Bioethics of neonatal circumcision

The bioethics of neonatal circumcision are sometimes controversial within practicing cultures. Male circumcision involves the excision of genital tissue from the human body.

Some studies indicate that the foreskin and frenulum perform certain physiological functions among the men tested which would be destroyed by excision. Other studies indicate that some human males with a foreskin are at increased risk of certain diseases. (See medical analysis of circumcision)

Because the tissues, once excised, cannot be replaced, there are differing views regarding the appropriateness of their removal in a healthy child who is unable to provide consent. Non-therapeutic neonatal circumcision is sometimes performed exclusively for social or cultural reasons. Such practices and differing views are widespread in the United States.

Medical ethics
Some medical associations take the position that the parents should determine what is in the best interest of the infant or child, 

“We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors. 

but the Royal Australasian College of Physicians (RACP) and the British Medical Association (BMA) observe that controversy exists on this issue. The BMA insists that a non-therapeutic circumcision must not go ahead without the consent of both parents and, if competent, the child himself.

Commenting on the development of the 2003 British Medical Association guidance on circumcision, Mussell 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."

Neonatal circumcision is performed with surrogate consent, which is appropriate according to the American Academy of Pediatrics:

The Academy states that both parents and physicians have an ethical duty to secure the child's best interest and well-being. In the case of an individual child, however, they argue that it is often uncertain what is in their best interest. 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 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.

The Royal Australasian College of Physicians comments 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 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 UTI’s 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."

Views differ on whether limits should be placed on caregivers having a child circumcised.

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.

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."

Denniston (1996) argues that informing parents that circumcision is "in any way useful" constitutes a failure to make "relevant scientific information available to that parent." He states that "[c]ircumcision is unnecessary and harmful: therefore, not in the infant's best interest." Benatar and Benatar argue that circumcision is "neither a compelling prophylactic measure nor a form of child abuse", and that it is therefore suited to parental discretion. Viens 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 which 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."

Richards (1996) argues that parents only have power to consent to therapeutic procedures. Povenmire argues that parents should not have the power to consent to neonatal non-therapeutic circumcision.

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."

Guidance on the circumcision of male (2003) has been enunciated by the Committee on Medical Ethics of the British Medical Association. That view 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. They state that a physician has a right to refuse to perform a non-therapeutic circumcision. A similar position (2004) has been taken by the College of Physicians and Surgeons of British Columbia.

Holm (2004) alleges that, in the absence of "valid comparative data" on the effect of infant circumcision on adult sexual function and satisfaction, "the circumcision debate cannot be brought to a satisfactory conclusion, and there will always be a lingering suspicion that the sometimes rather strident opposition to circumcision is partly driven by cultural prejudices, dressed up as ethical arguments."

Describing arguments in support of circumcision as "rationalisations", Hellsten (2004) expresses the view 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." 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".

Circumcision to reduce the risk of HIV infection
Rennie et al. (2007) remark that the results of three randomised controlled trials, showing reduced risk of HIV among circumcised men, "alter the terms of the debate over the ethics of male circumcision."

Supporters of circumcision argue that using circumcision and other available means to halt the spread of HIV is in the common good. They argue that the reduced risk of catching HIV and other alleged benefits of circumcision make it worthwhile. 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." However, there remains a risk of HIV while engaging in unprotected sex and other high risk behaviors.

The World Health Organization (2007) describes the efficacy of circumcision as "proven beyond reasonable doubt", but 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."

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. They argue that a child's sexual behaviour as an adult is very difficult to predict, as is the future of HIV and treatment or prevention of AIDS. If the child chooses to remain celibate or if a couple remain faithful to each other, or if HIV is eliminated by the time the child is an adult, the surgery would not have been needed. Moreover, they argue that circumcising a child strictly to protect him from HIV infection may be seen as permission, or even entitlement to engage in dangerous sexual practices. Others would argue that baby boys do not immediately need such protection and can choose for themselves, at a later stage, if they want a circumcision.