CANADIAN PAEDIATRIC SOCIETY
October 18, 1997
Dr. C. Robin Walker
Dear Dr. Walker:
I would like to express my concerns about some statements you were reported to have made last Friday in regard to infant circumcision. According to The Ottawa Citizen, you feel it is not unethical for doctors to carry out what you term a "cosmetic procedure," though you refuse to perform that procedure yourself.
Routine infant circumcision is the summary ablation of an anatomical structure whose protective, mechanical, and sensory functions are well documented in the medical literature. Moreover, researchers at the University of Toronto reported earlier this year that circumcision causes heightened pain responses in infants months later. A study conducted at the University of Chicago found that circumcision has lifelong effects on sexual behaviour. It seems to me that classifying an operation with such serious consequences as a "cosmetic procedure" gives a false colouring to the whole issue.
Men in increasing numbers are expressing open dissatisfaction with their circumcised status. It seems to me that, as children's advocates, pediatricians should be upholding the rights of children to physical integrity and self-determination, instead of pleading helplessness in the face of irrational demands from uninformed parents. It was not parents who introduced circumcision into the practice of medicine a century ago. Nor is it parents who wield the scalpels and collect the fees today.
A recent study conducted by the government of Egypt found that 97 percent of 14,779 women polled in that country had been circumcised, and 82 percent of ever-married women 15-49 years of age believe that the practice of female circumcision should be continued. In spite of the extraordinarily high approval rating given to this ancient procedure by those who have undergone it, I doubt that you would perform it yourself, or condone it when performed by others.
I am unable to perceive any ground for condemning the removal of erogenous tissue from females, while simultaneously maintaining that such an operation is "not unethical" when performed on males. In a study published last year in the British Journal of Urology, Dr. John R. Taylor of the University of Manitoba concluded that the preputial mucosa was an "important component of the overall sensory mechanism of the penis." In the absence of any medical need, is the destruction of an important component of the male genitals any more acceptable than the destruction of an important component of the female genitals?
What basis is there in medicine, ethics, or law for suggesting that physicians may, under pressure from parents, amputate non-regenerative tissue performing important sensory, mechanical, and protective functions from healthy infants of either sex?
November 5, 1997
Dear Mr. H arrison:
I certainly appreciate your writing to me to express your opinion on some statements reported to have been made by me in the Ottawa Citizen. Although nothing ever comes out in the paper exactly as it was said, the Citizen did a fairly good job of reporting those statements; in particular, they accurately reported my concern that a procedure with which I disagree should nonetheless therefore automatically be considered "unethical"indeed the words "criminal assault" were used by the particular commentator.
You and I fully agree that this procedure is not indicated for medical reasons. However, other experts quite as sincerely disagree with our position, as exemplified by the statement of the Fetus and Newborn Committee of the American Academy of Pediatrics a couple of years ago. Therefore, even though you and I have a strong position, it would be foolish for us not to recognize the reality that many other equally expert individuals profoundly disagree with our position. In the face of such disagreement over the science, it seems to me to be rather a cheap shot to label physicians who continue to practice the procedure as "criminals."
Thus I essentially agree with almost all your letter since you are merely reflecting my own opinion on the practice and its effects. Nevertheless, until there is general agreement throughout the medical profession that the procedure is unwarranted and indeed that performance of the procedure is inappropriate, I believe it is inappropriate to call those physicians who continue to do this procedure unethical. Moreover, until such time as the law is amended, parents do in Canada have the right to make choices on behalf of their children. To equate male circumcision with the misnamed practice of female circumcision is inappropriate since the latter involves grotesque mutilation and major disruption to subsequent function. Indeed, if you lived in Ottawa where we have a large population of Somali origin you would perhaps be more aware of the enormous differences between these procedures, and the offensiveness to women in that community of comparing the two procedures.
In summary, therefore, you and I agree on most aspects of this issue including the lack of medical need for the procedure for male infant circumcision, its potential long-term effects and the fact that those of us who disagree with the procedure will not and must not perform it. However, we will have to disagree on the ethics of the procedure until such time as there is much greater consensus in the scientific and medical community to support our personal views. Once again many thanks for having taken the time to write to me.
December 12, 1997
Dr. M. Somerville,
Dear Dr. Somerville:
Firstly, allow me to apologize for my somewhat tardy response to your very thoughtful letter of November 10th. I will plead only pressure of work at this time, particularly the pressure of grants, abstracts, and papers for research.
Firstly, thank you for your comments on my remarks as reported in the pressthe attenuation of one's comments necessitated by space concerns in newspapers or indeed in any other media often leaves such comments difficult to interpret or even open to frank misinterpretation. Indeed, while you appear supportive of those remarks as reported, you will be aware that I received correspondence from one or two others who were much more disappointed with what I had to say!
