We’ve come a long way, as a species. And we’re better at many things than we ever were before – not just slightly better, but unimaginably, ridiculously better. We’re better at transporting people and objects, we’re better a killing, we’re better at preventing infectious diseases, we’re better at industrial production, agricultural and economic output, we’re better at communications and sharing of information.
But in some areas, we haven’t made such dramatic improvements. And one of those areas is parenting. We’re certainly better parents than our own great-great-grandparents, if we measure by outcomes, but the difference is of degree, not kind. Why is that? Continue reading
This is a brief note to alert the readers of Practical Ethics that research by myself, Anders Sandberg, and Julian Savulescu on the potential therapeutic uses of “love drugs” and “anti-love drugs” has recently been featured in an interview for the national Canadian broadcast program, “Q” with Jian Ghomeshi (airing on National Public Radio in the United States).
Readers may also be interested in checking out a new website, “Love in the Age of Enhancement” which collects the various academic essays, magazine articles, and media coverage of these arguments concerning the neuroenhancement of human relationships.
The first two weeks of 2013 were marked by a flurry of news articles considering “the new science” of pedophilia. Alan Zarembo’s article for the Los Angeles Times focused on the increasing consensus among researchers that pedophilia is a biological predisposition similar to heterosexuality or homosexuality. Rachel Aviv’s piece for The New Yorker shed light upon the practice of ‘civil commitment’ in the US, a process by which inmates may be kept in jail past their release date if a panel decides that they are at risk of molesting a child (even if there is no evidence that they have in the past). The Guardian’s Jon Henley quoted sources suggesting that perhaps some pedophilic relationships aren’t all that harmful after all. And Rush Limbaugh chimed in comparing the ‘normalization’ of pedophilia to the historical increase in the acceptance of homosexuality, suggesting that recognizing pedophilia as a sexual orientation would be tantamount to condoning child molestation.
So what does it all mean? While most people I talked to in the wake of these stories (I include myself) were fascinated by the novel scientific evidence and the compelling profiles of self-described pedophiles presented in these articles, we all seemed to have a difficult time wrapping our minds around the ethical considerations at play. Why does it matter for our moral appraisal of pedophiles whether pedophilia is innate or acquired? Is it wrong to imprison someone for a terrible crime that they have not yet committed but are at a “high risk” of committing in the future? And if we say that we can’t “blame” pedophiles for their attraction to children because it is not their “fault” – they were “born this way” – is it problematic to condemn individuals for acting upon these (and other harmful) desires if it can be shown that poor impulse control is similarly genetically predisposed? While I don’t get around to fully answering most of these questions in the following post, my aim is to tease out the highly interrelated issues underlying these questions with the goal of working towards a framework by which the moral landscape of pedophilia can be understood. Continue reading
On the morning of December 14th, 20-year old Adam Lanza opened fire within the halls of Sandy Hook Elementary School in Newtown, Connecticut, killing 20 children and six adult staff members before turning his gun on himself. In the hours that followed, journalists from every major news station in the nation inundated the tiny town, and in the days that followed, the country as a whole started down a familiar path characterized best by the plethora of ‘if only-isms’.
It began in the immediate hours following the shooting: if only we had stricter gun control laws, this wouldn’t have happened. This is perhaps an unsurprising first response in a country that represents 4.5% of the world’s population and 40% of the world’s civilian firearms. Over the next few days, as a portrait of the shooter began to emerge and friends and family revealed that he was an avid gamer, a second theory surfaced in the headlines: if only our children weren’t exposed to such violent video games, this tragedy never would have occurred.  And just in the past few days, public discourse has converged on the gunman’s mental health, the general conclusion being that if only we had better mental health services in place, this wouldn’t have happened. (The National Rifle Association [NRA] even tried to jump on board, suggesting that “26 innocent lives might have been spared” if only we had an armed police guard in every school in America. They seem to be the only ones taking themselves seriously.) Continue reading
“Treating” homosexuality in minors: Protected free speech or child abuse?
Should mental health providers be allowed to try to “cure” minors of their homosexuality?
Regularly, media reports reveal that Western companies have children working in their manufactures in Third or Second World countries – may it be for clothing, furniture or, as recently, technical gadgets. Such reports are often followed by people calling for a boycott of the company’s products.
‘Work done by children’ is an extremely broad expression. There is nothing else than to vehemently fight against ‘work’ that goes along with gross abuse like forced labour, prostitution, involvement in drug trafficking, carrying heavy weights or any other activity putting a child’s physical or mental wellbeing in danger.
But also in cases where no such exploitation is taking place, we have good arguments against children doing work. We fear they might be ‘the cheapest to hire, the easiest to fire, and the least likely to protest.’ And we don’t want them to be deprived of the opportunity to get a proper education.
So what should we do if we read media reports about a company employing minors? Even if we don’t know the exact circumstances: joining a boycott of this company’s products can’t be wrong, can it?
