Circumcision of Male Infants: Ethical and Legal Guidance for Doctors

Note:

The Medical Ethics Committee of the British Medical Association issued a new statement in April 2003 to replace the 1996 statement in this file. This statement is retained for historical purposes, however, it is outmoded and should not be relied upon in clinical practice.)

Circumcision of Male Infants: Guidance for Doctors

There has been much debate on the ethics of circumcising baby boys, and this guideline outlines the position of the BMA, with regard to circumcision for medical purposes, and the issues doctors should take into account when asked to perform circumcision for religious or cultural reasons. The subject should not be confused with female circumcision which was outlawed by the 1985 Prohibition of Female Circumcision Act. This issue is addressed by a separate

BMA Guidance.

Circumcision for medical purposes

These guidelines do not attempt to offer detailed guidance as to the appropriateness of accepted therapeutic clinical procedures. Their aim is to offer guidance on the ethical duty of doctors to treat patients appropriately, and to keep themselves educated and aware of developments in clinical practice.

This advice applies to all aspects of practice, including circumcision, and can be outlined as follows:

It is rarely necessary to circumcise an infant for medical reasons. Doctors must recognise that the appearance of the foreskin in infancy does not act as a guide to whether it will become retractile in later life. Normal anatomical and physiological characteristics of the infant foreskin can be misinterpreted as being abnormal, and doctors should be familiar with recognising this and reassure parents accordingly.

Circumcision for religious or cultural reasons

This guideline only addresses the position of doctors performing ritual circumcisions, and not religious or cultural leaders.

Legality

Male circumcision is lawful under English common law. In the case of R v Brown [1993] 2 All ER 75 HL, Lord Templeman talks about the circumstances in which violence is not punishable under the criminal law.

Even when violence is intentionally afflicted and results in serious bodily harm the accused is entitled to be acquitted if the injury was a foreseen incident of a lawful activity in which the person injured was participating. Surgery involves intentional violence resulting in serious bodily harm but surgery is a lawful activity. Other activities carried on with consent by or on behalf of the injured person have been accepted as lawful not withstanding that they involve actual bodily harm or may cause serious bodily harm. Ritual circumcision, tattooing, ear-piercing and violent sports including boxing are lawful activities.

Circumcision, in common with ear piercing and cosmetic surgery, has never been the subject of a case in English law, but this assumption of lawfulness has never been challenged.

Note:

This was written in 1996, prior to the passage of the

Human Rights Act 1998. The lawfulness of child circumcision is now less clear. See for more information see The Impact of the Human Rights Act 1998 on Medical Decision Making.

Note:

When this passage was written in 1996 no case had considered circumcision. Since that time the case of Re J has been decided. Doctors should be aware of the implications of this case on the practice of male circumcision of minors in the U.K.

The duty to balance potential benefit and harm

With all procedures, professionals have an ethical obligation to weigh the potential benefits and harms of the procedure and explain these in an appropriate manner to the patient or person consenting on the patient's behalf Doctors unfamiliar with the practice and who receive a request for circumcision may find it helpful to seek advice about the physical risks of the procedure from doctors experienced in conducting circumcisions. Paediatric surgeons and urologists are trained in circumcision.

The BMA does not have a policy on the ethics of male circumcision for religious or cultural purposes but issues this guidance in response to doctors for all relevant factors to be taken into account. The practice of circumcision has previously been considered to be morally neutral, that is, no harm was caused to the child and therefore with appropriate consent from both parents or a person lawfully exercising parental responsibility, it could be carried out. The neutrality of the procedure, however is now being increasingly challenged although it is argued that it is in the best interest of the child to be circumcised, to be accepted into a religion or community. Arguably the procedure can confer social benefits in some such circumstances.

Potential health benefits

However, the health, as opposed to the social, benefits of circumcision are increasingly disputed. It is clear that there is no consensus amongst the profession as to whether circumcision does carry benefits to health sufficiently large to justify the procedure. Arguments in favour of circumcision cite reduced infection rates and hygiene. It is claimed that it is protective against penile cancer, reducing the incidence by a factor of 5000.[1] Arguments against circumcision usually stress the damage caused to the penis from the operation, including scarring and a lack of sensation. In addition, poorly performed circumcision can give rise to infection and distress.

