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Ethical Concerns
Burden of Proof

Flatt vs. Kantak and Meritcare   ND FGM Lawsuit     Appeals Court Documents
ND Board of Medical Examiners   1990s History  
Here's What's Lost    Legal URLs    Religious Considerations   FGM & MGM   >CIRP   N.Y. Stowell Case    Relevant Statutes  
   
         

The burden of proof of possible physical and psychological damage is not on those trying to conserve the genital integrity of children; it is on those who forcibly tear and amputate healthy genitals and claim without proof that there is no harm.
   
Some items on this page:
The Logic of Ethical Considerations

Circumcision Is Not Just A Manicure
Desmond Morris, The Human Sexes, A Natural History of Man and Woman
Top Ten Reasons Pediatricians Are Sued
Charles Hartshorne, a Famous Philosopher Speaks Out
AMA's Principles of Medical Ethics

Medical School Oaths--University of ND Oath
The Medical Code of Ethics Declaration of Geneva



Logic of the Ethical Considerations         

 

1. Any surgery, including the amputation of the prepuce or any genital part, as with any surgery, is painful and leaves one’s  body in a diminished condition (if the surgery was is not done to correct a physical abnormality).

 

2. The issue is whether the surgical procedure is justified.

 

3. If there are any medical benefits to routine circumcision, they are only potential, not actual, since by accepted standard of practice only healthy infants are routinely circumcised.

 

4. Since only healthy infants are circumcised, the potential benefits to some members of a class of individuals (namely, those circumcised) must outweigh the actual harm to every member in order for the procedure to be justified on medical grounds.

 

5. No research has proved the potential medical benefits outweigh the actual suffering and potential risks even if one ignores >long-term psychological trauma and sexual diminishment. In fact, recent studies trying to weigh all the known immediate medical and cost factors conclude: circumcision cannot be decided on a health or cost basis.

 

6. Therefore, circumcision  is done for non-therapeutic, cultural, ritual purposes.

 

7. Surgical procedures which are always invasive and in this case, irreversible, cannot be justifiably imposed on one person by another unless there is a clear medical reason to do so: The non-consenting individual must not be capable of giving  informed consent, and it must be clear that he would be irreversibly harmed without the surgery.

 

8. Culturally imposed ritual surgeries of any kind, that are (1) not medically necessary and (2) performed on non-consenting individuals, cannot be condoned by our society, no matter what rationalizations are given to justify them. Only societies that deny persons the right to maximum freedom and self-directed fulfillment, can justify such behavior.

 

9. Protection from genital harm: A social and professional obligation. Many professionals are already legally obligated to report suspected cases of abuse.

 

10. The denial of the harm of circumcision, prevents others from helping those harmed, thereby aggravating the harm. “It is not [just] the act itself--it is the ramifications--knowing there was no one to protect you." Ophra Winfrey, speaking of Female Genital Mutilation.

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In light of the January, 2001 suit by an 18-year-old New Jersey man for being circumcised, babies who are now being cut will know this information was available to physicians before they were circumcised. If you can find this information, so can physicians, who obviously have a higher level of responsibility because they are the ones who are doing the cutting. Future claims of circumcisers' malfeasance will be even more binding.

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Before you cut your son, remember this:
Your infant son will read this website someday.

A picture worth a thousand words:
>
Baby Confronts Circumciser
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Using infant foreskins for industrial purposes:
Nairn P (Chairman), Human Tissue- Ethical and Legal Issues, 1995, ISBN 0-9522701-1-0.

"Parents should be wary of anyone who tries to retract their child's foreskin, and especially wary of anyone who wants to cut it off. Human foreskins are in great demand for any number of commercial enterprises, and the marketing of purloined baby foreskins is a multimillion-dollar-a-year industry." -- Paul M. Fleiss, MD. Mothering (The Magazine Of Natural Family Living) Winter 1997, page 39. "Where Is My Foreskin? The Case Against Circumcision." >http://www.mothersagainstcirc.org/fleiss.html

Here is one industry profiting from purloined foreskins:
 >http://www.pharma.us.novartis.com/product/pi/pdf/apligraf.pdf

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The First Amendment of the U.S. Constitution
says one cannot be forced to support another's religion.

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Read up on > The United Nations Convention on the Rights of the Child--UN General Assembly Resolution 44/25, Nov. 1989, and which nations have not ratified it.

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Calgary Herald
Thursday, 12 April, 2001, Letters
CIRCUMCISION NOT JUST A MANICURE
Margaret A. Somerville

Margaret Somerville is a bioethicist and founding director of McGill University's Centre for Medicine, Ethics and Law.

In her column of March 31[, 2001Calgary Herald], "Ancient ritual does no harm," Catherine Ford provides a stunning example of ignorance regarding the current medical knowledge about infant male circumcision. She demonstrates a similar lack of understanding of the ethical and legal arguments relevant to circumcision that are set forth in my book, The Ethical Canary.

