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Patricia Godden
Intake Officer
Ontario Health Professions Board

Dear Ms. Godden:

This letter is further to our conversation last week.

Regarding the Ontario College of Physicians and Surgeons' having enclosed information on your organization and my right to appeal their decision, I have checked my files, in which complete letters, including envelopes, have been kept. I find no reference to your organization or my right to appeal. I therefore claim my right to appeal in spite of the lapse of more than 35 days since their decision.

I have included all of my correspondence with them in a package so marked. In addition to this, I have added further information to support my appeal.

My appeal is based on the following:

1. In Ms McCulloch's letter she paraphrases Dr Dixon 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 accurate. The experts have concluded that "Circumcision of newborns should not be routinely performed" [1] and as far back as 1975, that "there is no medical indication for circumcision during the neonatal period,"[2] and refer to circumcision as a "mutilative operation of questionable benefit."[3] The Canadian Paeditric Society has made three statements, in 1975, 1982 and 1996. In each statement they uphold and indeed strengthen their conviction that circumcision is not necessary, and may be harmful to the baby.

   Even if the C.P.S statements are completely disregarded, and one forwards a case for the prophylactic benefits of routine circumcision, the surgery is at very best non-therapeutic. The college therefore 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 non-consensual non-therapeutic surgeries.

   Would the doctors need to have a specific policy with respect to index fingers in order to prevent them from being amputated? I think they would rather need proof that such amputation was therapeutic in order to allow it.
    

2. Ms McCulloch also writes "There are, of course, many reasons why a family would choose circumcision after reviewing the indications and contraindications with their medical advisors." According to the C.P.S., any reasons to choose circumcision must be ascribed to "social status" [4], "conformity" [5], or "ritual" [6]. In any case, my position is that the patient is not in a position to review this material. The college must remember that the patient in these cases is not the parents, but the infant, as it is the infant that is undergoing the surgery. 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 in this family/health care advisor decision-making process" in this circumstance constitutes a lack of protection for the baby which does not or may not want his penis to be interfered with by his parents and their doctor.
    
3. 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 ... abates junctional mucosa that appears to be an important component of the overall sensory mechanism of the human penis"[7]. The article also states that "Meissner's corpuscles of the prepuce may be compared with similar nerve-endings in the finger-tips and lips" [8], that "the prepuce provides a large and important platform for several nerves and nerve endings....the innervation is impressive" [9], and refers to parts of the foreskin as "primarily sensory tissue" [10].

   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.

   In fact, the sensitivity of the prepuce has been recognized since at least as early as 1959, when Dr. Winkelman of the Mayo Clinic wrote:

   [T]he specific type of erogenous zone is found in the mucocutaneous regions of the body. Such specific sites of acute sensation in the body are the genital regions, including the prepuce, penis, clitoris, and external genitalia of the female, and the peri-anal skin, lip, nipple and conjunctiva. It is the special anatomy of these regions that require the use of the term "specific" when one speaks of erotic sensations originating in the skin. This anatomy favors acute perception [11].

   Therefore, rather than being a surgery with no consequences to the patient save that of therapy/lack of therapy, it clearly diminishes the organ's sexual sensitivity. In light of this, only the patient can judge whether any supposed prophylactic benefits would outweigh the sacrifice of sexual sensitivity.
    

4. 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, and constitutes unequal protection. Is it the colleges position to require the consent of the parents of babies in order to pursue a case of female genital mutilation?
    
5. I enclose several legal references as well, some from abroad and some from Canada. It should be noted that the constitutional rights enjoyed by other countries are largely recognized here. The Ontario College of Physicians and Surgeons, their members, the physicians and surgeons of Ontario themselves, the hospitals and clinics in which circumcisions are performed, and even the parents "consenting" to the surgery should be made aware that their actions could leave them liable to legal action under sections several sections of the criminal code.

The Canadian Charter of Rights and Freedoms is equally clear on this matter. Section 15(1) states that "Every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination and in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex, age or physical or mental ability."

This position is perhaps most eloquently stated by Margaret Somerville, Professor of Medicine, Ethics, and Law at McGill University in correspondence between herself and several justice ministers. I do not have a complete set, but what I have of these letters have also been included here.