Thus I will preface this letter by commenting that I have been convinced for many years that routine neonatal male circumcision is not warranted and have worked hard for some 20 years to have the practice ended. Moreover, I am one of the authors of the Canadian Paediatric Society statement "Neonatal Circumcision Revisited" published last year which states quite explicitly in its recommendation (from the abstract) "circumcision of newborns should not be routinely performed." Thus I have no argument with your interpretation of the literature on this subject or that of the other correspondence to me since my remarks were reported in the press.
Where I do differ, as you note in your letter, is on the use of the term "criminal assault" to describe the procedure when performed by physicians who happen to disagree with you and me about its medical justifications. I have merely pointed out the obviousthere is as yet no clear consensus in the medical profession as to the lack of indication for this procedure. Nor is this based solely on ignorance; the committee on the Fetus and Newborn of the American Academy of Pediatrics, a body surely as expert as our own Canadian equivalent, has come to a completely different conclusion from our own on the merits of male circumcision. In the absence of even expert consensus, I find it hard to elevate my own opinion above that of other experts and then use this to define a procedure with which I personally disagree as "unethical."
Now having said this, I am nonetheless delighted to see your initiation of the debate on the ethics of the procedure. One hopes that it is precisely because of such debate that more parents will start to question the merits of the procedure, which we know is usually decided on the basis of non-medical reasonsand one would argue largely irrational or emotional reasons. I fully agree with your position that once a procedure has been shown to be medically unnecessary, it may well be unethical to consider doing it (although one must still deal with issues such as cosmetic surgery of course). However, where there is not general agreement that the procedure is unwarranted, and indeed where different bodies of experts come to different conclusions on the same evidence, then it is surely up to each individual physician to decide whether the procedure is in fact, in his or her opinion, indicated or warranted, and therefore ethical or legal. Your own letter indeed concedes this point as you say that "physicians should not do this procedure unless they can show it is ethical and legal to do so." Exactly soand for me personally there is no doubt in my mind that I will never perform the procedure for exactly these reasons. However, I have many colleagues who are as expert or more so than I am at interpreting scientific evidence and who profoundly disagree with my interpretation of that evidence. For them, therefore, the procedure is indicated and warranted and their performing the procedure is in their view entirely ethical and legal. I have had similar discussions with senior members of the Jewish and Muslim faith; needless to say that they too are in no doubt as to the ethical and legal justifications for the procedure!
Finally, I do note in your letter that you said that infant male circumcision undertaken for non-medical reasons was "technically criminal assault." That word "technically" did not appear in the newspaper article that I read and does somewhat change the implications. While I have difficulty in calling colleagues who in good faith perform the procedure "unethical," because they believe the procedure to be indicated; and whilst I would certainly not accept any attempt to criminalize this procedure until there is broader consensus about its necessity; nevertheless I do understand the argument that non-medical performance of circumcision could be considered "technical" criminal assault. It is a fine point but not completely lost on me!
In summary, I think we share a similar view of the appropriate interpretation of the weight of evidence on the medical necessity of this procedure and a similar desire to see further debate on the ethics of male circumcision. We perhaps differ a little on the extent to which we see our view as now being sufficient to take a more forceful stand with those who continue to perform the procedure. And there is no question that we are absolutely united in our desire to see this procedure at least performed with appropriate pain control, without which it is unquestionably barbaric. I thank you very much for having taken the time to write to me on this subjectyour letter has certainly helped educate me on some aspects of the ethical arguments. I hope that you will have further opportunities to educate the medical profession on the ethical aspects of the procedure. Very best wishes.
July 15, 1999
Dear Dr. Walker:
In previous correspondence you have taken exception to the idea that routine infant male circumcision is unethical. In a letter dated November 5, 1997, you stated that "until there is general agreement throughout the medical profession that the procedure is unwarranted and indeed that performance of the procedure is inappropriate, I believe it is inappropriate to call physicians who continue to do this procedure unethical."
I enclose a copy of a news item on female circumcision published recently in the British Journal of Urology. It makes reference to a Dr. Saed Thabet, professor of gynaecology at a teaching hospital in Cairo. According to Dr. Thabet, female circumcision is necessary. Dr. Thabet is by no means unique in holding this opinion. His views are shared by Dr. Munir Fawzi, a British-trained professor of gynaecology at Ain Shams University Medical School (Washington Post, 25 June 1997, page A26). In short, there does not appear to be agreement throughout the medical profession in Egypt that female circumcision is harmful.
I have little doubt that you yourself look upon female circumcision as unethical, regardless of what your Egyptian colleagues might think. This leads me to believe that the ethical standard against which medical practice is measured is not as dependent on agreement in the medical community as you suggest in your letter.
