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Correspondent: TORONTO ETHICISTS June 26, 2000 Dear __________: I am writing to ask your professional opinion on the ethical and legal implications of a medical study carried out recently at the Hospital for Sick Children. The study involved measuring pain responses in healthy male infants undergoing routine 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. Neonatal circumcision 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. [Editor's note: the following section, highlighted in red, has been tailored for each addressee. Its purpose is to demonstrate clearly that the addressee is well qualified to answer questions regarding the ethics of research on human subjects. The example below pertains to Professor Bernard Dickens, a law professor at the University of Toronto.] As a law professor and an expert in medical ethics, you may be in an excellent position to comment on this study. Can children be enrolled as subjects in non-therapeutic medical research that causes pain, carries risk, and permanently alters the body? Do parents have the legal authority to consent to invasive, irreversible surgical operations being performed on their children for non-medical reasons? I would appreciate your help in understanding the ethical, legal and human rights issues raised by this study. I have been doing research on circumcision and have been surprised by what I have found.
Sincerely,
DR. JOSEPH M. BOYLE Principal, University of St. Michael's College Awaiting reply. DR. RAISA DEBER Professor of Health Policy Faculty of Medicine, University of Toronto Awaiting reply. PROF. BERNARD M. DICKENS Professor, Faculty of Law University of Toronto July 6, 2000 Dear Mr. H arrison I am sorry that I could not reply more promptly to your letter of June 26, 2000, and am replying now in a somewhat summary fashion between travel. Circumcision is usually justified not on medical but on "health" grounds. The World Health Organization describes health as a state of physical, mental and social well-being. Accordingly, ritual circumcision is justified on grounds of mental and social well-being, permitting young males to identify themselves with the traditions of their people. Non-ritual circumcision is not as defensible on this ground, but is usually taken to be within the legitimate decision making authority of parents. Hygienic grounds have been proposed for the procedure, and recent evidence of susceptibility to HIV infection would no doubt be brought into play. You are correct to say that the procedure is not clearly indicated on medical grounds, but the principal objection to it is evidence recently gathered of pain. Accordingly, minimization of pain seems to be the acceptable approach, rather than prohibition of the practice. The final record is not yet in on the practice, and challenge to it has mounted in parallel to objections to female genital mutilation. It is contestable whether the pain and the risks of the two procedures are comparable, or significantly different to justify the tolerance of male circumcision and prohibition of female circumcision. My understanding is that the female practice covers a spectrum of invasiveness, the more and moderately invasive being considerably more dangerous and objectionable than token interventions. Further, the religious basis of ritual practice seems considerably less established for female practice than for male practice. However, my understanding, as that of others, is no doubt incomplete. At present, however, male practice within days of birth seems a legitimate choice of parents, although momentum is gathering, as you indicated, to undertake minimization of pain. The issue is usually approached not in absolute terms of complete license against complete prohibition, but the balance of ritual and non-ritual practice against risk. Parents can expose their children to reasonable degrees of risk if the compensating advantages, both short-term and long-term, appear adequate. I hope the above is of use to you. Sincerely, [signed] Bernard Dickens
July 13, 2000 Dear Professor Dickens, Thank you for your letter of July 6, 2000. I appreciate your taking the time to respond during a break in travel. Your letter raises a few issues. Can the concept of social well-being, which forms part of the extremely broad WHO definition of health, be used to justify a wounding that would not otherwise be tolerated under the Criminal Code? If so, why are the milder forms of female genital mutilation (FGM) not justifiable on the same grounds? Some types of FGM involve merely nicking the clitoral hood without excising any tissue. In any case, can the need to identify with a group be used as a justification for wounding a person who has not given informed consent? You indicate that the main objection to circumcision is the pain associated with the procedure. But circumcision also entails the permanent loss of part of an organ. The foreskin is a normal body part, found in all mammalian species, and recent anatomical research has shown that it consists of highly specialized sensory tissue. I have been researching male and female circumcision for some time, and I enclose material that might be of interest to you:
Sincerely, [signed] D ennis H arrison
