 2002 REGISTERED MAIL Dr. Dody Bienenstock
Dear Dr. Bienenstock: On August 16, 2002, I wrote to the College Registrar, Dr. Rocco Gerace, regarding neonatal circumcision. Unfortunately, I have received no reply to that letter, or to a follow-up letter I sent on October 8th. I realize infant male circumcision provokes strong emotions, but that does not exempt the College from answering reasonable questions about this issue. The CPSO has a moral and statutory obligation to serve the public. The College of Physicians & Surgeons of Saskatchewan has launched an initiative aimed at reducing the incidence of neonatal circumcision in Saskatchewan. The CPSS has issued two memos to its members cautioning them that routine circumcision of newborn males is not good medical practice. One of the memos advises physicians to "respectfully decline to perform the procedure." Copies of both memos are enclosed with this letter. Since the issue of infant male circumcision is of concern to me, I would like to hear the CPSO's opinion of the Saskatchewan memo. Specifically, I would appreciate answers to the following questions:
Sincerely,
February 19, 2003 Dear Mr. Miller: Re: Routine Infant Male Circumcision Thank you for your letters of August 16 and October 8, 2002 and for the enclosed copy of a memorandum from the Registrar of the College of Physicians and Surgeons of Saskatchewan (the CPSS) concerning routine circumcision of infant males. I apologize for the delay in responding. I can now advise you that this matter was brought before the Executive Committee of the College of Physicians and Surgeons of Ontario (CPSO) at its meeting in January. After reviewing the materials before it—including your correspondence, two memoranda from the Registrar of the CPSS and a statement from the College of Physicians and Surgeons of British Columbia—and considering the matter, the Executive Committee decided that the development of a policy on this issue is not warranted. Consequently, no further action will be taken. Your expression of interest is appreciated. Yours truly, [signed] Rocco Gerace MD
October 24, 2003 Dr. Rocco Gerace
Dear Dr. Gerace: I am writing to inquire why the College does not have a policy on infant male circumcision. This matter is of concern to me because two of Canada's top medical ethicists have warned that routine infant circumcision poses serious ethical and legal problems. Even the medical licensing authority in Saskatchewan has cautioned physicians that performing surgery of questionable value on an infant would generally be considered "imprudent if not improper." The Colleges of Physicians and Surgeons of Saskatchewan, British Columbia, and Manitoba have all issued statements on routine infant circumcision. In Alberta, a statement is under development. Neonatal circumcision is rarely performed in Quebec and the Atlantic provinces. That leaves Ontario as the only province where circumcision is still relatively common and where the College of Physicians and Surgeons has neither drafted a policy on the procedure nor indicated an intention to do so. The CPSO promptly took a stand against non-therapeutic surgery on female genitals (FGM) when this issue was placed on the public agenda a decade ago. Dr. Roy Beckett, associate registrar for the College at the time, told the press that "it's better to come out with a clear position so doctors know where they stand with respect to the college and the law." If it is advantageous to have a clear position on female circumcision, then it's also advantageous to have a clear position on male circumcision. To suggest otherwise is illogical and discriminatory. I would very much appreciate it if you could clarify whether the College plans to formulate a policy on infant male circumcision. If the College does not plan to formulate such a policy, could you please explain why? Sincerely, [signed] D ennis H arrison
November 24, 2003 Dear Mr. H arrison: Re: Infant Male Circumcision Thank you for your letter of Oct. 24, 2003 regarding the above-noted issue, which has been forwarded to the policy department for response. The College is aware of the positions of other provincial Colleges on this issue and has considered the issue in the last year. It decided not to proceed with a policy on infant male circumcision. The College has no plans to develop a policy on this issue at present. When the College considers a policy issue, relevant information is considered and the issue is discussed in light of the College's strategic goals. I trust this is helpful to you. Sincerely, [signed] Maureen Boon
December 5, 2003 Dr. Rocco Gerace