She is wrong when she says there is medical evidence the procedure does no harm to the child. Leaving aside circumcisions that go wrong -- and in rare cases have even resulted in death -- and the serious pain involved, circumcision removes healthy, erogenous tissue with specialized mechanical, protective and sexual functions.

But even if Ford were correct about the medical evidence, it would not justify circumcision. To justify, ethically and legally, carrying out surgery on persons unable to consent for themselves, the surgery must be necessary therapy and the least harmful and invasive way to obtain the therapeutic benefit. Routine circumcision fulfils neither of these requirements.

Ford accuses me of seeking to break the covenant that circumcision constitutes for Jews by speaking against it. She also accuses me of wanting to marginalize religions that mandate circumcision by my suggesting that, if circumcision were generally prohibited, it might be able to be justified on the basis of a charter right to freedom of religion, for those people for whom it is a religious obligation.

In other words, I'm damned if I speak against it (as I believe ethically I must) and I'm damned if, in doing so, I act on the basis of a deep respect for people's religious beliefs and practices (as I also believe ethically I must).

The freedom of religion charter claim raises very complex issues about parents' rights to impose their religious beliefs on their children (see the Sheena B case, Supreme Court of Canada). And such a right is in conflict with the child's charter right to security of his person and protection of his bodily integrity.

Ford obviously does not understand the legal basis of the charter challenge to circumcision that is based on the Criminal Code prohibition on female genital mutilation. The argument is that in passing a law to protect the bodily integrity of girls and not giving similar protection to boys, the law discriminates on the prohibited ground of sex and, therefore, is unconstitutional.

The aim is certainly not to wipe out the protection of genital integrity given to girls, but to have a respectful discussion of what we owe to boys in terms of protecting them. No reasonable, properly informed person, including rabbis who strongly support infant male circumcision, believes it is like a manicure, as Ford describes it.

Ford might like to consider that the reason the baby was so quiet after the procedure was he was in a state of shock. The serious pain of circumcision, and of the resulting open wound which is in contact with the child's acid urine for about a week, is a matter of common sense.

There is also medical evidence of the impact of the pain, with possibly life-long effects. We can speak of a human right not to have pain unjustifiably inflicted on us, and this includes children. The fact that circumcision has such important religious significance makes it an extraordinarily difficult and sensitive issue to discuss. But sometimes it is unethical to avoid such discussions, which must be carried out in an atmosphere of deep mutual respect.

I was not sure whether Ford was implying that my statements were anti-Semitic. But if she were, she might be interested to know that when the same has been alleged in the past, many Jewish people, including rabbis, have expressed their dismay at such labeling.

Margaret A. Somerville,
Montreal, Que. Canada

And from her book, The Ethical Canary. 2001:204-205)
"A common error made by those who want to justify infant male circumcision on the basis of medical benefits is that they believe that as long as some such benefits are present, circumcision can be justified as therapeutic, in the sense of preventive health care. This is not correct. A medical-benefits or "therapeutic" justification requires that overall the medical benefits should outweigh the risks and harms of the procedure required to obtain them, that this procedure is the only reasonable way to obtain these benefits, and that these benefits are necessary to the well-being of the child. None of these conditions is fulfilled for routine infant male circumcision. 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". 

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From The Human Sexes, A Natural History of Man and Woman, by Desmond Morris:

After the dramas of birth and baptism, a child's ordeals are far from over. In many cultures the children must face the ritual genital mutilation we call circumcision. This extraordinary procedure which, were it not hallowed by ancient tradition, would be prosecuted as child abuse, occurs in several forms in different parts of the world, sometime applied to young males and sometimes to young females. Literally millions of cases of these genital assaults occur annually and a whole range of preposterous excuses and explanations have been given as to why this savaging of young humans is necessary. In earlier days most of the explanations had to do with religious dictates, sacred demands that could not be queried rationally. With the fading of religious beliefs in some countries in later years, new excuses had to be found and a set of spurious medical reasons invented. The Jewish faith calls for circumcision on the eighth day following birth. The baby suffers acute pain, but is otherwise uninvolved in the ritual. In some countries, however, the mutilation is deferred until the male children are fully aware of what is going on. When a boy is selected, his mother may not intervene. He is held down by his godfather while his foreskin is cut away. Afterwards he is given a diploma and must kiss the hand of the man who has mutilated him. No other species behaves in this bizarre way towards its young· No matter how cruel or pointless they may be, they become stubbornly resistant to common sense or objective medical opinion.

________________________________________________

 Are experiments on the effects of neonatal circumcision pain ethical
if circumcision is not necessary for the health of the child?

_________________________________________

Charles Hartshorne
(June 5, 1887-Oct. 9, 2000)
 famous American philosopher at 97 years old
commenting on circumcision in a letter to Duane Voskuil (4/94):

 “About circumcision, the only serious mistake my parents made about me was in that. The effects you specify I can identify in my case, except that it was so different from all the other things my parents did that some of the shock to the child-parent relationship was mitigated.... But on the whole I agree such things should not be done to either sex. My sex has a lot of misbehavior to answer for. Our species is both the best and the worst of the earth’s animal species, the wisest and the most foolish. Our radical superiority in linguistic power is a somewhat self-destructive advantage.”

