Value judgment, harm, and religious liberty

Journal of Medical Ethics

Volumn 30, Issue 3, 2004, Pages 241-247

  Viens, Adrian M ^a  

^a UNIVERSITY OF OXFORD   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CHILD WELFARE; CIRCUMCISION; DECISION MAKING; FEMALE; HEALTH CARE POLICY; HUMAN; HUMAN RIGHTS; INFANT; MALE; MEDICAL DECISION MAKING; MEDICAL ETHICS; MEDICOLEGAL ASPECT; MORALITY; PARENTAL CONSENT; POLITICAL SYSTEM; RELIGION; RISK BENEFIT ANALYSIS; SAFETY;

EID: 3042792544     PISSN: 03066800     EISSN: None     Source Type: Journal    
DOI: 10.1136/jme.2003.003921     Document Type: Article

References (47)

1. Hutson JM. Circumcision: a surgeon's perspective. J Med Ethics 2004;30:238-40.
2. I believe that the term "routine infant circumcision" is a misnomer. It denotes a position that nobody really holds, namel that as a matter of routine, all healthy boys should be circumcised. Opposition to a policy of "routine infant circumcision" does not have to indicate opposition to a parent's right to choose for their son to undergo the procedure, nor the provision of the procedure in general.
3. Somerville MA. The ethical canary: science, society and the human spirit. Toronto: Penguin, 2000:202-19.
4. This poltical conception is most vividly argued for by Rawls J, Political liberalism. New York: Columbia University Press, 1996.
5. Ainslie DC. Bioethics and the problem of pluralism. Soc Philos Policy 2002;19:1-28 (see p14).
6. By religious liberty in the context of bioethics, I mean legitimacy and extent to which individuals and/or groups should be able to use religious principles and beliefs to make decisions concerning the desirability or exemption of medical procedures and treatments.
7. However, there would have to be a difficult cost/benefit analysis made concerning the cost of being circumcised and not becoming an adherent of your parent's religion versus not being circumcised and being brought up in the faith community where it is prescribed. It would require a complex argument on both sides; however, I am inclined to believe that it would be difficult to successfully argue that, on balance, it would be more detrimental to have the parent's right to religious freedom trump their child's right rather than vice versa in this particular case.
8. Meeler D. Reasonable sanctions for reasonable doctrines. J Soc Phil 2000;31:153-9.
9. This is a different question from whether a religious doctrine is unreasonable. The question of whether the religious mandate for circumcision is unreasonable and justifiably prohibited - for instance it violates a person's rights and/or liberties as citizens - is examined in II (C).
10. Moreover, although I am primarily concerned with "non-therapeutic" infant male circumcisions required as religious rites of passage, I am inclined to believe that what I have to say can also apply to parents who decide to have their son circumcised on value judgments of a non-religious nature.
11. For detailed examinations of some of this literature, see Niku SD, et at Neonatal circumcision. Urol Clin North Am 1995;22:57-65;
12. Benatar M, Benatar D. Between prophlaxis and child abuse: the ethics of neonatal male circumcision. Am J Bioeth 2003;3:35-48. That is not to say that I will not be relying on medical evidence in this paper, only that I will not be using it to advance a substantive position concerning the overall benefits or risks of circumcision.
13. American Academy of Pediatrics (Task Force on Circumcision). Circumcision policy statement. Pediatrics 1999;103:686-93.
14. British Medical Association. The law and ethics of male circumcision: guidance for doctors (March 2003).
15. Canadian Paediatric Society (Fetus and Newborn Committee). Neonatal circumcision revisited. CMAJ 1996; 154:769-80. This statement was reaffirmed in March 2002. In this report, the committee only considered medical evidence: "religious and personal values were not included in the assessment".
16. Royal Australasian College of Physicians (Paediatrics and Child Health Division). Position statement on circumcision, Sydney: Royal Australasian College of Physicians, 2002. This statement was developed as a unified position of six medical societies in Australia and New Zealand: the Royal Australian College of Physicians, the Australian Association of Paediatric Surgeons, the New Zealand Society of Paediatric Surgeons, the Urological Society of Australasia, the Royal Australasian College of Surgeons, and the Paediatric Society of New Zealand.
