Ethics of circumcision

Ethics of circumcision

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Male circumcision is the surgical removal of the foreskin (prepuce) from the human penis.[1] The ethics of non-therapeutic circumcision being imposed on unconsenting minors (babies and children) has been a source of ongoing controversy.[2][3][4]

Some medical associations take the position that the parents should determine what is in the best interest of the infant or child.[5] Others say that circumcision is an infringement of the child’s autonomy and should be prolonged until he is capable of making the decision himself. [6][7]

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The Royal Australasian College of Physicians (2004) commented that, ” The difficulty with a procedure which is not medically indicated is whether it may still be in the child’s “best interests” (that is, in the case of circumcision, decreasing the risk of UTI [urinary tract infection] and penile cancer, and ensuring acceptance within a religio-cultural group) on the one hand or whether it may constitute an assault upon the child and be a violation of human rights on the other. Arguments to justify the “best interests” case are based upon data to suggest a decreased risk of medical conditions later in life, none of which, with the possible exception of UTIs in boys, requires a decision in the neonatal period, and this could be seen to be an argument to defer a decision until the individual can express his own preferences. [...] One issue, which is agreed, is that before parents make a decision about circumcision they should have access to unbiased and clear information on the medical risks and benefits of the procedure.”[3] Views differ on whether limits should be placed on caregivers having a child circumcised.

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The Canadian Paediatric Society (CPS) issued a position statement on September 8, 2015. With regard to ethics, it stated:

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The Danish Medical Association (Lægeforeningen) has released a statement (2016) regarding the circumcision of boys under the age of eighteen years. The organization says that the decision to circumcise should be “an informed personal choice” that men should make for themselves in adulthood.[9] According to Dr. Lise Møller, the chairwoman of the doctors’ association’s ethics board, “It is most consistent with the individual’s right to self-determination that parents not be allowed to make this decision but that it is left up to the individual when he has come of age.”[10]

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The Royal Dutch Medical Association (Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst) (KNMG) and several Dutch specialist medical societies published a statement of position regarding circumcision of male children on 27 May 2010. The KNMG states that “there is no convincing evidence that circumcision is useful or circumcision of male minors is necessary for prevention or health”, that “circumcision of male minors entails the risk of medical or psychological complications”, that “circumcision of male minors is contrary to the rule that minors may only be exposed to medical treatments if illness or abnormalities are present”, that “circumcision of male minors conflicts with the child’s right to autonomy and physical integrity”, that circumcision of male minors should be restricted “as much as possible,” and that “it is reasonable to put off circumcision until the age at which … the boy himself can decide about the intervention, or can opt for any available alternatives.” The Royal Dutch Medical Association questions why the ethics regarding male genital alterations should be viewed any differently from female genital alterations, when there are mild forms of female genital alterations (like pricking the clitoral hood without removing any tissue or removing the clitoral hood altogether). They have expressed opposition to both male circumcision and all forms of female circumcision.[7]

In 2013 children’s ombudsmen from SwedenNorwayFinlandDenmark, and Iceland, along with the Chair of the Danish Children’s Council and the children’s spokesperson for Greenland, passed a resolution to, “Let boys decide for themselves whether they want to be circumcised.”[11] They further declared that “Circumcision without a medical indication on a person unable to provide informed consent conflicts with basic principles of medical ethics.”[12]

The Nordic Association of Clinical Sexologists supports the position of the Nordic Association of Ombudsmen:

The medical doctors at Sørland Hospital in Kristiansand, Southern Norway have all refused to perform circumcisions on boys, citing reasons of conscience.[14]

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The medical ethics committee of the British Medical Association states:

Commenting on the development of the 2003 British Medical Association guidance on circumcision, Mussell (2004) states that debate in society is “intensely fraught, with individuals and groups holding conflicting positions.” Identifying three positions, “support,” “qualified support,” and “opposition,” he suggests that this controversy “is also reflected within the multicultural, multifaith BMA membership.” He identifies this as a difficulty in achieving consensus within the medical ethics committee. Arguments put forward in discussions, according to Mussell, included that circumcision “is a net benefit focused on concepts such as social integration and cultural acceptance”, but also that it is “a net harm focused on the breach of children’s rights—the right of the child to be free from physical intrusion and the right of the child to choose in the future.”[16]

In a paper published June 2006, the British Medical Association Committee on Medical Ethics does not consider circumcision of an adult male to be controversial, provided that the adult is of sound mind and grants his personal consent after receiving all material information regarding the known risks, disadvantages, and potential benefits to be derived from the surgical operation.[15]