In summation, I would submit to you that infant male circumcision is at best medically unnecessary, at worst harmful, with psychological and vagal consequences unstudied, but which can be guessed at. The circumcised penis is very likely to be less sensitive than the uncircumcised penis. The infant cannot consent, and the parent's consent is of questionable validity. Removal of healthy foreskin from an unconsenting minor is a violation of the patient's rights, and a violation of physician's own rules of conduct.

There would seem to be a necessity for society in general, and for your office and that of The College in particular, to protect male infants from circumcision.

I will be sure to be incontact with you if I obtain other information that I feel will be useful.

I thank you for your time and await your reply.

Sincerely,
 
[signed]
 
Lawrence Barichello

Notes:

1. Canadian Medical Association Journal, "Neonatal Circumcision Revisited" by Fetus and Newborn Committee, Canadian Paediatric Society. Abstract, pp. 769. Mar 15, 1996.
2. Canadian Paediatric Society Statement: Circumcision in the Newborn Period, 1975 par. 2.
3. Ibid, par 15.
4. Ibid, par 1.
5. Ibid, par 11.
6. Ibid, par 21.
7. The prepuce: specialized mucosa of the penis and its loss to circumcision. J.R. Taylor et al, British Journal of Urology, 1996. Abstract, pp. 291.
8. Ibid, pp. 294.
9. Ibid, pp. 294
10. Ibid, pp. 295.
11. The Erogenous Zones: Their Nerve Supply and Its Significance, 34 Proc. Staff Meetings Mayo Clinic, Jan 21, 1959 at 39.

Enclosures:

1. Correspondence between myself and the Ontario College of Physicians and Surgeons
2. Canadian Paediatric Society Statement on Circumcision in the Newborn Period, by the Fetus and Newborn Committee, Dr. P. R. Swyer (chairman) et al, 1975.
3. Platform: Benefits and risks of circumcision: another view. by the Fetus and Newborn Committee, Dr. E. W. Outerbridge (chairman) et al., 1982.
4. Neonatal Circumcision Revisited by the Canadian Paediatric Society Fetus and Newborn Committee, 1996.
5. The prepuce: specialized mucosa of the penis and its loss to circumcision. by J. R. Taylor et al, 1996
6. Finding sheds light on 'unkindest cut' The Health Page of the Free Press, by Alexandra Paul.
7. Margaret Somerville. Letters.
8. Circumcision as child abuse: the legal and constitutional issues. The Journal of Family Law, 1984-1985. by William E Brigman.
9. Circumcision no longer a 'routine' surgical procedure. Canadian Medical Association Journal, June 1 1995, by Eleanor LeBourdais.
10. Therapeutic Privilege: Variation on the Theme of Informed Consent. Law, Medicine and Health Care, by Margaret A. Somerville.
11. Medical Intervention and the Criminal Law: Lawful or Excusable Wounding. McGill Law Journal. by Margaret Somerville
12. Therapeutic and Non-Therapeutic Medical Procedures--What are the Distinctions? Health Law in Canada. by Margaret Somerville.
13. Circumcision, & Treatment of Children, from: Canadian Patients Book of Rights: A Consumer's Guide to Canadian Health Law. by Lorne Elkin Rozovsky.

Dennis Condos
Chair, Health Professions Appeal and Review Board
Health Boards Secretariat
Toronto, Ontario

Dear Mr. Condos:

I am writing to seek your assistance in a matter involving the College of Physicians and Surgeons of Ontario. I would like the College to explain on what basis its members are circumcising male infants. Neonatal circumcision is not medically justified, and medical ethics forbid performing surgical operations on non-consenting persons without medical justification.

The College has repeatedly refused to give straightforward answers to my questions. I respectfully request that the College be directed to answer the four questions I asked in my letter of June 14, 2000. I believe that these questions are reasonable, and that the College, as the professional body responsible for regulating the practice of medicine in Ontario, has an obligation to answer them in a straightforward manner.

I enclose copies of my correspondence with the College.

Thank you for your help in this matter.

