08Joe, I apologize for the delay in responding to your last post.
The medical community does addresses ethical issues. In the case of routine infant circumcision (RIC), it appears that the AAP is ignoring some of those issues. I will expand on this below.
Well, let's be clear on this point: the medical community addresses ethical issues only
as they pertain to physicians and other medical professionals. I have, throughout this discussion, assumed that you were not
referring to them when you said that it was "unethical" to authorize this procedure. Is that assumption correct?
Purely cosmetic procedures are non-therapeutic when performed on a non-consenting individual. The criteria for performing cosmetic surgery is for the individual to gain a psychological benefit that outweighs the risks. Only the individual can give consent for, and benefit from, a strictly cosmetic procedure. If the individual's thoughts and feelings cannot be part of the decision then the psychological component of a cosmetic procedure cannot be determined.
This is rather confused. You previously based your objection on the ground that circumcision is not "medically necessary." Now you're saying that circumcision is a cosmetic procedure, which, presumably, in some cases might actually be necessary
-- if not medically then at least psychologically. If that's the case, then you've brought the issue of consent back into the picture.
Let's see if we can determine exactly where this leads us. One type of birth defect is polydactyly
-- in laymen's terms, extra fingers or toes. Now, in some cases this is one aspect of a serious congenital defect, but in other cases it's simply an extra digit or two. The bonus finger or toe may be functional, or it may simply be rudimentary. Typically, such extra digits are surgically removed (the procedure may be as simple as tying a string around it and waiting for it to fall off).
Now, in cases where the sixth finger or toe doesn't really affect the infant's health or long-term medical prospects, one could certainly argue that any operation to remove the extra digit is purely cosmetic, much as operating to remove a third nipple would be cosmetic. Indeed, apart from the difficulties involved in buying gloves, one could expect to lead a full and satisfying life with eleven or twelve fingers. So, in those cases, would you argue that it is unethical to operate on the infant to remove that digit?
It's not that the consent changes the risks or benefits. The benefits and risks change the criteria for proxy consent based on whether or not a procedure is therapeutic (or diagnostic). In the case of RIC (an invasive, non-diagnostic, non-therapeutic procedure), a guardian is not given the right to proxy consent.
"We now realize that the doctrine of "informed consent" has only limited direct application in pediatrics. Only patients who have appropriate decisional capacity and legal empowerment can give their informed consent to medical care. In all other situations, parents or other surrogates provide informed permission for diagnosis and treatment of children with the assent of the child whenever appropriate" -AAP Committee on Bioethics - Informed Consent, Parental Permission, and Assent in Pediatric Practice
That certainly does not support your point that parents and guardians do not have the right to authorize circumcision on male infants. Indeed, it would be surprising if the AAP guidelines you cite would stand for that proposition, given that the AAP guidelines on circumcision specifically permit
parents/guardians to authorize the procedure.
The key being 'diagnosis and treatment(therapeutic) of children'. There is no right given for prophylactic(non-therapeutic) medical procedures.
In the case of male infant circumcision, you are most definitely wrong.
Medical organizations ARE in the ethics business. The AAP's policy on circumcision is out of sync with the medical community at large and even other policies within the AAP itself. What we have is no major medical organization in the world that recommends RIC (or ever has, to my knowledge) and some that recommend against it. Just the fact that a medical procedure is not discouraged by some medical organizations does not mean it meets the requirements of a therapeutic procedure.
It's getting very hard to figure out what forms the basis for your charge that circumcision is unethical. Initially, you argued that a parent could not ethically authorize circumcision because the procedure was not "medically necessary." As you stated: "The whole gist of my premise is that routine infant circumcision is unethical because it is not a medically indicated procedure." When asked to provide the basis for this claim that circumcision was "medically unnecessary," you have cited some of the very same organizations that you simultaneously criticize for being inconsistent.