Dear Dr. Gerace: Re: Infant Male Circumcision On October 24th I wrote to inquire why the College does not have a policy on the above issue. I received a reply from Ms. Maureen Boon, Manager, Policy, affirming that the College has decided not to develop a position on circumcision, but offering no substantive explanation of the basis for that decision. I am requesting that the College provide a clear justification for its decision not to proceed with a policy on infant male circumcision. As you know, the issue of newborn circumcision has been addressed by Colleges in other provinces. The College of Physicians & Surgeons of Saskatchewan, for instance, has notified its members that infant male circumcision is "of great concern to the College, and ought to be of concern to all physicians who perform the procedure." If circumcision is of great concern in Saskatchewan, then it ought to be of concern in Ontario. If not, I would like to know why. The Saskatchewan college was particularly troubled by a lack of informed consent. The frequent absence of informed consent for infant male circumcision is well documented in the medical literature. For example, a survey of new parents conducted at the University of Western Ontario in 1994 found that "informed consent [for infant male circumcision] was often lacking." The College of Physicians & Surgeons of Saskatchewan addressed the lack of informed consent for circumcision by launching an educational strategy aimed at raising professional and public awareness of the issue. The first step in that strategy was to distribute a memo on circumcision to all physicians who performed the procedure. If the College of Physicians & Surgeons of Ontario thinks a similar initiative is unwarranted in this province, then I would like to know why. As you are aware, informed consent is a legal requirement under the Health Care Consent Act, S.O. 1996, c. 2, sched. A. In summary, the documented lack of informed consent for infant male circumcision attests to the need for a policy on the procedure. Colleges in other provinces have recognized this need, and have acted on it. In these circumstances, I think the College of Physicians & Surgeons of Ontario owes the public a reasonable explanation for its decision not to draft a policy on infant male circumcision. Thank you for your consideration of this matter. Sincerely, [signed] D ennis H arrison
December 18, 2003 Dear Mr. H arrison: I am sorry that you were not satisfied with my colleague's response to your earlier letter about this issue. As she indicated to you, our Executive Committee considered the issue of whether or not development of a policy concerning infant male circumcision was warranted and determined it was not. There is no further information that we can provide about this, as the deliberations of the Executive Committee are not public. We will not respond to any further inquiries you make about this matter. Sincerely, [signed] Shenda Tanchak
June 6, 2004 Dear Dr. Gerace: I am writing to inquire why the College does not have a policy on infant male circumcision. This matter is of concern to me because I believe that irreversible, medically unnecessary surgery on infants is problematic. I have been researching this issue for several years. Two of Canada's top medical ethicists have warned that routine infant circumcision raises serious ethical and legal problems. Dr. Margaret Somerville, founding director of McGill University's Centre for Medicine, Ethics and Law, has written, "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." Dr. Kluge, founding director of the Canadian Medical Association's Department of Ethics and Legal Affairs, has characterized infant male circumcision as the "non-consensual mutilation of a minor for non-medical reasons." The College of Physicians and Surgeons of Saskatchewan has cautioned physicians that performing surgery of questionable value on infants would generally be considered "imprudent if not improper." The Saskatchewan College has advised physicians not to perform infant male circumcision unless they believe the procedure is medically indicated. Statements on infant male circumcision have also been issued by the Colleges of Physicians and Surgeons of British Columbia and Manitoba. The CPSO issued a statement on non-therapeutic surgery on female genitals (FGM) when this issue was placed on the public agenda a decade ago. I fail to see why guidance on non-therapeutic surgery on male genitals should not be provided as well, for the sake of equality. I would very much appreciate it if you could clarify whether the College plans to formulate a policy on infant male circumcision. If the College does not plan to formulate such a policy, could you please explain why? Sincerely yours, [signed] Geoffrey T. Falk
June 10, 2004 Dr. Barry Adams
Dear Dr. Adams: Re: Infant male circumcision I am concerned about the absence of a guideline on the above procedure. Newborn circumcision is an irreversible surgical operation that is not recommended by the Canadian Paediatric Society and is not deemed medically necessary by the Ontario Health Insurance Plan (OHIP). Medical ethics prohibit operating on incapable patients who have no medical need for surgery. Pursuant to the Regulated Health Professions Act and the Medicine Act, 1991, the College must maintain standards of professional ethics. To assist me in understanding why the College does not have a policy on newborn circumcision, I would appreciate copies of any Council minutes pertaining to this procedure, insofar as such minutes are open to public scrutiny. I would also appreciate copies of any public report on this issue presented to Council by the Executive Committee, and any other relevant material that may have been provided to Council. Thank you for your assistance in this matter. Sincerely, [signed] D ennis H arrison