Sincerely,
 
[signed]
 
Lawrence Barichello
 

Dear Mr. Barichello:

Re: The correspondence to Dennis Condos dated October 2, 2000

In the captioned correspondence, you request the Board's assistance in obtaining an explanation from the College of Physicians and Surgeons regarding the basis on which its members are circumcising male infants.

The Board instructs me to advise you that it is unable to provide you with the assistance you have requested. The Board's jurisdiction does not extend beyond the provisions of the Regulated Health Professions Act 1991, which do not enable it to make such a requirement of a college in that circumstance.

Yours sincerely,
Health Professions Appeal and Review Board
 
[signed]
 
Abby Katz-Starr
Registrar
 

Hon. Elizabeth Witmer
Minister of Health and Long-Term Care

Dear Minister:

I am writing to request your assistance in a matter involving the Hospital for Sick Children. The hospital has not answered questions I have raised in regard to a medical study approved by the hospital's Research Ethics Board. The purpose of the study was to measure pain responses in male infants undergoing circumcision.

I am concerned about this matter for the following reasons:

1. The hospital's own guidelines stipulate that research on children is ethically justified "only when the potential benefit significantly outweighs the potential for harm." Neonatal circumcision clearly fails to meet this condition. Medical authorities throughout the world agree that any potential benefit from neonatal circumcision does not significantly outweigh the potential for harm. The Canadian Paediatric Society, for instance, recommends that "circumcision of newborns should not be routinely performed." The Ontario Health Insurance Plan (OHIP) dropped routine infant circumcision from the list of insured services in 1994 after recognizing that the procedure was not medically justified. By approving research on a neonatal intervention whose potential benefit does not significantly outweigh the potential for harm, the hospital's Research Ethics Board appears to have violated its own guidelines.
    
2. If the potential benefit from a surgical intervention on a non-consenting minor does not significantly outweigh the potential for harm, then the intervention cannot be ethically or legally justified on the basis of parental consent. Consequently unless some other justification was present, this study does not appear to have been established on a firm ethical and legal foundation.
    
3. In a 1986 landmark decision called Re Eve [1986] 2 S.C.R. 388, which involved the proposed sterilization of a young woman with mental disabilities, the Supreme Court ruled that parents do not have the legal authority to consent to an invasive, irreversible surgical operation being performed on their child unless the operation is deemed necessary for the child's mental or physical health. Insofar as circumcision is an invasive, irreversible surgical operation that is not deemed necessary for an infant's mental or physical health, it would seem on the basis of the Eve case that parental consent for neonatal circumcision is legally ineffective.
    
4. Failure on the part of medical researchers to obtain ethically and legally valid informed consent can result in negligence liability for the hospital, as illustrated in Weiss v. Solomon [1989] R.J.Q. 731. In that case, a teaching hospital's research ethics review committee was held to have been negligent in its review of a research protocol after one of the subjects died from a rare complication. The remote risk that this complication could occur and cause death had not been disclosed in the informed consent form which the research ethics review committee had approved.

The questions I asked the hospital are not inflammatory. All I want is blank copies of consent forms and an explanation as to why experimental protocols are not open to public scrutiny. I think that the Hospital for Sick Children, as a publicly funded institution, has an obligation to respond to such requests in a reasonable and timely fashion.

I enclose copies of letters I sent to Ms. Cyndy DeGiusti, the hospital's Chief of Public Affairs, on September 14th and October 12th. I have received no reply to either letter.

The Government of Ontario is committed to a policy of increased accountability in education and health care. Under the provisions of section 6 of the Public Hospitals Act (R.S.O. [1990] c. P.40), the Minister of Health "may make any [other] direction related to a hospital that the Minister considers in the public interest." Under section 7, the Lieutenant Governor in Council "may appoint one or more persons to investigate and report on the quality of the management and administration of a hospital, the quality of the care and treatment of patients in a hospital or any other matter relating to a hospital where the Lieutenant Governor in Council considers it in the public interest to do so."

On that basis, I respectfully request that you write to the Hospital for Sick Children and ask them to reply to my letters of September 14th and October 12th. I would appreciate a copy of any correspondence you might decide to send to the hospital.

