Editorial The ethics of infant male circumcision Brian D Earp INTRODUCTION Is the non-therapeutic circumcision of infant males morally permissible? The most recent major development in this longsimmering debate was the 2012 release of a policy statement and technical report on circumcision by the American Academy of Pediatrics (AAP). In these documents, the US paediatricians’ organisation claimed that the potential health benefits of infant circumcision now outweigh the risks and costs. They went on to suggest that their analysis could be taken to justify the decision of parents to choose circumcision for their incompetent children.1 Circumcision and ‘health benefits’ The AAP’s pronouncement unleashed a firestorm of commentary, much of it censorious. In this issue, human rights attorney J Steven Svoboda and Professor of Clinical Paediatrics Robert Van Howe take the AAP to taski for committing numerous significant errors, both in their analysis of relevant evidence and in basic medical-ethical reasoning.3 In addition, an independent international panel—composed of 38 leading paediatricians, paediatric surgeons, urologists, medical ethicists and heads of hospital boards and children’s health societies—has likewise condemned the findings of the AAP. Writing in the journal Pediatrics, these authors state: Only one of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.4 i A formal response by the AAP has been published alongside the critique by Svoboda and Van Howe.2 Correspondence to Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House, St Ebbes Street, Oxford OX1 1PT, UK; brian.earp@gmail.com Earp BD. J Med Ethics Month 2013 Vol 00 No 00 My own analysis of the AAP documents —and of ‘health benefits’ defences of circumcision generally—can be found elsewhere.5 Let me turn my attention in this editorial, then, to the question of cultural and religious justifications for the procedure. These are more principally the theme of the Special Issue, and have taken centre stage especially in Europe since the recent decision of a Cologne court that ritual removal of the foreskin constitutes an unconstitutional form of bodily injury.ii day ritual circumcision not only inherits and reflects, but also serves to perpetuate, at least some of the underlying metaphysic of that earlier epoch.12 The result is a rather uncomfortable tension between the implicit meta-ethical logic of this prehistoric practice and the normative foundation of (much of ) contemporary Western law and custom. As I noted recently in The Philosophers’ Magazine: Ritual circumcision is a pre-Enlightenment tribal tradition. [Both the Jewish and Islamic versions require] males [to sacrifice] functional erogenous tissue to an excruciating surgery done years before they are old enough to give [meaningful] consent. … Both versions are consistent with the norms of [patriarchy]; both elevate the concerns of the community over the freedom of the individual to make decisions about his own body in his own time; and both brand a child with a permanent mark of religious belonging despite the significant possibility that he may one day fail to embrace the belief system and/or cultural practices of his parents.13 Circumcision as a religious practice Defenders of religiously or culturally motivated circumcision sometimes stress that it is an ancient tradition, stretching back thousands of years. By doing so they seem to suggest that the sheer antiquity of the practice implies a kind of venerability, or even sanctitude. How could the fundamental legal status of so timeworn a religious custom be seriously called into question? This perspective is not uncommon, and those who hold to it are undoubtedly sincere in their convictions. In the United States, especially, attitudes toward circumcision are predominantly favorable: there —unlike in Europe, Canada, Australia and New Zealand—circumcision remains a popular, if waning, cultural habit even outside of any religious context. Since most Americans, including many American doctors, are simply unaware of the complex anatomy and diverse sexual functions of the foreskin (i.e., functions that are necessarily lost to circumcision3) the age-old benignity of ‘snipping it off ’ seems practically self-evident. What is left unacknowledged by appeals to antiquity, however, is that while they can in some cases lend an air of historical augustness, they can also signal the potential for the existence of an ethical minefield. In the case of circumcision, the practice is so ancient that its origins can be traced to a period as problematic as the Bronze Age9—an era in which, as Hanoch Ben Yami intimates,10 superstition reigned supreme, harmful propitiations were the norm, and women and children were considered chattel.iii Unfortunately, modern ii The Cologne court ruling is discussed in detail by Reinhard Merkel and Holme Putzke,6 as well as by Joseph Mazor7 and Matthew Johnson.8 iii See related arguments by Van Howe.11 By contrast, contemporary medical ethics as well as the philosophical basis of many modern legal codes came to fruition in a seculariv, post-Enlightenment era—one that favours a very different set of values from the ones alluded to above.v These include such concepts as autonomy, consent, individual rights, bodily integrity, the freedom to join (or to leave) a religion, the needfulness of protecting the vulnerable in