Female circumcision: When Medical Ethics Confronts Cultural Values

Eike-Henner Kluge, PhD
Chair,  Department of Philosophy,  University of Victoria, British Columbia; Member of Advisory Committee on Ethical Issues in Health Care to  British Columbia Ministry of Health; Director of Ethics and Legal Affairs,  Canadian Medical Association (1989-91).

SUPPOSE a physician is asked to perform a procedure that has no recognized medical value and may harm the person who undergoes it. Suppose that the person requesting it is doing so not on her own behalf, but for her young daughter. How should the physician respond?

The answer is easy. The doctor will probably say that medical ethics forbids undertaking any procedure that is potentially harmful and has no therapeutic value.

But suppose that the request is so deeply rooted in the cultural background of the woman making the request that the mere suggestion that the procedure is inappropriate would be regarded as a deep insult to her cultural identity. Furthermore, suppose that the woman claims that failure to perform the procedure would harm the girl's self-esteem and cultural identity, and affect her societal integration. And suppose she points out that the World Health Organization's (WHO) definition of health includes the notion of social well-being.

Is the physician who refuses to perform the procedure not making a judgement about the ethical acceptability of those cultural values and rejecting WHO's definition of health?

Female circumcision, which has already been banned by the College of Physicians and Surgeons of Ontario, does indeed present an ethical problem. But is it unethical for a physician to perform it? The answer is yes, but explanations are needed.

If a woman competently requests the circumcision for herself and fully understands the nature and implications of what she is asking, it is like any other request for a procedure that involves medical skill and expertise. The physician must be sure that the woman really does understand the nature of her request, and that it is voluntary. When all is said and done, if there really is an informed, competent and voluntary request, then it is essentially a request for cosmetic surgery, albeit an extreme version.

But this does not mean that a physician automatically has to perform the procedure. Here the nature of the physician-patient relationship, and the ethical duties of the medical profession, come into play.

The profession has a monopoly on providing medical services. This means that it must provide all medical services that are appropriate and necessary, and can be provided under the prevailing circumstances. Therefore physicians have a duty to provide such services even if they do not like it---assuming the duty is a condition of their profession.

However, having a duty to provide all medically appropriate and necessary services that are possible is different from having a duty to provide all medical services that are possible and that anyone might ask for. At that point, we are no longer dealing with the services that form the basis of the professional monopoly or that are socially mandated.

We are in the realm of what physicians and patients might voluntarily agree to as a matter of contract. Here, the personal values of physicians can play a role as long as they are not unethical: the physician may refuse to provide the service.

People who think that physicians have to ignore their own qualms and simply do what they are asked have a mistaken understanding of the physician-patient relationship, and of the medical profession's obligations.

The patient (or patient proxy) does have the ultimate right to decide whether to accept or reject any diagnostic measure or treatment---this is the heart of patient autonomy. However, the physician's entry into a professional relationship with a patient does not turn that doctor into a moral eunuch. Unquestionably, physicians may not impose their own values on patients. But that does not mean that physicians must be ethically uncritical.

If what the patient wants violates a fundamental ethical principle, then no matter how much the patient wants it, the physician does not have to agree to do it. The reason is simple: no one has a duty to do something that is unethical. This is not a matter of personal values, but of basic, universal and fundamental ethical principles that apply to all people.

Of course, the request for female circumcision is usually made by a woman on behalf of a child. Should the physician then refuse? Yes. Female circumcision is special because the woman is acting as a proxy decision maker for a child. Proxy decision makers do not have the right to use their values and perspectives---they must do what is in the best interests of the incompetent person, and may use their values or standards as long as this will not imperil the welfare of their charge. Most important, they may use them only ifthey do not demean the incompetent person.

Values that treat people as mere objects for the gratification of others, or for advancing a certain view, fail that test. It does not matter that such values are hallowed in tradition and are a cultural mainstay.

Canada is not a melting pot of cultures: it is a mosaic. The people who live here are not forced to abandon their cultural heritage and adopt a homogeneous cultural identity. In fact, at its best Canada encourages its people to preserve their cultural heritage. By charter and law, it is illegal to discriminate on the basis of that heritage or background. This cultural attitude is the reflection of a fundamental ethical principle: respect for people. Every person is someone of incommensurable value, and the beliefs of thatperson are worthy of respect.