Thank you for your assistance in this matter.

Sincerely,
 
[signed]
 
D ennis H arrison
 

cc:	Mr. Alexander R. Aird, Chairman, Board of Trustees, The Hospital for Sick Children
	Ms. Cyndy DeGiusti, Chief, Public Affairs
	Dr. Christine H arrison, Director, Department of Bioethics
	Dr. Max Perlman, Chair, Research Ethics Board

 

Hon. Elizabeth Witmer
Minister of Health and Long-Term Care

I am writing to request your assistance in getting straightforward answers to questions I have asked of the College of Physicians and Surgeons of Ontario. The questions relate to infant male circumcision. I wrote to the College on June 23, 2000 to inquire about the ethical and legal aspects of a circumcision pain study undertaken at the Hospital for Sick Children. In a reply dated July 7, 2000, the College did not address any of the issues I had raised in my letter. Nor has the College responded adequately to other inquiries I have made over the past year and a half.

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 do not see how the public interest can be protected unless the College accounts for the conduct of its members.

Section 3 of the Regulated Health Professions Act imposes a duty on the Minister of Health to ensure "the health professions are regulated...in the public interest," and "appropriate standards of practice are developed and maintained."

On that basis, I respectfully request that you write to the College and ask them to respond to the specific questions I asked in my letter of June 23, 2000. I would appreciate a copy of any correspondence you might decide to send to the College.

Thank you for your assistance in this matter.

Sincerely,
 
[signed]
 
D ennis H arrison
 

Enclosures:	1.	Correspondence with Ontario College of Physicians & Surgeons.
	2.	"The Ethics of Circumcision", Globe and Mail, Nov. 18, 2000, p. D6.

Hon. Elizabeth Witmer
Minister of Health and Long-Term Care

Dear Minister:

I am writing to seek your assistance in a matter involving the College of Physicians and Surgeons of Ontario. The College has repeatedly refused to answer basic questions about the principles governing the performance of infant male circumcision.

The College itself emphasizes the need to conform to fundamental principles. Recently the College suspended the licence of Dr. Frank Adams, a recognized expert on pain management, for failing to obey basic rules of medical practice. The College maintained that the only way to protect the public is to make sure physicians follow the rules.

Yet when it comes to circumcision of male infants, the College takes a completely different tack. When confronted with the issue of infant male circumcision, the College argues that the public interest is best served if the College takes a laissez-faire approach. The College does not explain why the public interest is served if rules are enforced in one area of medical practice but not in another.

The College also stresses the need for an evidence-based, scientific approach to medical practice. Yet the College says it does not endorse the Canadian Paediatric Society's evidence-based position statement on neonatal circumcision. When asked to identify a nationally recognized authority on neonatal circumcision other than the Canadian Paediatric Society, the College did not respond.

All I want from the College is reasonable answers to the following very basic questions:

1. In the College's opinion, is infant male circumcision justified on medical grounds? If not, then on what other grounds can it be justified?
    
2. Does the College believe it is ethical for a physician to circumcise a non-consenting minor for non-medical reasons?
    
3. Does the College consider male circumcision to be comparable to excision of the clitoral hood, a procedure prohibited by criminal law? If not, please explain why.
    
4. Does the College believe that parents have the legal authority to consent to circumcision of a minor child if the operation is not medically required? If so, please provide a reasoned argument or cite supporting Canadian case law.

Section 3 of the Regulated Health Professions Act imposes a duty on the Minister of Health to ensure that "the health professions are regulated...in the public interest," and "appropriate standards of practice are developed and maintained." I respectfully request that in accordance with this legislation, you direct the College to respond in a reasonable fashion to my letter of June 14, 2000. I believe that the College, as the professional body responsible for regulating the practice of medicine in Ontario, has an obligation to provide complete and candid answers to basic questions concerning the ethics of medical practice.

I would appreciate a copy of any correspondence you might decide to send to the College.

I enclose copies of my correspondence with the College, as well as a backgrounder on infant male circumcision.

Thank you for your assistance in this matter.