Circumcision of adults as a public health measure for the purpose of reducing the spread of HIV also involves ethical concerns such as informed consent and concerns about reducing attention paid to other measures. According to the CDC website, research has documented a significant reduction of HIV/AIDS transmission when a male is circumcised.[17]

In the same British Medical Association paper, circumcision of a child to treat a clear and present medical indication after a trial of conservative treatment also is not considered to be ethically questionable, provided that a suitable surrogate has granted surrogate consent after receiving all material information regarding the known risks, disadvantages, and potential benefits to be derived from the surgical operation.[15]

The non-consensual circumcision of children for non-therapeutic reasons is controversial. Infants cannot speak and are, therefore, unable to consent. If a circumcision is to be done, then informed consent for circumcision can only be granted by a surrogate. Some believe that surrogates are not empowered to grant consent for non-diagnostic and non-therapeutic procedures. Some believe that parents have a right to circumcise a child, regardless of the child’s wishes. Some believe that non-therapeutic circumcision of a child violates the human rights and bodily integrity of the child and can not be in the child’s best interests. Some believe that their religion requires males to be circumcised. Some believe that circumcision is a lifelong irreversible injury. Some believe that non-therapeutic circumcision provides certain health benefits. Some believe that the foreskin has numerous physiological functions and should be preserved. These conflicts have created a wide diversity of opinion regarding the propriety and ethics of child circumcision as discussed below.

It is also argued that there is no reason to perform non-therapeutic circumcision on a child since circumcision can be performed at a later date when the child has become able to provide informed consent.

The BMA statement of 2003 took the position that non-therapeutic circumcision of children is lawful in the United Kingdom.[18] British law professors Fox & Thomson (2005), citing the House of Lords case of R v Brown, challenged this statement. They argued that consent cannot make an unlawful act lawful.[19] The BMA accepted this criticism and revised its statement to incorporate certain changes based on the critique by Fox & Thomson. The revised statement (2006) now reports the controversy regarding the lawfulness of non-therapeutic child circumcision and recommends that doctors obtain the consent of both parents before performing non-therapeutic circumcision of a male minor.[15]

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The American Academy of Pediatrics (1999) states that both parents and physicians have an ethical duty to secure the child’s best interest and well-being. They state that in the case of circumcision, where there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, the parents ought to determine what is in the child’s best interests, and that it is legitimate for parents to take into account cultural, religious, and ethnic traditions, as well as medical factors. They state that physicians should not coerce parents, but should assist parents in their decision by “explaining the potential benefits and risks and by ensuring that they [the parents] understand that circumcision is an elective procedure.” The Academy’s Committee on Bioethics approved this policy statement.[5]

Neonatal circumcision is performed with surrogate consent, described as follows by the American Academy of Pediatrics (1999):

The Academy (2012) states in part with regard to ethics:

The American Academy of Pediatrics (AAP) position statement on male circumcision (2012) has attracted significant critical comment.

Van Howe & Svoboda (2013) said:

Frisch et al. (2013) said:

The American Medical Association (2013) states, “There is strong evidence documenting the health benefits of male circumcision, and it is a low-risk procedure, said Peter W. Carmel, M.D., AMA president. “Today the AMA again made it clear that it will oppose any attempts to intrude into legitimate medical practice and the informed choices of patients.”

“The AMA supports the general principles of the 2012 Circumcision Policy Statement of the American Academy of Pediatrics, which reads as follows: “valuation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction”[23]

In August 2017, the American Medical Association Journal of Ethics featured two separate articles challenging the morality of performing non-therapeutic infant circumcision.

The Journal of Medical Ethics published a “symposium on circumcision” in its June 2004 issue.[26] The symposium published the original version (2003) of the BMA policy statement and six articles by various individuals with a wide spectrum of views on the ethicality of circumcision of male minors. In the introduction, Holm (2004) states:

Hutson (2004) states:

Short (2004) disputes Hutson’s claims and argues that male circumcision has future prophylactic benefits that make it worthwhile. He concludes:

Viens (2004) contends that “we do not know in any robust or determinate sense that infant male circumcision is harmful in itself, nor can we say the same with respect to its purported harmful consequences.” He suggests that one must distinguish between practices that are grievously harmful and those that enhance a child’s cultural or religious identity. He suggests that medical professionals, and bioethicists especially, “must take as their starting point the fact that reasonable people will disagree about what is valuable and what is harmful.”[30]