Of course, it's not difficult to figure out why you're having these problems. The same organizations that say that circumcision is unnecessary are the same organizations that say its OK for doctors to perform the procedure. So at the same time you rely on them for medical
support you reject them when it comes to ethical
In fact, according to the AAP, RIC is a non-recommended, non-therapeutic, elective surgery with no proven net benefit. The Council on Scientific Affairs of the AMA has recognized RIC as a non-therapeutic, elective procedure. The AAP and ACOG both have stated "There are no medical indications for routine neonatal circumcision". The Agency for Healthcare Research and Quality's "U.S. Preventive Services Task Force" has not recognized circumcision as a preventive procedure. The American Cancer Society and the American Urological Association do not recommend RIC as a preventative procedure.
This may all very well be true (although it is customary to provide links when citing these sorts of authoritative statements), but then do any of these organizations forbid
their members from performing male infant circumcisions?
There is a real ethical dilemma when presenting an invasive, preventive, procedure where the benefits do not outweigh the risks. This is compounded when there are less invasive options available to gain similar benefits while virtually eliminating all of the risks of the circumcision procedure itself. Because RIC is non-therapeutic it has been dropped from a number of state medicaid programs, some private insurance, and from the British and Canadian national health services. The burden of proof for performing RIC rests on the ones promoting the procedure. They have failed to make their case.
Clearly, you've mixed up two very different things: medically necessary
and medically acceptable
procedures. At the point where you were arguing that medical necessity was the key factor, I suppose you could get away with this mix-up. Now, however, you've drifted off into an argument based on consent, so you must explain how the "medical necessity" issue comes back into the picture.
To make things easy for you, let me ask specifically:
1. Are you contending that the only procedures that can ethically be performed on an infant are those that are "medically necessary?"
2. If the answer to the previous question is "yes," is that because you are relying upon a "presumed consent" standard, whereby you presume that an infant, if it had the ability to grant consent, would only give consent to those procedures that are "medically necessary?"
3. If you answered the first question "yes," then what are the criteria that determine "medical necessity?"
RIC is an ethical violation based on the following:
1) Violates the primary tenet of medicine: "First do no harm" and the AMA's Code of Ethics Principle 4 (rights of patient). RIC is an invasive, prophylactic, procedure with no recognized medical net benefit, that violates the inherent bodily integrity, security of the person and freedom from unnecessary medical procedures.
Well, even if we were to accept this point, it would only restrict physicians. It would, on the other hand, not constitute an ethical constraint on parents, guardians, mohels, witch doctors, enthusiastic amateurs, or anyone else who either authorizes or performs these procedures.
2) Violates the AAP's Workgroup on Breastfeeding recommendation...
Your points 2 through 8 merely cite purported inconsistencies within the AAP's position. But, of course, the AAP dictates neither the ethics for the entire medical profession nor for non-professionals in any respect. Furthermore, such inconsistencies are a little difficult to square with the AAP's specific
statement regarding circumcision. If the AAP is being inconsistent, we should be just as entitled to claim that its other
working groups are wrong as we would be to claim that the circumcision guidelines are in error.
Where there is a conflict between legal procedures and ethical concerns, the ethical concerns rise above the legal principles: "Ethical values and legal principles are usually closely related, but ethical obligations typically exceed legal duties." AMA Medical code E-1.02 The Relation of Law and Ethics.
Physicians have an obligation to to not perform unnecessary procedures: "Physicians should not provide, prescribe, or seek compensation for services that they know are unnecessary." AMA Medical code E-2.19 Unnecessary Services.
There is no provision for providing invasive prophylactic treatment where there is no medical indication. E-8.20 Invalid Medical Treatment.
Yet, again, the AMA adopts the AAP guidelines regarding circumcision. If the AMA has issued inconsistent rulings, we are just as entitled to state that its circumcision guidelines are correct
as we are to assert that they are in error.
A lot of clarity can be seen in the most recent statement on circumcision from a major medical organization:
"Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention." COLLEGE OF PHYSICIANS & SURGEONS OF BRITISH COLUMBIA - Infant Male Circumcision
And yet this group also permits its members to perform male infant circumcisions (you didn't provide the link, so I will: CPSBC Policy Manual