Yours sincerely,
 
[signed]
 
Lawrence Barichello
 
Enclosures:

• Background information sheet
• Correspondence with College of Physicians and Surgeons dated:
  • April 11, 2000
  • May 1, 2000
  • June 14, 2000
  • June 21, 2000
  • July 11, 2000

Ministry of Health and Long-Term Care
Program Policy Branch

Dear Mr. Barichello:

Thank you for your letter to the Minister of Health and Long-Term Care regarding infant male circumcision. The Minister has asked me to respond.

In Ontario, the profession of medicine is self-regulated under the Regulated Health Professions Act, 1991 (RHPA) abd the Medicine Act, 1991. Under these Acts, the College of Physicians and Surgeons of Ontario (CPSO) is responsible for ensuring that physicians provide health services in a professional and ethical manner. It is also responsible for determining the acceptability of a doctor's actions.

The college will investigate complaints and discipline members, as necessary. Neither the minister nor ministry staff may take action in individual complaint cases. The CPSO is legislated to do this as well as setting out standards of practice. I note that you have already contacted the CPSO. May I suggest that you direct your queries relating to policy and clinical procedures to the Registrar of the college, Dr. John Bonn, at: [address].

Again, thank you for taking the time to share your concerns with the ministry.

Sincerely,
 
[signed]
 
Mary Beth Valentine
Director
 

Dear Minister Witmer:

On July 6, 2000 I wrote jointly to you, Attorney General Flaherty, and Solicitor General Tsubouchi in regard to the transplantation of human tissue. Ministers Flaherty and Tsubouchi indicated that this matter came under your purview and that you would be responding in due course. To date, I have received no response from your office.

I would appreciate it if you would expedite a response to my letter of July 6, 2000.

For your ease of reference, I enclose copies of my letter of July 6, 2000 and the responses I received from Ministers Flaherty and Tsubouchi.

Sincerely,
 
[signed]
 
D ennis H arrison
 

Dear Ms. Valentine:

Thank you for your letter of March 26, 2001, in which you suggest that I direct my questions to the College of Physicians & Surgeons of Ontario. I have already done that, but to no avail. The College has not responded to the questions that I originally asked in a letter of April 11, 2000, and which I repeated in letters of June 14, 2000 and July 24, 2000.

The two most important of these questions are as follows:

1. Does the College believe it is ethical for a physician to operate on a non-consenting minor who has no medical need for surgery?
    
2. Does the College believe that parents have the legal authority to consent to circumcision of a minor child if the operation is not medically required? If so, please provide a reasoned argument or cite supporting Canadian case law.

Under Section 3 of the Regulated Health Professions Act, the Minister of Health must ensure that “the health professions are regulated...in the public interest,” and that “appropriate standards of practice are developed and maintained.” Accordingly, I am asking you once again to write to the College and direct them to answer the above questions. I would appreciate a copy of your letter.

Sincerely,
 
[signed]
 
Lawrence Barichello
 
cc: Dr. John Bonn, Registrar, College of Physicians & Surgeons of Ontario
 

Dear Ms. Valentine:

I wrote to you on April 9, 2001 in regard to a matter involving the College of Physicians and Surgeons of Ontario. To date I have received no response to my letter. Nor have I received a response to a message I left on your voice mail on Monday, July 16th.

For your ease of reference, I enclose a copy of my letter of April 9th. I would appreciate a reply at your earliest convenience.

Sincerely,
 
[signed]
 
Lawrence Barichello
 

Dear Mr. Barichello,

I am responding to your letter regarding your concerns about the circumcision of a minor child and your lack of a satisfactory response from the College of Physicians and Surgeons of Ontario.

As you are aware, the College of Physicians and Surgeons of Ontario (CPSO) regulates the profession of medicine in the province of Ontario. I understand that the College has advised you they neither endorse nor condone male circumcision. There is no policy on this procedure and it is not illegal for physicians to perform this operation.

As a self-regulating College, the CPSO is legislated to set out standards of practice. It is the College that has the responsibility of developing and maintaining ethical guidelines to assist physicians in making decisions that are in the public and their patient's best interest. You may wish to contact the Canadian Medical Association as they have information on this issue and may have developed a policy guideline for all Canadian physicians. The address is as follows [address given].

