Informed Consent for Circumcision

To the Editor: Binner et al¹ document that material prepared by the American Academy of Pediatrics in the brochure, Circumcision: Information for Parents² is inadequate to persuade parents to avoid circumcision. This is not surprising, because the information provided by the brochure does not satisfy the legal criteria for informed consent.

Binner et al¹ did not show that parents cannot be dissuaded from circumcision by sufficient information. Enzenauer et al³ counseled parents of boys with videotaped presentations regarding circumcision. The videotaped counseling achieved a significant reduction in the number of parents who elected to have their child circumcised. Thus, with sufficient information, a reduction in the high incidence of nontherapeutic circumcision indeed is possible and may be achieved.

Informed consent is governed by court decisions. Generally, the doctor must disclose all material information that the patient or his proxy representative would deem relevant about the benefits, risks, and possible outcomes of the proposed treatment and any alternative treatments. Medical practitioners who fail to provide sufficient information may be liable in negligence.⁴

The American Medical Association says that major factors in parental decision-making are the father's circumcision status, opinions of family members and friends, a desire for conformity in their son's appearance, and the belief that the circumcised penis is easier to care for with respect to local hygiene.⁵ Obviously, such decisions are not made in the child's best interest. The validity of the permission granted for circumcision based on such decisions may be challenged on the basis that they are made in the parents' interests rather than the child'sbest interest.

Medical societies are strengthening their advice to their fellows regarding informed consent for nontherapeutic neonatal circumcision. The American Academy of Family Physicians recently issued a new position statement on neonatal circumcision. The statement cautions doctors to discuss the benefits and risks with parents.⁶ In Canada, the Saskatchewan College of Physicians and Surgeons recently warned its fellows that medical practitioners must tell parents that male neonatal circumcision is not a recommended procedure.⁷

Thus it is now clear that medical doctors must impart all material information to the parents, not only about circumcision, but also about the option not to circumcise. This information must be far more extensive than the scanty information contained in the American Academy of Pediatrics brochure. In the case of nontherapeutic circumcision of a boy, electing not to have circumcision performed is a reasonable, practicable, and viable alternative, so patients or their proxy representatives must be given all material information about circumcision and its risks, potential benefits and possible outcomes; they must also be informed about the risks, potential benefits, and possible outcomes of remaining uncircumcised. No doctor should rely on such grossly inadequate material as a handout prepared by the American Academy of Pediatrics.

George Hill, BA
Executive Secretary
Doctors Opposing Circumcision
2442 NW Market St, Suite 42
Seattle, WA 98107

References

Binner SL, Mastrobatista JM, Day M, et al: Effect of parental education on decision-making about neonatal circumcision. South Med J 2002;95:457-461.
American Academy of Pediatrics: Circumcision: Information for Parents. Elk Grove Village, Ill, American Academy of Pediatrics, 2001.
Enzenauer RW, Powell JM, Wiswell TE, et al: Decreased circumcision rate with videotaped counseling. South Med J 1986;796:717-720.
Povenmire R: 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. J Gender Soc Pol Law 1998; 7:87-123.
Council on Scientific Affairs, American Medical Association: Report 10: Neonatal Circumcision. Chicago: American Medical Association, 1999.
Commission on Clinical Policies and Research: Position Paper on Neonatal Circumcision. Leawood, Kan, American Academy of Family Physicians, 2002. Available at http:www.aafp.org/policy/camp/4.html. Accessed April 21, 2002.
Kendel DA: Caution Against Routine Circumcision of Newborn Male Infants (Memorandum to physicians and surgeons of Saskatchewan), Saskatoon, College of Physicians andsurgeons of Saskatchewan, February 20, 2002.

Citation:

. Informed Consent for Circumcision. S Med J. 2002-08;95(8):946.

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