It has also been argued that male circumcision may confer some health benefits to female sexual partners. However, this view has been challenged, together with the validity of the research on which it was based, and there is no consensus on this issue at present.

Whatever the health implications of circumcision, the main impetus for circumcising comes from culture and religion, not from medical or scientific evidence.

Where such a lack of consensus exists, the position of doctors is unclear. Individual doctors approached by patients requesting circumcision for their son must counsel the parents about the implications of the procedure, including the health risks involved. Any surgical procedure, including one of a minor nature, carries with it risks and parents must be made aware of these in order to give valid consent to the operation. In addition, doctors usually consider appropriate anesthesia a requirement and this also carries an element of risk.

Doctors must use their judgement as to whether or not to perform circumcisions. In some circumstances, a doctor may think it better to do the circumcision, or refer the child to a plastic surgeon, if he or she feels the child is at risk of being circumcised in unhygienic or otherwise unsafe conditions.

Consent

The BMA strongly recommends that either the written consent of BOTH parents, or of the person with parental responsibility be obtained for circumcision. Parents must be aware of the nature and implications of the procedure, and the risks involved.

Doctors should be aware of potential difficulties if both parents do not follow the same cultural tradition. A case raised with the BMA concerned a GP who circumcised, without any enquiry, a baby unknown to him but whose parents were, in fact, unmarried and estranged. The child's father had taken the baby without the mother's permission, fully aware that the procedure would be completely contrary to her wishes and that he had no legal right to consent. The mother made a formal complaint about the doctor concerned.

Note:

The

General Medical Council subsequently has issued a detailed Guidance on Consent. See for more information see

Seeking patients' consent: the ethical considerations, especially parts 23-26.

Expertise

However, the Council would take action of a doctor were performing such operations incompetently. One doctor, who carried out a number of circumcisions that resulted in several boys being admitted to hospital in the period from 1991 to 1993, was found guilty of serious professional misconduct. Therefore doctors are advised not to undertake the procedure unless confident of their expertise but may refer the family to another competent practitioner.

Doctors commonly facing requests for circumcision will find it helpful to establish whether there are colleagues in their area expert in this field. Religious and cultural groups may have organisations, locally or nationally, who give advice and can suggest practitioners who perform circumcisions. For example, the Initiation Society, the professional body for the organisation of (Jewish) Circumcision Pratitioners sets professional standards and keeps a list of registered practitioners. Other religious groups may have similar national or local registers.

Charging patients

Some doctors have been willing to provide circumcision routinely on demand. While there is no duty upon doctors or hospitals to do so, some will do this procedure without charge rather than risk the procedure being carried out in unhygienic conditions.

Legal Issues

Circumcision, as any other surgical procedure, should never be carried out by a doctor not trained in that particular operation. Normally, that doctor would be a pediatric surgeon, a urologist, or other doctor experienced in performing the operation.

Poorly performed circumcisions hold legal implications for the doctor responsible. An action could be brought against a doctor responsible on the child's behalf if the circumcision was carried out negligently. Alternatively, the child could issue such proceedings in his own name on reaching the age of 18 and the normal time limit for starting legal proceedings would run from that birthday. However, because circumcision is not an unlawful procedure, action could not be taken against a doctor simply because a man was unhappy at having been circumcised at all. A valid consent from a person authorised to give it on the patient's behalf is sufficient in such cases.

Conscientious objection

Some doctors may wish to not perform circumcisions for reasons of conscience. In such situations, both the BMA and GMC make clear that doctors should not delay in explaining to the patient their own moral position but not seek to impose their own moral viewpoint on patients who do not share it. The provision of factual information is a different matter and doctors can also explain the background to their conscientious objection if the child's parents require them to do so.

[Note on acronyms: BMA = British Medical Association GMC = General Medical Council GP = General Practitioner]

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