We are also copying your letter to the Deputy Registrar of the College of Physicians and Surgeons, Dr. John Carlisle, so he is aware of your concerns. If you have further questions about the correspondence from the College or the College's position, please contact Dr. Carlisle directly.

Sincerely,
 
[signed]
 
Mary Beth Valentine
Director, Program Policy Branch
 

c:	William Tholl, Secretary General and CEO, Canadian Medical Association
	Dr. John Carlisle, Deputy Registrar, College of Physicians and Surgeons of Ontario

Mary Beth Valentine
Director, Program Policy Branch
Ontario Ministry of Health

Dear Ms. Valentine:

Thank you for your letter of August 21st. I would like to clarify what I want from the College of Physicians and Surgeons of Ontario, and what I am asking of the Ontario Ministry of Health.

As you point out in your letter, the College is a self-regulating body responsible for ensuring that physicians act competently and ethically. I have asked the College the following question:

Is it ethical for a physician to remove a healthy part of a normal organ from any person who is incapable of giving informed consent?

I believe that by sidestepping a straightforward question about medical ethics, and by refusing to account for the conduct of its members, the College has failed in its duty to protect the public. In such circumstances, the Minister of Health may intervene. Under Section 3 of the Regulated Health Professions Act, the Minister has the authority to ensure that "the health professions are regulated...in the public interest," and that "appropriate standards of practice are developed and maintained."

Therefore I am asking the Ministry to exercise its legislated authority and direct the College to answer the following question: is it ethical for a physician to remove a healthy part of a normal organ from any person who is incapable of giving informed consent?

Sincerely,
 
[signed]
 
Lawrence Barichello
 

c:	William Tholl, Secretary General and CEO, Canadian Medical Association
	Dr. John Carlisle, Deputy Registrar, College of Physicians and Surgeons of Ontario

Dear Mr. Barichello:

I am responding to your letter requesting that the ministry direct the College of Physicians and Surgeons to make a decision on the ethics of circumcision. I apologize for the delay in responding.

As I stated in my letter to you on August 21st, the College of Physicians and Surgeons (CPSO) regulates the profession of medicine in the province of Ontario. It is the CPSO that has legislative authority to determine whether ethical standards on circumcision are required for the profession.

In the case of all medical procedures, consent must be obtained. For those patients who do not have the capacity to consent, such as a neonate, consent must be obtained from the parents based on important ethical principles. Consent requires that the parents be informed of the procedure and the risks and benefits of the procedure so that they may make an informed decision.

As previously, we are copying your letter to the Acting Registrar of the College of Physicians and Surgeons, Dr. John Carlisle, so he continues to be aware of your concerns. If you require further information on the College's position, please contact Dr. Carlisle at ___________.

Yours sincerely,

[signed]

Mary Beth Valentine
Director
 

c.	Dr. John Carlisle, Acting Registrar, College of Physicians and Surgeons of Ontario

Hon. George Smitherman
Minister of Health and Long-Term Care
Queen's Park

Dear Minister:

I am writing to request your assistance in a matter concerning the College of Physicians and Surgeons of Ontario.

I have asked the College to explain why they recently decided not to proceed with a policy on infant male circumcision. The College has refused to give any explanation, aside from stating that deliberations of the College's Executive Committee are not open to public scrutiny. The College has also indicated that they would not respond to further inquiries I make about this matter.

I do not understand why the College is refusing to respond to my inquiries. I believe that my questions are reasonable, and that they come within the College's purview. Under the Medicine Act 1991, the College must "develop, establish and maintain programs and standards of practice to assure the quality of the practice of the profession." The Act also imposes a duty on the College to "serve and protect the public interest." Consequently, I believe the College is obligated to give a reason for not having a policy on a procedure like infant male circumcision.

The official recommendation of the governing medical specialty college, the Canadian Paediatric Society, is that neonatal circumcision "should not be routinely performed."