society against the unwarranted exertions of the powerful, and a child’s interests in—or as some would have it, ‘rights to’—selfdetermination and an open future.vi As several of the contributors to this Special Issue have taken pains to note, this deeplyrooted tension between pre- and postEnlightenment world views is the source of much of the current—as well as historical— controversy surrounding the ethics of infant male circumcision.vii Pre- vs. post-Enlightenment: resolving the tension How might this tension be resolved? Given that Western societies have gradually succeeded in abandoning a very wide range of once hallowed traditions that came to conflict with subsequent developments in law and morality, one possible argument—and iv Or at least: non-ecclesiocratic. See Svoboda.14 vi For an in-depth discussion of the child’s right to an open future, see Darby.15 vii See also Earp and Darby.16 v 1 Editorial one that is increasingly being advanced by legal scholars, ethicists, and more liberalminded Muslims and Jews— is that the time has come to likewise abandon the practice of cutting off infants’ foreskins. If this were accomplished through the enforcement of existing prohibitions on committing acts of sexual violence, it would certainly serve to eliminate a number of clumsy inconsistencies in Western legal statutes. For example, laws that uniquely exempt non-therapeutic infant male circumcision from the application of (otherwise straightforwardly interpretable) definitions of criminal assault could be relieved of their asterisks.viii Pursuing an outright ban, however, would seem to be rather extreme, heavyhanded or simply far-fetched. Indeed, an immediate prohibition on religious circumcision would be premature (to say the least), and likely even counterproductive. Much more debate is needed, in both the academic and the public arenas. At the same time, however, one should remember that it is already illegal in most jurisdictionsix to cut into the genitals of any female human being, to any degree, with any instrument, for any reason, at any age, without her informed consent—and in some places even with it—barring some emergency related to health. Even the tiniest ritual ‘nick’ is federally banned in the USA, and this is an intervention that removes no tissue whatsoever, making it substantially less invasive than the most commonly performed parallel for boys.x Western culture has evidently come to a point at which the taking of a sharp viii These laws do not literally have asterisks. In the typical case, there is one statute banning assault, or sexual assault, or invasive rites, or child abuse, and then a second law saying that no criminal violation shall result from ritual (male) circumcision—even though it formally fits the definition of assault/abuse in the first law. For examples, see Geisheker.17 ix Following the 1986 UN Convention on the Rights of the Child. x See Davis.18 In contrast with the outright prohibition of female genital cutting in Western democracies, male genital cutting is not only legally permitted, but is not even regulated. In other words, in most parts of the world, including in developed nations, any person, for any reason, using any implement, in any environment, with any degree of pain control (or none), any amount of training (or none), any assurance of a sanitary environment (or none), and any level of medical knowledge (or none), can attempt to perform genital surgery on a newborn boy if it is claimed that the procedure is a circumcision. It is only when such lay attempts lead to emergency hospitalisation of the infant because his life is in danger that public concern becomes aroused. See Geisheker17 for further discussion. 2 object to a little girl’s vulva is regarded as being beyond the pale, no matter how slight the intended incision, and no matter how pious the motivation of the parents. Since the same culture has so far failed to reach an equivalent point in considering analogous incisions into (and excisions from) the genitals of little boys, one wonders why it has failed to do so, and whether it should reasonably be expected to move more sure-footedly in that direction. The philosopher Anders Sandberg has recently offered a useful perspective on this matter: … what is [likely] going on is [a] status quo bias and [something about] the social capital of religions. We are used to [male] circumcision in Western culture, so it is largely accepted. It is very similar to how certain drugs are regarded as criminal and worth fighting, yet other drugs like alcohol are merely problems: policy is set, [not] based on actual harms, but based on a social acceptability scale and who has institutional power. This all makes perfect sense sociologically, but it is bad ethics.19 Getting practical Be that as it may, sociological considerations certainly do matter in the practical realm of passing laws and making policy. Accordingly, one argument against the immediate prohibition of infant male circumcision is that Western cultures may simply not yet be ready for so strict a legal manoeuvre—especially in light of the notorious ‘double standard’20 21 regarding male versus female genital cutting that prevails in Anglophone societies. Indeed, as Julian Savulescu,22 Matthew Johnson8 and Hanoch Ben Yami10 all point out, fully fledged prohibitions instituted in advance of cultural readiness can