Tuesday, June 14, 2011

A butchering of bioethics (Marin IJ)

There’s a truly heinous procedure – a cruel punishment wrought against newborns. Virtually every newborn in this country is subjugated to this bloody assault, one that severs an attachment with the mother. What is this horrific act and how can it possibly be legal? It’s the butchering of the umbilical cord after birth. Ok, butchering isn’t really a fair description. The clamps are sterile and the procedure is usually not very messy. And I think we can all agree that, while cutting the umbilical cord may be an invasive procedure, it is nonetheless necessary. It would be ridiculous to forbid the cutting of an umbilical cord but not so far-fetched is the banning of another widespread newborn procedure – circumcision.
You’ve no doubt heard about the recently certified resolution that will appear on the San Francisco ballot this fall which would make the “genital cutting of male minors” illegal and punishable (for practitioners such as physicians and mohels) with a $1,000 fine or up to one year in prison. The initiative would make it unlawful in the city of San Francisco “to circumcise, excise, cut, or mutilate the whole or any part of the foreskin, testicles, or penis of another person who has not attained the age of 18 years.” The sponsors of this bill have obtained the 7,700 city resident signatures necessary to place this statute on the ballot and the controversy is attracting comment from numerous cultural and media silos (including a rather distasteful comic, Foreskin Man, in which the villain is a scissors-wielding rabbi.)
Certainly, there are numerous ways to skin this story but, fundamentally, this is an ethical question. One of the core principles of biomedical ethics is autonomy – the ability of the patient to make informed decisions about his or her body and medical care. This is an essential principle – without it the experimental abuses of Nazi Germany and Tuskegee, Alabama might someday be relived. Newborn babies cannot, of course, make any decisions. They know how to cry, feed, sleep and fill up the diaper. That’s about it. Making an informed decision about “genital cutting” is not in their wheelhouse. Thus, this decision falls to others. In the vast majority of instances, a child’s parents are the appropriate decision-makers because they are both the progenitors of the new life as well as those most directly affected by its immediate fate. The rights of parents in this regard have not been explicitly defined. They are neither wielded through surrogacy nor autonomy but a combination of the two – I call it progenitonomy [the rights (under the law) of the progenitor]. Such rights, cannot, of course, be absolute. We do not allow, for instance, Jehovah’s Witnesses to deny their children a life-saving blood transfusions and the news is rife with other circumstances where the state must step in to guarantee the health of a child whose parents or guardians have abdicated their progenitorship. Is the circumcision of newborn males such a situation? I think most of us would agree that is not. (Most, of course, not including 7,700 or so people in San Francisco.) But in the name of informed debate, let’s examine the major risks and benefits of “genital cutting of male minors.”
Benefit #1: Protection against infection – including urinary tract infections in infants, infections of the glans of the penis, and sexually transmitted diseases such as HIV. It’s well established in the medical literature that uncircumcised men are at increased risk of infection due to the moist, germ-friendly environment under the foreskin. Note also that the infection-protection that circumcision provides is valuable not just to the individual and his sexual partners, but also to the public health at large. For example, the low rates of circumcision in Africa are thought to have contributed to the start of the AIDS epidemic and multiple studies have indicated that circumcision should be considered an effective “surgical vaccine” for HIV.
Benefit #2: Protection against penile cancer. Once again, well established. And while penile cancer is rare, it is worth noting that newborn circumcision provides 100% defense against it.
Benefit #3: Cultural and religious sensitivity. There is no denying that circumcision is of great importance to Jews and Muslims. It may also be of importance to some non-religious parents who live in areas with high rates of circumcision. Now, let’s be clear – there are limits to a “cultural” benefit. Most would agree that forced female circumcision during the adolescent years goes well beyond any defensible level of moral relativism.
What then about the risks or potential harm?
Yes, circumcision is a painful procedure. By measuring heart rate and stress hormone release (cortisol) in infants, this somewhat obvious observation has been scientifically validated. But, then again, I can’t imagine that penile cancer is pain free either. And, nowadays, various forms of anesthesia are routinely used for the procedure and this should mitigate concerns significantly. Complications of newborn circumcision are very rare, occurring much less than 1% of the time (actually 0% in a large Kaiser study published in 2006) and mortality is virtually unheard of (besides a few reported cases of in–the-home deaths of undiagnosed hemophiliacs). In terms of potential harm, circumcision is much less risky than other common parental decisions, such as foregoing routine vaccinations and placing earrings in youngsters.
So, where does this lead us? Circumcision is a common procedure that is safe yet potentially painful. It has some long-term health benefits, but not enough to consider it a recommended procedure on a medical platform alone. There is some possible harm, but is quite minor, and the real harm (for some) seems to be in the imagery it evokes. Ultimately, though, there does not appear to be any basis to deny parents the ability to make this decision for their child based on their own beliefs and circumstances. Thus, to punish practitioners for carrying out the progenitor’s circumcision request is, to quote the chief of pediatric urology at UCSF (Dr. Laurence Baskin), "a bunch of nonsense." In fact, it is, quite simply, a butcher-like approach to ethics and medicine.