Jerry Warner to AAP: 16 June 1997

Jerry W. Warner
10515 Karen Drive
Baton Rouge, LA 70815

June 16, 1997

Carole M. Lannon, MD, MPH
Chair, Task Force on Circumcision
c/o Mr. Edward Zimmerman
Director, Physician Payment Systems
American Academy of Pediatrics
P. O. Box 927
Elk Grove Village, IL 60009-0927

Re: Inconsistencies with AAP policy in previous task force statement on circumcision.

Dear Dr. Lannon:

The previous AAP statement on neonatal circumcision, which was produced under the auspices of Edgar J. Schoen, MD, Chairman,¹ is inconsistent in several areas with other published policy statements by the AAP. I would like to pointout these inconsistencies to you.

Pain

The 1989 Task Force statement on neonatal pain:

Infants undergoing circumcision without anesthesia demonstrate physiologic responses suggesting they are experiencing pain. The observed responses include behavioral, cardiovascular, and hormonal changes. Pain pathways are well developed by the third trimester. Responses to painful stimuli have been documented in neonates of all viable gestational ages.¹

The AAP position on neonatal pain:

There is an increasing body of evidence that neonates, including those born preterm, demonstrate physiologic responses to surgical procedures that are similar to those demonstrated by adults and that these responses can be lessened with anesthetic agents.²

Pain Control

The 1989 Task Force statement states:

Local anesthesia adds an element of risk and data regarding its use have not been reported in large numbers of cases. Circumferential anesthesia may be hazardous. It would be prudent to obtain more data from large controlled studies before advocating local anesthesia as an integral part ofnewborn circumcision.¹

but the AAP position on neonatal pain control is:

The Committee on Fetus and Newborn, the Committee on Drugs, the Section on Anesthesiology, and the Section on Surgery believe that local or systemic pharmacologic agents now available permit relatively safe administration of anesthesia to neonates undergoing surgical procedures and that such administration is indicated according to the usual guidelines for the administration of anesthesia to high-risk, potentially unstable patients.²

Child Rights

1989 Task Force statement on child rights:

The 1989 Task Force statement is silent on child rights.¹

However, the AAP position on child rights is:

The Committee on Bioethics asserts that(1) the opportunity to grow and develop safe from physical harm with the protection of society is a basic right of every child; ...³

The AAP asserts that every child should have the right to grow and develop free from preventable disease or injury.⁴

Religious/cultural circumcision

The 1989 Task Force statement:

In addition to the medical aspects, other factors will affect the parents' decisions, including esthetics, religion, cultural attitudes, social pressures, and tradition.¹

but the AAP states:

However, the constitutional guarantees of freedom of religion do not sanction harming another person in the practice of one's religion, and they do not allow religion to be used as a defense when one harms another.³

Constitutional guarantees of freedom of religion do not permit a child to be harmed through religious practices, nor do they permit religion to be a valid legal defense when anindividual harms or neglects a child.⁴

The basic moral principle of justice requires that children be protected uniformly by laws and regulations at the local, state, and federal level.⁴

Informed Consent

1989 Task Force statement on informed consent is:

When considering circumcision of their infant son, parents should be fully informed of the possible benefits and potential risks of newborn circumcision, both with and withoutanesthesia.¹

When circumcision is being considered , the benefits and risks should be explained to the parents and informed consent obtained.¹

but the AAP position on informed consent is:

Parents and physicians should not exclude children and adolescents from decision making without persuasive reasons.⁵

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 give informed permission for diagnosis and treatment of children with the assent of the child whenever appropriate.⁵

...proxy consent poses serious problems for pediatric health care providers. Such providers have legal and ethical duties to render competent care based on what the patientneeds, not what someone else expresses.⁵

A patient's reluctance or refusal to assent should also carry considerable weight when the proposed intervention is not essential to his or her welfare and/or can be deferred withoutsubstantial risk.⁵

The 1989 Task Force on Circumcision is a unique document that stands in opposition to many basic principles of proper medical care and ethics that have been enunciated or affirmed by the American Academy of Pediatrics. The replacement statement should reflect and be consistent with the values and principles that have been enunciated or affirmed by the AAP in the matters of pain, pain control, children's rights, protection of children from the religious beliefs of the parents, and limitation on the power of parents to consent.

Cordially yours,

JERRY W. WARNER

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