Hellsten (2004), however, describes arguments in support of circumcision as “rationalisations”, and states that infant circumcision can be “clearly condemned as a violation of children’s rights whether or not they cause direct pain.” He argues that, to question the ethical acceptability of the practice, “we need to focus on child rights protection.” Hellsten concludes, “Rather, with further education and knowledge the cultural smokescreen around the real reasons for the maintenance of the practice can be overcome in all societies no matter what their cultural background.[31]

Mussell (2004) examined the process by which the BMA arrived at a position on non-therapeutic circumcision male minors, when the organisation had groups and individuals of different ethnicities, religion, culture, and widely varying viewpoints.

Arguments were put forward that non-therapeutic male circumcision is a net benefit for some because it helps them to integrate in the community.

Arguments were also put forward that non-therapeutic male circumcision is a net harm because it is seen as a breach of children’s rights—the right of the child to be free from physical intrusion and the right of the child to choose in the future. This argument was given emphasis by Britain’s incorporation of the European Convention on Human Rights (1950) into domestic law by the Human Rights Act 1998.

The BMA produced a document that set forth legal and ethical concerns but left the final decision on whether or not to perform a non-therapeutic circumcision to the attending physician.[32]

The last document published by the Journal of Medical Ethics in its symposium on circumcision was a reprint of the BMA statement: “The law and ethics of male circumcision: guidance for doctors (2003).[18]

The Journal of Medical Ethics devoted the entire July 2013 issue to the controversial issue of non-therapeutic circumcision of male children.[33] The numerous articles represent a diverse variety of views.[34][35]

Povenmire (1988) argues that parents should not have the power to consent to neonatal non-therapeutic circumcision.[36]

Richards (1996) argues that parents only have power to consent to therapeutic procedures.[37]

Somerville (2000) argues that the nature of the medical benefits cited as a justification for infant circumcision are such that the potential medical problems can be avoided or, if they occur, treated in far less invasive ways than circumcision. She states that the removal of healthy genital tissue from a minor should not be subject to parental discretion, or that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient, regardless of parental consent.[38]

Canning (2002) commented that “[i]f circumcision becomes less commonly performed in North America [...] the legal system may no longer be able to ignore the conflict between the practice of circumcision and the legal and ethical duties of medical specialists.”[39]

Benatar and Benatar (2003) argue that “it is far from obvious that circumcision reduces sexual pleasure,” and that “it is far from clear that non-circumcision leaves open a future person’s options in every regard.” They continue: “It does preserve the option of future circumcised or uncircumcised status. But it makes other options far more difficult to exercise. Transforming from the uncircumcised to the circumcised state will have psychological and other costs for an adult that are absent for a child. … Nor are these costs “negligible”, [...]. At the very least, they are not more negligible than the risks and costs of circumcision.”[40]

The Committee on Medical Ethics of the British Medical Association (2003) published a paper to guide doctors on the law and ethics of circumcision. It advises medical doctors to proceed on a case by case basis to determine the best interests of the child before deciding to perform a circumcision. The doctor must consider the child’s legal and human rights in making his or her determination. It states that a physician has a right to refuse to perform a non-therapeutic circumcision.[4] The College of Physicians and Surgeons of British Columbia took a similar position.[41]

Fox and Thomson (2005) state that in the absence of “unequivocal evidence of medical benefit”, it is “ethically inappropriate to subject a child to the acknowledged risks of infant male circumcision.” Thus, they believe, “the emerging consensus, whereby parental choice holds sway, appears ethically indefensible”.[19]

Morris et al. (2014) argued that “…failure to circumcise a baby boy may be unethical because it diminishes his right to good health.”[42]

The Belgian Federal Consultative Committee for Bioethics (Comité Consultatif de Bioéthique de Belgique) (2017), after a three-year study, has ruled that circumcision of male children for non-therapeutic purposes is unethical in Belgium.[43][44] The process is irreversible, has no medical justification in most cases, and is performed on minors unable to give their own permission, according to the committee. Paul Schotsmans of the University of Leuven, on behalf of the committee, noted “the child’s right to physical integrity, which is protected by the International Treaty on the Rights of the Child, and in particular its protection from physical injury.”[44]

Rennie et al. (2007) remark that the results of three randomised controlled trials in sub-Saharan Africa, showing reduced risk of HIV among circumcised men, “alter the terms of the debate over the ethics of male circumcision.”[45] However, it should be noted that the methodology of the African RCTs has been severely criticised, thereby invalidating claims that circumcision reduces the sexual transmission of HIV.[46]

Supporters of circumcision argue that using circumcision and other available means to halt the spread of HIV is in the common good (but overlook the fact that HIV is transmitted in the seminal fluid). Rennie et al. argue that “it would be unethical to not seriously consider one of the most promising—although also one of the most controversial—new approaches to HIV-prevention in the 25-year history of the epidemic.”[45] However, there clearly remains a risk of transmitting or acquiring HIV while engaging in unprotected sex and other high risk behaviors (circumcised or not).