DR. PHILIP HÉBERT Assistant Professor Department of Family and Community Medicine University of Toronto Awaiting reply. PROF. TRUDO LEMMENS Ethicist, U. of T. Joint Centre for Bioethics Awaiting reply. DR. DANIEL H. OSMOND Department of Physiology University of Toronto July 6, 2000 Dear Mr. H arrison, Thank you for your letter of June 26 regarding the ethics of circumcision. Unfortunately, this topic is not familiar ground for me. I am not a professional theologian, philosopher, bioethicist or medical practitioner with academic and/or practical expertise in such matters but an experimental physiologist who researches mechanisms of blood pressure regulation and high blood pressure. I try to be well informed on ethical and moral issues surrounding the practice of science and at the interface of science and religious belief, most specifically Judeo-Christian belief. This is why I get listed in our university's "Blue Book," through which you connected with me. You raise the issue of children as subjects in studies of circumcision, of the legal authority of parents, of medical consequences and of ethical and human rights. It seems to me that a distinction should be made between communities that practise circumcision as an essential part of their religious observance, e.g. the Jews, and those who don't. The first category has practised circumcision for centuries and would probably continue doing so without regard for any new medical evidence since it is a religious/cultural imperative. The second category does not have the same religious/cultural imperative but considers election of circumcision to be a matter of free choice. For both categories, circumcision is a legal procedure, implying that all aspects of it, including parental choice on behalf of their newborns, are legal. Over the years, advantages of hygiene and health (including health of the spousal partner) have been claimed for circumcision. Such claims affirm the practice of circumcision among both categories. The ones who would practise it in any case feel affirmed in what they do and those who elect it are encouraged to continue the practice. It is as appropriate for those who are committed to a practice to have fuller knowledge about it as for those who often elect that practice based, perhaps, on incomplete evidence. For the latter group, not committed religiously, knowledge is doubly important because negative evidence would, and should, be used to discourage the practice of circumcision. I see no ethical grounds for denying studies that examine the physiological (sexual sensation), medical (various health issues), and ethical issues since they are not carried out in order to promote the practice but merely to understand its attendant consequences. Properly designed studies are very important. It should be borne in mind that circumcised babies are incapable of accurately communicating their experience of the surgery itself or of its sexual consequences. Once grown up, they are too far removed from the surgery and can only describe what they feel in their state of sexual maturity. They cannot describe how they felt as babies and they have never experienced sexual maturity as uncircumcised men so they cannot meaningfully compare their experience before and after circumcision personally. The issue of consent by the child is a challenging one. During the first months of its life, the child controls very little of what happens to it. It does not give its explicit consent to feeding, fluids, sleep, restriction of movement, diaper changing, vaccinations, inoculations, medicines, surgery or blood transfusions. All these are imposed on the child by well-meaning parents without explicit consent, sometimes with tokens of appreciation but often in the face of opposition manifesting itself in the form of crying, kicking and screaming. In this context, the absence of consent for circumcision is no different than the absence of consent for almost all that goes on in the child's life. All are "imposed" without consent. All in varying degrees probably impact on the child's life now and in the future. Some carry an element of risk. Circumcision can be regarded as part of a continuum of non-consensual parental impositions upon the child, presumed to be justified on the basis of benefits that exceed the risks. The benefits are not uniformly high and the negatives not uniformly serious. In short, circumcision is still legal in Canada and all its practitioners are free to choose for or against it. Parental intervention in this matter is ethically in line with all other interventions at this stage of life. For all practitioners, religious or otherwise, including their sons in appropriate studies imposes no hardship or suffering beyond that experienced in unstudied circumcision, so the studies need not be regarded as unethical. How do any benefits of circumcision stack up against any negatives? The remaining doubts will only be laid to rest on the basis of more evidence. Science works on the basis of accumulating evidence to a point beyond reasonable doubt. Existing studies may not have reached that point. The question of who bears the cost of circumcision is another matter. In the face of compelling evidence against it, I would think that those who elect it should pay for it. Indeed, the laws should probably be changed to reflect such confirmed medical realities but not so as to offend the religious/cultural imperatives. I hope you find this helpful. Yours sincerely,
DR. ROBERT H. PAINTER Bioethicist, Trinity College July 12, 2000 Dear Mr H arrison: I am writing in response to your letter to me dated June 26th, 2000 concerning a medical study to measure the pain responses in infants undergoing routine male circumcision. May I apologise for my delay in responding to your letter which I read only yesterday on returning from a short vacation. Since this study was carried out at the Hospital for Sick Children it would be under the jurisdiction of the Human Subjects Review Committee of that hospital. I believe that this committee would have sufficient expertise to deal with any issues that you may have in connection with this study and which you might wish to raise with them. I have advised the coordinator of this committee that I have referred you to them. Yours sincerely,
C.C. Dr Max Perlman, Chair of the Human Subjects Review Committee, The Hospital for Sick Children, Toronto.
DR. LAURA PURDY Bioethicist, U. of T. Joint Centre for Bioethics Awaiting reply. DR. NEIL SWEEZEY Ethicist, The Hospital for Sick Children Awaiting reply. ^Top |