Surely one of the ethical standards to which all practitioners must be held is that no practitioner should force any person to undergo an invasive, irreversible, non-therapeutic surgical intervention.
D ennis H arrison
November 9, 2004
Dear Dr. Walker:
Re: Neonatal circumcision
I am writing to you in your capacity as President of the Canadian Paediatric Society. I have previously written to Dr. Ohlsson (2000) and Dr. Barrington (2001) but neither physician has responded to my letters. Copies of these letters are attached for your review and response.
I would like to add to this previous correspondence by pointing out that the colleges of physicians and surgeons in British Columbia and in Saskatchewan have now distributed policy positions to their members regarding infant male circumcision. The wording in these positions is strong and unequivocal.
The College of Physicians and Surgeons of Saskatchewan (CPSS) characterizes routine infant circumcision as "imprudent if not improper" and counsels its members to "respectfully decline to perform the procedure." The College of Physicians and Surgeons of British Columbia (CPSBC) issued a guideline on circumcision earlier this year. While several important points are made in the policy, of particular note are statements such as
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 bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be "unwarranted mutilating surgery."and
While parental preference is important, factors like the best available evidence regarding potential benefits and complications, alternatives to this intervention, the infant's best interest, and current understanding of bioethics should be taken into consideration.It is clear that regulatory bodies have developed a heightened concern about the ethical, legal and human rights implications of non-therapeutic infant circumcision. It is also clear that the current CPS statement (revision in progress March 2004) on circumcision is outdated with respect to the ethics, human rights, and proxy consent difficulties posed by circumcision. By avoiding the consideration of these important aspects in its statements, I fear that the CPS is losing its leading position as an advocate for children and a developer of best practices. I would urge the CPS to update its position on neonatal circumcision to bring it in line with current principles of ethics, law, human rights, and consent. I note that the CPS web site indicates that the position on neonatal circumcision is currently under review.
I look forward to a definitive response on this important issue, at your earliest convenience. Please contact me if I can be of further assistance in this matter. I can be reached at the telephone number provided.
Arif Bhimji MD MBA
November 10, 2004
Dear Dr. Walker:
Re: Neonatal circumcision
As you know, significant changes in practice are occurring with respect to the above procedure. Infant male circumcision is now being actively discouraged by the medical licensing authorities in Saskatchewan and B.C. I am writing to inquire about the Canadian Paediatric Society's response to these developments.
In 2002, the College of Physicians and Surgeons of Saskatchewan (CPSS) issued a memo to its members describing routine infant circumcision as "imprudent if not improper." The CPSS advised physicians to "respectfully decline to perform the procedure." The CPSS even went so far as to warn physicians that those who circumcise infants in the absence of a medical indication could be vulnerable to lawsuits brought by the parents or by the infant himself when he reaches the age of majority.
The College of Physicians and Surgeons of British Columbia (CPSBC) issued a guideline discouraging circumcision earlier this year. Below are a few excerpts:
The concerns of regulatory bodies centre on ethics, law and human rights. The recent guidelines issued in Saskatchewan and B.C. focus almost exclusively on these issues. A clear statement from the CPS on the responsibilities of paediatricians could be helpful to medical licensing authorities who are thinking of following the lead of Saskatchewan and B.C.
The duties of paediatricians to child patients and the limits to proxy consent have been addressed in a policy statement issued by the Committee on Bioethics of the American Academy of Pediatrics:
Thus "proxy consent" poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. Although impasses regarding the interests of minors and the expressed wishes of their parents or guardians are rare, the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent.Unfortunately, these matters receive scant attention in Neonatal Circumcision Revisited, which merely notes without comment that parents' decisions "may ultimately be based on personal, religious or cultural factors." Treatment decisions for children are supposed to be based on the best interests of the child, not on the preferences of caregivers. Moreover, a child's best interests must be determined in an objective manner, not left to the parents to resolve in a personal, subjective way. As the Saskatchewan college says,
Where there is little evidence of expected benefit from a surgical procedure, but well recognized risk of surgical complications that may cause harm, it would generally be considered imprudent if not improper for a surgeon to perform such a surgical procedure.Like its Saskatchewan counterpart, the B.C. college recognizes the problems with proxy consent. The CPSBC gives the following advice to physicians who are asked to circumcise male infants:
Discuss the new ethical considerations of infant's rights and proxy consent for a non-therapeutic procedure.In light of the concerns now being expressed by provincial licensing bodies, will the CPS update its advice on neonatal circumcision to make it more consistent with contemporary principles of ethics, and more mindful of paediatricians' duties to child patients?
Thank you for taking the time to consider the above issues. I look forward to your reply.
D ennis H arrison