17. In addition to the use of a dorsal penile nerve block or subcutaneous ring block, the use of other interventions to minimise operative and postoperative pain, such as sucrose pacifier, buffered lidocaine, small needles, acetaminophen, swaddling, environmental modification, topical anaesthetic (for example, EMLA) are all useful measures should be employed. See Geyer J, Ellsbury D, Kleiber C, et al. An evidence-based multidisciplinary protocol for neonatal circumcision pain management. J Obstet Gynecol Neonatal Nurs 2002;31:403-10;
18. Litman RS. Anesthesia and analgesia for newborn circumcision. Obstet Gynecol Surv. 2001;56:114-17;
19. Kraft NL. A pictorial and video guide to circumcision without pain. Adv Neonatal Care 2003;3:50-62;
20. Taddio A, Pollock N, Gilbert-MacLeod C, et al. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med 2000;154:620-3.
21. I am primarily concerned with circumcisions that take place in a medical environment (for example, a clinic or hospital). However, I still believe that there is an obligation to obtain a skilled practitioner and proper pain control measures for circumcisions perform in a non-medical setting.
22. Gee WF, Ansell JS. Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and Plastibell device. Pediatrics 1976;58:824-7, 82A;
23. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989;83:1011-15;
24. Fredman, RM. Neonatal circumcision: a general practitioner survey. Med J Aust 1969;1:117-20. Such figures will vary depending on what is classified as a complication.
25. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83(Suppl 1):34-44.
26. Somerville 2000.
27. Fink KS, Carson CC, DeVellis RF. Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol 2002;167:2113-16;
28. Collins S, Upshaw J, Rutchik S, et al. Effects of circumcision on male sexual function: debunking a myth? J Urol 2002; 167:2111-12;
29. Laumann EO, Masi CM, Zuckerman, EW. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA 1997;277:1052-7.
30. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5.
31. There is indeed anecdotal evidence and case studies of a vey, small fraction of men circumcised as infants (an an even smaller number of men circumcised as adults) who report regretting havin undergo the procedure. To my knowledge, there is no strong medical or epidemiological evidence concerning, for instance, the comparative differences in sensation or body image between circumcised or uncircumcised men that would support a finding that men who were circumcised were substantially harmed. However, the use of anecdotal evidence would not seem to bolster the anticircumcision position, as a vast majority of circumcised men appear satisfied with their status or do not feel harmed or damaged for undergoing the procedure. It would be beneficial to have more evidence concerning the comparative sexual functioning between circumcised and uncircumcised men, although the inherent subjectivity of such reporting would make it difficult to assess the effects of the comparative states. It would nonetheless be helpful to have more evidence in this area to inform the current debate.
32. Somerville 2000. Somerville's position on religious circumcision is more permissive compared to non-religious circumcision. She believes "only those who believe they have a fundamental, absolute religious obligation to carry out infant mole circumcision should be exempt from a prohibition on it". However, if circumcision is the harm she makes it out to be, this exemption seems arbitrary and tenuous. As much as it seems that circumcision should be protected as an instance of religious liberty, why should we privilege religious value judgments over other non-religous value judgments? And what would stop others from going further and saying that no value judgemants (religious or otherwise) could justify a parent's decision to circumcise their son?
33. The question of how far a parent's ability to consent (on behalf of their children) extends is an important one. For instance, it has been maintained that a parent can only have the legal power to consent to a procedure that removes tissue when it is necessary for the diagnosis or treatment of disease (and only when that procedure is foreseen to present with negligible risk and minimal burden). See Nuffield Council on Bioethics. Human tissue: ethical and legal issues. London: Nuffield Council on Bioethics, 1995. However, this seems to be too limited. For instance, it has been seen permissible for older siblings (who are minors) to donate bone morrow to a younger sibling - a procedure which confers no medical benefit risk the donor and puts them under considerable risk of harm of death.
