Male Circumcision and the Enhancement Debate: Harm Reduction, Not Prohibition
This blog is a brief response to ‘Out of Step: Fatal Flaws in the Latest AAP Policy Report on Neonatal Circumcision’ by Steven Svoboda and Robert Van Howe, and the AAP Task Force on Circumcision’s Response. This is part of a special issue summarised by Brian Earp.
Around one third of men worldwide are circumcised. It is probably the most commonly performed surgical procedure. Circumcision is also one of the oldest forms of attempted human enhancement. It is and has been done for religious, social, aesthetic and health reasons.
Circumcision has a variety of benefits and risks, many of which are discussed in this issue. There is some dispute about the magnitude and likelihood of these benefits and risks. Some argue that the risks outweigh the benefits and circumcision should not be performed on children who are not competent to make their own decisions.
If it were true that the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure. Around one third of men have been harmed. This is an extraordinary public health injury. Presumably, some would be entitled to compensation.
The fact that few people think that there is not such a bad situation affecting millions of men indicates that most people implicitly believe that circumcision is not a significant harm, if a harm at all. (This is an example of the kind of argument called modus tollens. If p, then q. Not-q, therefore not-p.)
It is reasonable to conclude either that:
1) It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.
2) If circumcision is against the interests of an infant, it is only mildly so.
In general, people should make their own decisions about body modification and human enhancement when this is possible. Such an approach speaks in favour of waiting until a child is adult to make his or her own decision about circumcision. And procedures which are not clearly in a child’s interests should not be performed on that child. However, religious and other social exclusion may make delay in circumcision psychologically harmful.
It would be a mistake to ban circumcision, given its importance to many people. A dangerous “black market” would be created. As with other forms of potentially risky human enhancement, the best policy is one of harm reduction, not prohibition. Non-medical circumcision should be discouraged, but not prohibited(for further discussion see ‘Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgements of What Is Best for Their Patients’and ‘Liberal Rationalism and Medical Decision-Making’).
Many of the risks of circumcision, such penile injury, herpetic infection and pain are almost entirely avoidable with modern surgery. What seems ethically clear is that male circumcision in developed countries should only be performed by a properly qualified paediatric surgeon in a hospital setting, with appropriate analgesia. Where religion requires that circumcision be conducted by a religious official, that official should be surgically trained or participate in the surgical procedure in a way that does not compromise the interests of the infants.
Religious practices have been adapted in other cases. Circumcision is a challenge to modern religion to embrace modern medicine and surgery to protect the child.
There is one objection to circumcision which is common in folk debate but which should be dismissed. Some people would object that the removal of the foreskin is “not natural” and so should not be performed on a child. This kind of naturalistic objection dominates discussion of enhancement in general.
Medicine, of course, is not natural. Vaccination is not natural. Pain relief is not natural. In both these cases, some religious fundamentalists objected on the grounds that vaccination and pain relief in labour thwarted God’s will. Thankfully, such arguments are no longer popular today. We have embraced many non-natural medical interventions which are not aimed at treating diseases, such as contraception, abortion and cosmetic surgery. The first two enhance reproductive freedom. Indeed, elective Caesarean section is not natural but an increasingly attractive option for some women as a way to maximize the outcome of pregnancy for their baby and themselves.
Imagine a child was undergoing an abdominal surgical procedure for some pain. The surgeon inspects the appendix and it is normal. However, the surgeon decides to remove the healthy appendix anyway to prevent future appendicitis and because the procedure was already in progress. Whether such a decision was right does not turn on whether natural bodily integrity is important to preserve, or whether there is some right to an appendix, but on the risks and benefits of removing a healthy appendix in this situation.
Circumcision is not natural. Whether it is an enhancement depends on the way it is performed and the situation in which it is performed. It is clear that the routine circumcision of male infants that was practiced in many parts of the developed world is no longer justified or necessary. However, the best practice should be for doctors to engage parents in dialogue about the risks and benefits of circumcision, perhaps attempting to discourage it. But if parents are adamant, frequently for religious reasons, then the procedure should be performed by a surgical professional in a hospital environment where the risks are minimized and hopefully removed entirely.
In cases of controversial contested enhancement, the best social policy is one of harm reduction, not prohibition.
Post script: sex, the foreskin and enhancement
Another objection stereotypical of the enhancement debate occurs in the male circumcision debate. Some claim that circumcision reduces sexual function, though others deny this. Thus some objectors claim that the foreskin is necessary for optimal sexual functioning.
Let’s assume for argument’s sake that circumcision does reduce sexual sensitivity (though the evidence on this appears conflicting). It does not follow that the male foreskin is necessary for optimal sexual functioning. The possibility of enhancement implies that we, at some point, may be able to do better than nature. That is, at some point in the future artificial foreskins may be available that surpass the natural variety in promoting sexual pleasure.
Bizarrely, there are already attempts to replicate nature – there are artificial foreskins (for example, the SenSlip). It is only a matter of time before these are better than what nature provided. The results of nature are not the result of design (even religious fundamentalists agree with this in the case of the foreskin), but of blind evolutionary processes which enable survival and reproduction in a particular evolutionary niche. It is possible, in principle, to do better than the foreskin.
Finally, if the foreskin is important to sexual functioning, there might be opportunity for further compromise. Circumcisions can be comparatively ‘tight’ or ‘loose’. Loose circumcisions preserve some of the rolling action in the prepuce that acts as a natural lubricant. One form of harm minimization that would respect religious liberties while reducing loss in sexual function would be to try to ensure all circumcisions are ‘loose’.*
Dialogue and compromise may be preferable to extremist positions such as zero-tolerance prohibition and laissez-faire.
*Thanks to Bennett Foddy for this point.