June 11, 2004 Dear Mr. Falk: Thank you for your letter of June 6th, which has been forwarded to Policy for response. The College is aware of the positions of other provincial Colleges on this issue and has considered the issue in the last year. It has decided not to proceed with a policy on infant male circumcision. The College has no plans to develop a policy on this issue at present. When the College considers a policy issue, relevant information is considered and the issue is discussed in light of the College's strategic goals. This area is a highly contentious one, with heated debate on both sides. The College recognizes that physicians will have different opinions on a variety of issues and generally feels that physicians are entitled to express those opinions. I trust this information is of assistance to you. Yours very truly, [signed] Olga Kits
June 16, 2004 Dear Mr. H arrison: Thank you for your letter of June 10th, which has been forwarded to Policy for response. In January of 2003 our Executive Committee considered the issue of whether or not development of a policy concerning infant male circumcision was warranted and determined it was not. This issue therefore did not go to Council. There is no further information that we can provide about this, as the deliberations of the Executive Committee are not public. When the College considers a policy issue, relevant information is considered and the issue is discussed in light of the College's strategic goals. This area is a highly contentious one, with heated debate on both sides. The College recognizes that physicians will have different opinions on a variety of issues and generally feels that physicians are entitled to express those opinions. I trust this information is of assistance to you. Yours very truly, [signed] Olga Kits
August 27, 2004 Dear Dr. Adams: I’m writing to inquire about the College’s policy on infant male circumcision. I’m concerned about this practice because I think it raises important ethical issues. From media reports I am aware of a new circumcision policy in B.C. It says circumcision may be a human rights violation, a “mutilating surgery,” and questions whether parents can consent to it. Below are a few quotations from the B.C. College of Physicians and Surgeons Policy Manual: “The prepuce is composed of an outer skin and an inner mucosa that is rich in specialized sensory nerve endings and erogenous tissue.” “...male circumcision is an unnecessary and irreversible procedure.” “Parental preference alone does not justify a non-therapeutic procedure.” “Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and body integrity.” There is also a policy discouraging infant male circumcision in Saskatchewan. I would like to take this opportunity to ask the College if you have issued any kind of guideline on circumcision for doctors in Ontario. If not, do you have any plans to do so? Thank you. Yours truly, [signed] Tony Marcu
September 15, 2004 Dear Mr. Marcu: Thank you for your recent letter about the College’s policy on infant male circumcision. The College receives occasional inquiries concerning our position with respect to this issue and it is periodically reviewed by our Executive Committee. Although we seldom develop policies related to specific clinical issues such as this, as we expect physicians to seek guidance elsewhere, we are aware that there are some changes occurring at the national level. As recently as January 2003, the Executive Committee directed that this issue would not be brought forward for further policy development, but, if the Canadian Paediatric Society revises its current recommendations on this issue, we will review their revised policy to determine what further steps this organization should take to provide information and guidance to the profession. Thank you for taking the time to write. Yours truly, [signed] Jill Hefley
March 22, 2005 Dear Dr. Gerace: Re: Infant male circumcision I’m writing in connection with an article published on March 19th in Windsor’s main daily newspaper, the Windsor Star. Headlined “Circumcisions spark debate,” the article deals with circumcision practices at Windsor Regional Hospital. This article also appeared in other CanWest Global newspapers, including the Calgary Herald and the Regina Leader-Post. A copy is enclosed for your review. The reporter paints a picture of an exceptionally high rate of neonatal circumcision and a frequent absence of informed consent from caregivers. When asked why he chose to have his son circumcised, a new father is reported to have replied, “Why not? ...We didn’t really look into the pros and cons.” Neonatal circumcision is not recommended by the Canadian Paediatric Society. As I consider circumcision to be an important human rights issue, I would appreciate answers to the following questions:
Sincerely, [signed] D ennis H arrison
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