34. For instance, the American Academy of Pediatrics' Committee on Bioethics have maintained that "the constitutional guarantees of freedom of religion do not sanction harming another person in the practice of one's religion". Compare with: Committee on Bioethics. American Academy of Pediatrics. Religious objections to medical care. Pediatrics 1997;99:279-81.
35. For an excellent examination of these issues, see Griffin J. Do children have rights? In: David Archard, Colin Mcleod, eds. The moral and political status of children: new essays. Oxford: Oxford University Press, 2002; 19-30;
36. Sumner LW. The moral foundations of rights. Oxford: Oxford University Press, 1987:10-11 and 202-5.
37. Sumner puts the point nicely: "like the arms race the escalation of rights rhetoric is out of control. In liberal democracies of the West ... public issues are now routinely phrased in language of rights". (1987:1).
38. Ainslie 2002:17.
39. For instance, in October 2001, a new low in Sweden stipulates that a licensed doctor can only perform circumcisions or a person certified by the National Board of Health (in the case of circumcisions performed by mohels, there were additional requirements that they be accompanied by a physician or nurse for anaesthesia). The Jewish community objected to the law claiming it interferes with their religious traditions. Department of State, United States Government. " Sweden" in The International Religious Freedom Report 2002. (http://www.state.gov/g/drl/rls/irf/2002/13983.htm). I am inclined to believe that most members of the religious community would agree that although it is an interference with religious tradition, it is a reasonable constraint on the practice.
40. At the Rainbow Flag Health Service Sperm Bank in Alameda, California, the clinic has a policy not to offer its services to individuals who would want to have their son circumcised (http://www.gayspermbank.com/philosophy.htm). Although there is no positive obligation on medical practitioners to perform circumcisions, it is worth considering the extent to which limits to such a procedure actually, if at all, impinges on religious liberty. This, however, is a separate, yet related, consideration concerning the ability of parents to access this procedure in a hospital or clinical setting, and not the ability of parents to practice the rite of circumcision (for example, as a religious ceremony in the home or place of worship).
41. Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision in English boys: survey of trends in practice. BMJ 2000;321:792-3.
42. Celia W. Dugger. Tug of taboos: African genital rite vs. US law. New York Times (12 December 1996), p 9; Coleman DL. The Seattle compromise: multicultural sensitivity and americanization. Duke Law Journal 1998;47:717-83.
43. I use the term female genital cutting, instead of "Female circumcision" in order to make clear the marked difference between this procedure and male circumcision. The removal of the male foreskin is in no way similar or equivalent (morphologically or symbolically) to the removal of the clitoris and/or labia.
44. Studies have shown that parents are often unhappy with the information they receive from physicians about circumcision. See Adler R, Ottaway S, Gould S. Circumcision: we have heard from the experts; now let's hear from the parents. Pediatrics 2001;107:e20. This study demonstrated that satisfaction with a parent's decision concerning circumcision was highly correlated with the discussion and information provided by the medical profession. However, there are other studies which show that many parents make their decision whether or not to circumcise their son prior to discussions with physicians, and physician discussions appear to have little impact on a parent's decision.
45. See Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract 1999;12:16-20;
46. Brown MS, Brown CA. Circumcision decision: prominence of social concerns. Pediatrics 1987;80:215-19;
47. Bean GO, Egelhoff C. Neonatal circumcision: when is the decision made? J Fam Pract 1984;18:883-7. Nevertheless, although Physician discussion may ultimately have little affect in changing a parent' s mind (for example, if a parent does not believe a circumcision is in her son's interest, then having a physician present its potential benefits will not tend to change their decision) we have good reason to require that parents are presented with all potential benefits and risks for the purposes of ensuring fully informed consent.