Respect---but not unreflective acceptance. Some of the countries where female circumcision is common have accepted that it is a violation of the dignity and integrity of a woman. They have outlawed the practice, tradition notwithstanding. The United Kingdom and France have done the same.

For its part, Canada and Canadian physicians cannot consistently espouse the principle of respect for people on the one hand, and then agree to a practice that violates that principle. Canadian physicians cannot consistently accept the principle of respect for people in the name of medical ethics, and then perform procedures they know to be medically inappropriate, harmful, and demeaning only because they do not want to offend a misplaced cultural sensitivity.

With due alteration of detail, the same ethical reasoning holds for male circumcision. There rarely are medical reasons for performing the procedure; personal preference or religious values of the parents usually underlie the request.

If these are insufficient to justify the circumcision of girls then, unless there are distinguishing medical reasons, they are also insufficient to justify the circumcision of boys. To argue differently is to be guilty of discrimination on the basis of sex. The fact that female circumcision is a more serious intervention does not alter the situation. Both involve what in other contexts would be called non-consensual mutilation of a minor for non-medical reasons.

LETTER

Can Med Assoc J 1994;149(1):16-17. [1 July 1993]

Dr. Kluge has done a commendable job of discussing the ethical implications of female circumcision. He has also succinctly argued why ethical physicians should not condone a procedure that is seen as a violation of the dignity and integrity of a woman.

However, he has suggested that the circumcision of boys is also non-consensual mutilation of a minor for non-medical reasons and as such, is no different from the circumcision of girls. This seems a much less ethically tenableposition.

Although there is ample evidence that the clitoris plays an important role in the life of adult women, the prepuce serves little, if any, physiologic function.¹ There are no known medical indications for or benefits from the circumcision of a healthy newborn girl, but the circumcision of the penis decreases the risk of urinary tract infections,² virtually eliminates the development of phimosis and balanitis,^3,4 improves penile hygiene³ and almost eliminates the risk of penile tumours.⁵

With all this in mind I find it difficult to consider circumcision of the prepuce and the clitoris medically and ethicallyequivalent.

Shabbir M.H. Alibhai
Richmond Hill, Ont.

LETTER

Can Med Assoc J 1994;149(10):1382-3. [15 November 1993]

Dr. Shabbir M.H. Alibhai attempts with meretricious arguments to justify male circumcision (ibid: 16-17). He cites references suggesting that circumcision prevents urinary tract infections and phimosis and that it improves penile hygiene---a screed of canards.

It has been suggested that venereal disease is more common in uncircumcised males.¹ Although this may be true in the United States, where being intact is not socially acceptable,² a closer examination of the habits of those who contract these conditions provides a more scientific explanation.^1,3 Physicians with experience in the Middle East, especially during World War II, noticed no shortage of venereal disease in the local inhabitants. After the Allied landings in Italy there was a titanic outbreak of gonorrhea among US troops. The incidence was so high that what little penicillin was available had to be divertedfrom the treatment of wounds.

Alibhai seeks to ask whether circumcision is cost-effective in preventing penile cancer. A renowned US genitourinary surgeon calculated that if a surgeon performed one circumcision every 10 minutes, 8 hours a day, 5 days a week, he would seem to be able to prevent one penile cancer by working steadily between 6 and 29 years. Since a significant number of penile cancers are curable, still more time and labour might be required to prevent a fatality from this disease.⁴ He went on to write that if cancer prevention is to be an end in itself, then simple mastectomy of female infants would presumably be an even more effective measure.

Some years ago I echoed our medical school teaching: that the prepuce has a function---namely, to protect the glans, which is almost insensitive to most ordinary tactile and thermal stimuli.^1,3 Removal of the prepuce exposes the glans to foreign stimuli, which dull the special receptors. During coitus the uncircumcised phallus penetrates smoothly, the prepuce retracting as the organ advances. In contrast, when the circumcised organ is introduced, friction develops. Penetration in the circumcised man is akin to thrusting the foot into a sock held open at the top. In contrast, in the intact counterpart it has been likened to slipping the foot into a sock that had been previously rolled up. (This simile has been attributed to the late Philip Mitchener, a fine surgeon and a mordant wit, who reigned for years at St. Thomas's Hospital in London, England.)³

The hazards of circumcision are considerable,^5-7 and the indications for the procedure are few.⁸ Nevertheless, there may be one reason for it, and this came to my attention when I was in the Royal Army Medical Corps. Those circumcised British servicemen who served in the Western desert found themselves slightly more comfortable in a sandstorm than their uncircumcised comrades.