lead to troubling side effects, such as a black market for the banned practice, which in this case might involve ‘back-alley’ circumcisions performed by incompetent individuals. Accordingly, Savulescu advocates a policy of harm reduction rather than prohibition; Johnson suggests that religious groups should be held accountable for any injuries that do ensue from their ‘invasive rites’; and Ben Yami outlines a series of gradual reforms such as mandatory administration of anaesthesia and the narrow illegalisation of the metzitzah b’peh.xi Ben Yami argues that these measures could reduce risk, pain xi Metzitzah b’peh is a form of circumcision practiced by some Orthodox Jews in which the ritual circumciser takes the baby’s penis into his mouth to suck away the blood after the wound has been inflicted, sometimes transmitting the and suffering in the short-term while contributing to a wider culture shift in the long term. CONCLUSION With perspectives in this issue ranging from Joseph Mazor’s7 articulate defence of infant male circumcision as both morally and legally permissiblexii to J Steven Svoboda’s14 contention that circumcision is an unambiguous affront to human rights, it is clear that the debate on this issue is far from over. Nevertheless, the overall balance of opinion may be shifting toward one of general scepticism concerning circumcision—even within religious communities. Increasingly, individual Muslim and Jewish thinkers are managing to persuade their fellow faith practitioners that the involuntary ablation of children’s foreskins is unnecessary for contemporary religious observance.xiii This type of intra-religious influence can be traced at least to the famous 19th century debates within the German Jewish community concerning whether or not circumcision was to be performed in the modern era.23 It continues today with the founding of such groups as Jews Against Circumcision24 as well as with the establishment of symbolic alternatives to preputial amputation. One such alternative is the non-violent, nonsexistxiv welcoming ceremony known as brit shalomxv officiated by a growing number of Jewish rabbis.25 As Dena Davis puts it in the title to her essay,18 we are dealing with a fundamental incompatibility between what she calls ‘ancient rites’ and ‘new laws.’ How this incompatibility will be addressed, and whether it can be dealt with in a way that herpes virus. See the discussions by Ben Yami10 and Davis.18 xii Mazor concedes, however, that circumcision probably should not be performed in the ‘secular’ case when considering the child’s best interests—one of which is an interest in self-determination. He simply leaves the ultimate decision up to the parents. xiii Of course, religious fundamentalists within Islam and Judaism will not find these sorts of arguments compelling, but they do not have— and are not entitled to—a monopoly on matters of theology, faith or ritual practice. xiv In Judaism, female babies are unapologetically excluded from participation in the sealing of the divine covenant; hence, the practice is inherently sexist. Islam is more ‘egalitarian’ in permitting circumcision of girls as well as boys. xv Brit shalom means ‘covenant of peace.’ Contrast with brit milah, the name for the traditional Jewish genital cutting ceremony, which means (loosely) ‘covenant of circumcision’ (milah means ‘to cut’). More information on this alternative, peaceful brit can be found by visiting the website at ref. 25 Earp BD. J Med Ethics Month 2013 Vol 00 No 00 Editorial ensures not only the coherence and proper functioning of religious communities but also the well-being and basic rights of the children being raised within their care— only time will tell. This Special Issue on circumcision marks an important contribution to the ongoing discussion. What is needed now is productive and respectful dialogue moving forward. 4 Competing interests None. 7 Provenance and peer review Commissioned; internally peer reviewed. To cite Earp BD. J Med Ethics Published Online First: [ please include Day Month Year] doi:10.1136/ medethics-2013-101517 Received 5 April 2013 Accepted 11 April 2013 J Med Ethics 2013;00:1–3. doi:10.1136/medethics-2013-101517 5 6 8 9 10 11 REFERENCES 1 2 3 American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics 2012;130:e756–85. American Academy of Pediatrics Task Force on Circumcision 2012. The AAP Task Force on Neonatal Circumcision: a call for respectful dialogue. J Med Ethics Published Online First: 18 Mar 2013. doi:10.1136/medethics-2013-101456 Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circmcision. J Med Ethics. Published Online First: 18 Mar 2013. doi:10.1136/medethics-2013-101346 Earp BD. J Med Ethics Month 2013 Vol 00 No 00 12 13 14 15 Frisch M, Aigrain Y, Barauskas Y, et al. Cultural bias in the AAP’s 2012 technical report and policy statement on male circumcision. Pediatrics. Published Online First: 18 Mar 2013. doi:10.1542/peds.2012-2896 Earp BD. The AAP report on circumcision: bad science + bad ethics = bad medicine. Practical Ethics (blog), 30 Aug 2012. http://blog.practicalethics.ox.ac.uk/ 2012/08/ the-aap-report-on-circumcision-bad-sciencebad-ethics-bad-medicine/ (accessed 31 Dec 2012). Merkel R, Putzke H. After Cologne: male circumcision and the law: parental right, religious liberty, or criminal assault? 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