  ________________________________________

American Medical Association's
Principles of Medical Ethics

Preamble: The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following [11] Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient [patient, not parent].

IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

IX. A physician shall support access to medical care for all people. _________________________________________________

Found in the American Medical Association website.

For centuries, physicians have taken oaths to uphold certain moral values and virtues. The most famous of these, of course, has been the Hippocratic Oath. But others have been used, such as the Prayer of Maimonides and the Declaration of Geneva. Today, some medical schools even use their own crafted oaths, sometimes drafted by faculty members, sometimes drafted by students. The last few years has witnessed a general increase in the frequency of oath-taking among medical students. This ritual of oath-taking suggests a strong renewal of the commitment of medical students and physicians to the moral enterprise of medicine. The Oath Registry contains the oaths currently being administered in US medical schools. This will provide educators an opportunity to compare their own oath with other schools.

The University of North Dakota School of Medicine and Health Sciences: The Contemporary Oath of Hippocrates Today.
       In the presence of family, friends, teachers, and colleagues, I dedicate myself to the profession of Medicine. I pledge myself to the service of humanity. I will use my skills to care for all in need, without bias and with openness of spirit. The health of my patients will be my first concern. I vow to hold sacred the bond between doctor and patient. I will hold in confidence all that my patients entrust to me. I will strive to alleviate suffering. I will respect the dignity and autonomy of my patients in living and in dying. As a Physician, I recognize my duty to society. I will work to promote health and prevent disease. I will advocate for the welfare of my community. Even under duress, I will not use my knowledge or my skills against humanity. I will acknowledge my limitations and my mistakes so that I may learn from them. To uphold these responsibilities, I will maintain my own well-being and the well-being of those close to me. I will promote the integrity of the practice of Medicine. In the tradition of my profession, I honor all who teach me this Art. Through honest and respectful collaborations with my colleagues, I will uphold the highest standards in the service of patients. I will seek new knowledge, reexamine ideas and practices of the past, and teach what I have learned. Above all, the health of my patients will be my first concern. This Oath I take freely and upon my honor.

________________________________

The College of Physicians and Surgeons of British Columbia  issued a guide for physicians regarding routine infant male circumcision which reads in part [emphasis added]:

Legal Considerations
To date, the legality of infant male circumcision has not been tested in the Courts.  It is thus assumed to be legal if it is performed competently, in the child’s best interest, and after valid consent has been obtained.

 

....However, proxy consent by parents is now being questioned.  Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non-therapeutic procedures.

 

Human Rights Considerations
The matter of infant male circumcision is particularly difficult in regards to human rights, as it involves consideration of the rights of the infant as well as the rights of the parents. 

 

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”.

 

Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision.  They claim that an infant’s rights should take priority over any parental rights to make such a decision.  This procedure should be delayed to a later date when the child can make his own informed decision.  Parental preference alone does not justify a non-therapeutic procedure.

 

Others argue that this stance violates the parents’ right to religious or cultural expression, and that adherence to their religious and cultural practices would be in the best interests of the infant.

 

Ethical Considerations
Ethical considerations regarding infant male circumcision centre on the welfare (or “best interests”) of the infant and the potential benefit and harm associated with the procedure.  Ethics points us to corrective vision, i.e. to question practices that have become routine, or which we take for granted. 
Therefore, each request for the procedure should be carefully evaluated, and an agreement to perform the procedure should take into consideration the ethical principles of beneficence (duty to benefit); non-maleficence (do no harm); veracity (accurate information); autonomy (consent); and justice (fairness). 

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The PIAA top ten reasons that Pediatricians are sued
>http://www.aapca1.org/aapca1/nl972.html

Submitted by George Thomasson, MD to AAP of California

       1.  Failure to diagnose meningitis
       2.  Brain damaged infant
       3.  Routine infant and child health checks
       4. Congenital dislocation of the hip
       5.  Failure to diagnose appendicitis
       6.  Premature infant
       7.  Asthma
       8.  Cerebral palsy
       9.  Circumcision's adverse outcomes
     10.  Respiratory problems of the newborn

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The Second General Assembly of the World Medical Association 1948. 
The Medical Code of Ethics Declaration of Geneva, 1948

At the time of being admitted as a Member of the medical profession I solemnly pledge myself to consecrate my life to the service of humanity : I will give to my teachers the respect and gratitude which is their due; I will practise my profession with conscience and dignity; The health and life of my patient will be my first consideration; I will respect the secrets which are confided in me; I will maintain by all means in my power, the honour and the noble traditions of the medical profession; My colleagues will be my brothers : I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life, from the time of its conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity; I make these promises solemnly, freely and upon my honour... 

 

 

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