Finally, we should ask ourselves whether it is likely that nature, in her wisdom, would permit every male child to be born with a useless appendage, the presence of which, according to some, frequently leads to serious consequences, including death. Why do men in Europe live so long despite not being raped at birth?

Keith Morgan, MD, FRCP(Ed), FRCPC, FACP
London, Ont.

LETTER

Can Med Assoc J 1994;150(10):1541-2. [15 May 1994]

I am astounded at Dr. Eike-Henner Kluge's article Female circumcision: When medical ethics confronts cultural values (Can Med Assoc J 1994;148:288-9) and Dr. Mary E. Lynch's letter (Can Med Assoc J 1994;149:16). Kluge falsely equates male circumcision with clitoridectomy and then dismisses the former as having little medical value, and Lynch ridicules parents who think male circumcision will prevent phimosis or urinary tract infections (UTI).

Wiswell and Hachey's¹ report of nine studies indicated that uncircumcised male infants are on average 12 times more likely to have a UTI. They found no contrary studies.¹ Some UTIs scar the kidneys and may result in end-stage renal disease.² As well, older uncircumcised males are at increased risk for UTIs.³

Penile cancer occurs almost exclusively in uncircumcised men. Meanwhile, the female sexual partners of men with penile cancer are at increased risk for cervical cancer.^4,5

Fink⁶ reviewed more than 50 studies showing that uncircumcised men are at increased risk for sexually transmitted diseases. Important African studies---some by Canadians---have demonstrated that uncircumcised heterosexual men have a fivefold to eightfold increased risk for HIV infection.⁷ Moreover, a new US study has shown that uncircumcised homosexual men have a twofold increased risk for HIV infection.

It is unfortunate that some provincial health plans no longer prophylactic circumcision in male newborns and even more unfortunate that some doctors appear to be giving false information on the subject. Medical ethics dictates that new parents receive informed counselling about consent for and refusal of the procedure.

Michael Jones
Dallas, Tex.

[Dr. Kluge responds:]

Mr. Jones presents a one-sided picture of research into the medical appropriateness of male circumcision. To get another picture one should read Dr. Keith Morgan's letter (Can Med Assoc J 1994;149:1382-3) and research cited by Poland.¹

However, to continue citing opposing research results would merely be to engage in a battle of references without coming to grips with the central issue, as outlined by Morgan in his discussion of penile cancer, among other issues: Is it ethically appropriate to perform circumcisions because there is some statistical evidence that a potentially curable disease with a low incidence may be prevented by surgery, even though the disease also occurs in people who have undergone the surgery² and the incidence of the disease in countries where the surgery is not routinely performed is similar to that in countries where it is?³

If the answer to this question is Yes, then the same underlying principle should be applied to all similar cases: whenever there is statistical evidence that a potentially curable disease or condition with a low incidence could be prevented by surgery, but the evidence also indicates that the incidence is the same in other countries where the surgery is not routinely performed, we should still perform the surgery in every person in whom the disease or condition might develop. All sorts of medical conditions would be implicated. I suspect that we would be operating nonstop on just about every part of the human body if we took this stance. I shudder to think of the cost---and the implications for public health. The more appropriate action would be to investigate why the incidence of the disease or condition differs between countries.

Even if further investigation corroborated the results of studies Jones cites on the risk of HIV infection among uncircumcised men, the very mention of this issue in this context is disturbing. Because condoms are good protection against HIV infection the transmission rates among circumcised and uncircumcised men using condoms should be the same. Therefore, Jones must be talking about transmission rates among men who do not use condoms. It is universally agreed that unprotected sexual intercourse is inappropriate. The sexual transmission of HIV will be retarded or stopped not by circumcising males but, rather, by appropriate sexual behaviour. To suggest that all men be circumcised so that some who engage in inappropriate sexual behaviour will have a lower rate of HIV transmission runs the risk of encouraging such behaviour among circumcised men. Is that appropriate?

Eike-Henner Kluge, PhD, Professor
Department of Philosophy, University of Victoria

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