The World Health Organization (2007) states that provision of circumcision should be consistent with “medical ethics and human rights principles.” They state that “[i]nformed consent, confidentiality and absence of coercion should be assured. … Parents who are responsible for providing consent, including for the circumcision of male infants, should be given sufficient information regarding the benefits and risks of the procedure in order to determine what is in the best interests of the child.”[47] However, since babies and children are not sexually active, sexually-transmitted HIV infection is not a relevant concern. Critics of non-therapeutic circumcision argue that advocating circumcision to prevent HIV infection may detract from other efforts to prevent the spread of the virus such as using condoms. If the adult chooses to remain celibate or if a couple remain monogamous, or if HIV is eliminated by the time the child is an adult, the sexual reduction surgery would not have been needed. Moreover, they argue that circumcising a child purportedly to partially protect him from HIV infection in adulthood may be seen as granting permission to engage in dangerous sexual practices. Obviously baby boys do not need such protection and can choose for themselves as consenting adults if they want a circumcision.[38]

The UK National Health Service (NHS) has critiqued the African studies, and has stated that practising safe sex including condom use is the best way to prevent sexually-transmitted disease when having sex.[48]

Patient autonomy is an important principle of medical ethics.[49] Some believe that consent for a non-therapeutic operation offends the principle of autonomy, when granted by a surrogate.

Since children, and especially infants, are legally incompetent to grant informed consent for medical or surgical treatment, that consent must be granted by a surrogate — someone designated to act on behalf of the child-patient, if treatment is to occur.[50]

A surrogate’s powers to grant consent are more circumscribed than the powers granted to a competent individual acting on his own behalf.[50][51] A surrogate may only act in the best interests of the patient.[50] A surrogate may not put a child at risk for religious reasons.[50] A surrogate may grant consent for a medical procedure that has nomedical indication only if it is the child’s best interests.[50]

The attending physician must provide the surrogate with all material information concerning the proposed benefits, risks, advantages, and drawbacks of the proposed treatment or procedure.[50][51]

The Committee on Bioethics of the AAP (1995) states that parents may only grant surrogate informed permission for diagnosis and treatment with the assent of the child whenever appropriate.[51]

There is an unresolved question whether surrogates may grant effective consent for non-therapeutic child circumcision.[50][36][52] Richards (1996) argues that parents may only consent to medical care, so are not empowered to grant consent for non-therapeutic circumcision of a child because it is not medical care.[37] The Canadian Paediatric Society (2015) recommends that circumcisions done in the absence of a medical indication or for personal reasons “should be deferred until the individual concerned is able to make their own choices.”[8]

Regardless of these issues, the general practice of the medical community in the United States is to receive surrogate informed consent or permission from parents or legal guardians for non-therapeutic circumcision of children.[15][36]