Two of Canada's most distinguished medical ethicists, Dr. Margaret Somerville and Dr. Eike-Henner Kluge, have stated publicly that non-therapeutic infant male circumcision presents serious ethical difficulties. Dr. Somerville is the founding director of McGill University's Centre for Medicine, Ethics and Law, while Dr. Kluge is the founding director of the Canadian Medical Association's Department of Ethics and Legal Affairs.

Guidance on infant male circumcision has been provided by medical licensing authorities in other provinces. The College of Physicians and Surgeons of Saskatchewan, for instance, has advised physicians to "respectfully decline to perform the procedure." The Saskatchewan college has also expressed "great concern" over the relatively high rate of infant male circumcision in Saskatchewan. At about 17 percent, the infant circumcision rate in Saskatchewan is comparable to that in Ontario.

There is evidence that consent for infant male circumcision is not being properly obtained. Of particular concern to me is a survey of new parents published in 1997 in Canadian Family Physician, a peer-reviewed medical journal. This survey, which was carried out in southwestern Ontario, concluded that informed consent for infant male circumcision was often lacking. The authors found that "many parents were not well informed about risks or benefits." As you are aware, informed consent is a requirement under the Health Care Consent Act.

In short, infant male circumcision is (a) carried out against the recommendation of the governing medical specialty college, (b) deemed unethical by ethicists, (c) strongly discouraged by medical licensing authorities in other provinces, (d) frequently undertaken without informed consent, and (e) performed on infants—one of the most vulnerable groups in society.

It is hard to understand why a body responsible for regulating medical practice would choose not to provide guidance on a procedure with the above characteristics.

The frequent absence of informed consent for a common surgical procedure suggests that the College is not enforcing proper standards of medical practice. In such circumstances, the Minister of Health and Long-Term Care has the power to intervene. Under section 3 of the Regulated Health Professions Act, the Minister must ensure that "the health professions are regulated and co-ordinated in the public interest," and that "appropriate standards of practice are developed and maintained."

I am requesting that you use the above authority to compel the College to respond to my inquiries. I would appreciate a copy of any correspondence you might send the College.

I enclose copies of the following:

1. My letter to the College, dated October 24, 2003.
2. The College's reply, dated November 24th.
3. My letter dated December 5th.
4. The College's reply, dated December 18th.
5. The abstract of the study showing that informed consent for infant male circumcision in Ontario is often lacking.
6. A cautionary memo sent to physicians by the College of Physicians and Surgeons of Saskatchewan in 2002.

Sincerely,

[signed]

D ennis H arrison
 

Dear Mr. H arrison:

I am writing in response to your letter, dated February 27, 2004, to the Honourable George Smitherman, Minister of Health and Long-Term Care. The Minister has requested that I respond to your concerns related to the College of Physicians and Surgeons of Ontario (CPSO) and infant male circumcision. I apologize for the delay in responding.

Under the Health Professions Procedural Code (HPPC), which is Schedule 2 of the Regulated Health Professions Act, 1991 (RHPA), all health regulatory colleges have a Council, similar to a board of directors, which manages and administers the affairs of the college. Colleges also have an Executive Committee that between council meetings has all the powers of the Council with respect to any matter that requires immediate attention other than certain activities that are outlined in the legislation. If the Executive Committee exercises its power, it must report on its actions at the Council's next meeting. In addition, the Executive Committee must annually submit a report of its activities to the Council.

Council meetings, as a general rule, are open to the public. In certain circumstances, however, as provided by the HPPC, a Council may exclude the public from all or part of a meeting. The grounds for closing a meeting are noted in the Council minutes, but deliberations during the closed portion are confidential and not disclosed.

You may wish to ask the CPSO for any public Council minutes concerning infant male circumcision and for any public report made by the Executive Committee to the Council concerning infant male circumcision. In addition, you may wish to ask for any other public material related to the issue that may have been provided to the Council.

Under the RHPA and the Medicine Act, 1991, the CPSO sets standards of practice for the medical profession in Ontario. This includes determining whether certain practice issues require policies. Regarding your issue, I note that the CPSO has decided not to proceed with a policy on infant male circumcision.

I appreciate your writing and bringing this issue to the attention of the Ministry. I hope the above information will be of assistance to you.

Yours truly,

[signed]

Marilyn Wang
 

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