  1. ^ Sawyer S. Pediatric Physical Examination & Health Assessment. Jones & Bartlett Publishers; November 2011. ISBN 978-1-4496-7600-1. p. 555–556.
  2. ^ Boyle G.J., Svoboda J.S., Price C. P., Turner J.N. (2000). “Circumcision of healthy boys: Criminal assault?”. Journal of Law and Medicine7: 301–310.
  3. Jump up to: a b “Policy Statement On Circumcision”Royal Australasian College of Physicians. September 2004. Archived from the original (PDF) on 2008-07-20. Retrieved 2007-02-28The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision.Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups.…In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.…The complication rate of neonatal circumcision is reported to be around 1% and includes tenderness, bleeding and unhappy results to the appearance of the penis. Serious complications such as bleeding, septicaemia and may occasionally cause death (1 in 550,000). The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarizing the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate.
  4. Jump up to: a b Medical Ethics Committee. British Medical AssociationThe law and ethics of male circumcision – guidance for doctors; June 2006 [archived 2007-11-12; Retrieved 2006-07-01].
  5. Jump up to: a b c Task force on circumcision.  Circumcision policy statementPediatrics. 1999;103(3):686–93. doi:10.1542/peds.103.3.686PMID 10049981.
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  7. Jump up to: a b Non-Therapeutic Circumcision of Male Minors. Utrecht: Royal Dutch Medical Association, 2010.
  8. Jump up to: a b Sorakan ST, Finlay JC, Jefferies AL.  Newborn male circumcisionPaediatr Child Health. 2015;20(6):311–5. PMID 26435672PMC 4578472.
  9. ^ Erin McCann. Danish Doctors’ Group Wants to End Circumcision for BoysThe New York Times. 8 December 2016.
  10. ^ Danish doctors come out against circumcision. (The Local) 5 December 2016.
  11. ^ Nordic Association of Ombudsmen. Adopted at Oslo, 30 September 2013.
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  13. ^ Statement on Non-Therapeutic Circumcision of Boys.. Nordic Association of Clinical Sexologists, Helsinki, 10 October 2013.
  14. ^ Solrun F. Faull. Hospital doctors in Southern Norway will not circumcise boysNorway Today. 30 August 2016.
  15. Jump up to: a b c d e f Committee on Medical Ethics. The law & ethics of male circumcision: guidance for doctors; June 2006 [Retrieved 25 November 2013.].
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  17. ^ “HIV and Male Circumcision | Gateway to Health Communication | CDC” 23 February 2017.
  18. Jump up to: a b British Medical Association.  The law and ethics of male circumcision: guidance for doctorsJ Med Ethics. 2004;30(3):259–63. doi:10.1136/jme.2004.008540PMID 15173359PMC 1733850.
  19. Jump up to: a b Fox M, Thomson M.  A covenant with the status quo? Male circumcision and the new BMA guidance to doctorsJ Med Ethics. 2005;31(8):463–9. doi:10.1136/jme.2004.009340PMID 16076971PMC 1734197.
  20. ^ Task Force on Circumcision.  Male circumcisionPediatrics. 2012;130(3):e756–e785. doi:10.1542/peds.2012-1990PMID 22926175.
  21. ^ Svoboda JS, Van Howe RS.  Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. 2013;39:434–41. doi:10.1136/medethics-2013-101346PMID 23508208.
  22. ^ Frisch M, Aigrain Y, Bauraskas V, et al.  Cultural bias in the AAP’s 2012 Technical Report and Policy Statement on Male CircumcisionPediatrics. 2013;131(4):796–800. doi:10.1542/peds.2012-2896PMID 23509170.
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  24. ^ Svoboda JS.  Nontherapeutic circumcision of minors as an ethically problematic form of iatrogenic injuryAmerican Medical Association Journal of Ethics. 2017;19(8):815–24. doi:10.1001/journalofethics.2017.19.8.msoc2-1708.
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  30. ^ Viens AM.  Value judgment, harm, and religious libertyJ Med Ethics. 2004;30(3):241–7. doi:10.1136/jme.2003.003921PMID 15173355PMC1733861.
  31. ^ Hellsten SK.  Rationalising circumcision: from tradition to fashion, from public health to individual freedom—critical notes on cultural persistence of the practice of genital mutilationJ Med Ethics. 2004;30:248–53. doi:10.1136/jme.2004.008888PMID 15173357PMC 1733870.
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  36. Jump up to: a b c Povenmire, R. (1998–1999). “Do Parents Have the Legal Authority to Consent to the Surgical Amputation of Normal, Healthy Tissue From Their Infant Children?: The Practice of Circumcision in the United States”Journal of Gender, Social Policy and the Law7 (1): 87–123. PMID 16526136. Retrieved 2013-11-25.
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  48. ^ “Circumcision and STIs”. 2009-03-26.
  49. ^ Beauchamp, Tom L., and Childress, James F.. Principles of Biomedical Ethics. New York: Oxford University Press; 2001.
  50. Jump up to: a b c d e f g J. Steven Svoboda, Robert S. Van Howe, James C. Dwyer, Informed Consent for Neonatal Circumcision: An Ethical and Legal Conundrum. 17 J Contemp Health Law & Policy 61 (2000).
  51. Jump up to: a b c Committee on Bioethics.  Informed consent, parental permission, and assent in pediatric practicePediatrics. 1995;95(2):314–7. PMID 7838658.Reaffirmed May 2011.
  52. ^ Peter W. Adler. Is Circumcision Legal? 16(3) Richmond J. L. & Pub. Int. 439 (2013).

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