By Brian Earp
This is a rough draft of a lecture delivered on October 1st, 2012, at the 12th Annual International Symposium on Law, Genital Autonomy, and Children’s Rights (Helsinki, Finland). It will appear in a revised form—as a completed paper—at a later date. If you quote or use any part of this post, please include the following citation and notice:
Earp, B. D. (forthcoming, pre-publication draft). Assessing a religious practice from secular-ethical grounds: Competing meta-ethics in the circumcision debate, and a note about respect. To appear in: Proceedings of the 12th Annual International Symposium on Law, Genital Autonomy, and Children’s Rights, published by Springer. * Note, this is not the finished version of this document, and changes may be made before final publication.
* * * * * *
Hello. My name is Brian Earp; I am a Research Associate [Editor’s note: now Research Fellow] in the philosophy department at the University of Oxford, and I conduct research in practical ethics and medical ethics, among some other topics. As you saw from the program, my topic today is the ethics of infant male circumcision—specifically as it is performed for religious reasons.
I should begin by saying that in debates on this topic, I’ve noticed that there is sometimes a very serious reluctance to address the issue of religious motivation directly. And this is true even among those who are otherwise outspoken in their opposition to circumcision on other grounds. For example, in 2007, Harry Meislahn of the Illinois chapter of NOCIRC—a prominent anti-circumcision organization—was asked if he would argue that Jews should discontinue circumcising their babies, along with secular or non-religiously-motivated parents who might be doing it out of a sense of cultural habit, or because they thought it could be good for the baby’s health. He replied: “No. I don’t prescribe for Jews, at all. This is an absolute loser. I’m not Jewish. … I withdraw from this field because it generates lots of heat [and] very little light” (quoted in Ungar-Sargon, 2007).
(He went on to say, however: “I would maintain that a Jewish baby feels pain just as a non-Jewish baby feels pain, and there are Jewish men, just like non-Jewish men, who are real angry that this was done to them.”)
The philosopher Iain Brassington has recently expressed a similar concern. On the Journal of Medical Ethics blog, he wrote: “Though I [have] mentioned the [recent] decision of the German court that ritual circumcision constituted assault, I’ve wanted to stay clear of saying more about it [because] it seemed too potentially toxic” (Brassington, 2012, para. 2). To give another example, the bioethicist Dan O’Connor from Johns Hopkins University—in an article entitled “A Piece I Really Didn’t Want to Write on Circumcision”—has recently said that: “when [a reporter] calls my work and ask[s] if there is a bioethicist in the house who will give the anti-circumcision viewpoint, I beg off. … I would be a terrible interviewee anyway, [since I would have to preface] my every argument against circumcision with rambling spiels about what loving and caring parents my [Jewish] friends are” (O’Connor, 2012, para. 10).
Finally, as a philosopher colleague of mine wrote to me in a recent email: “To be honest with you, I am strongly anti-circumcision. The reason I don’t [write papers on the topic] is that I have a large number of circumcised Jewish … friends who I think would be offended if they found out [about my views]” (personal communication, May 17, 2012).
Like all of the individuals I have just mentioned, I find myself in the position of being largely skeptical about the moral permissibility of ritual circumcision—for reasons I will give in just a moment—and yet I am well aware that since I myself am neither Jewish nor Muslim, I have an especially good chance of offending someone who is when I subject the practice to critical scrutiny. This chance is, of course, magnified by the fact that circumcision is seen by some as being a central, or even obligatory, ritual in each of these religions. And just like the bioethicist Dan O’Connor and the philosopher-colleague whose email I quoted above, this potential for causing offense extends to many of my closest friends, to colleagues of mine, and to a pretty wide range of people I have no particular interest in irritating.
So perhaps there is a reason to hesitate. Because religious convictions are a deep, and certainly emotionally-charged, aspect of the lives of so many, attempts to question a religiously-motivated practice—especially by one who is not religious, or differently religious—can lead to outcomes that are very far from productive. To illustrate, here is a quote from a comment I received on my Facebook page in response to a post I published on this topic in 2011:
Sorry Brian, you’re entitled to your non-Jewish opinion, but we’ve been doing very nicely for 5,771 years with this ancient tradition of our people. And I don’t even know who the hell you are, but this kind of nonsense just pisses me off. (quoted in Earp, 2011).
So, as I say, sometimes the conversation doesn’t turn out to be as productive as I’d hoped. Part of what I think is going on here, is that we have an unwritten rule in polite society that says that certain ideas or practices are out of bounds for critical discussion. The English humorist Douglas Adams made a similar point in a speech he gave in Cambridge in 1998. Talking about religious customs specifically, he said:
Here is an idea or a notion that you’re not allowed to say anything bad about; you’re just not. Why not? — because you’re not!’ If somebody votes for a party that you don’t agree with, you’re free to argue about it as much as you like; everybody will have an argument but nobody feels aggrieved by it. If somebody thinks taxes should go up or down you are free to have an argument about [that], but on the other hand if somebody says ‘I mustn’t move a light switch on a Saturday’, you say, ‘Fine, I respect that’. (Adams, 1998)
Now, obviously I don’t have any arguments about whether—or when—it’s OK to use a light switch. I do want to focus, however, on this idea about respect. I don’t think it actually is showing respect to anyone to give an automatic pass to anything she says or does just because it might have to do with her religious practice. I think that sort of avoidance has much more to do with fear than with respect—fear that you might upset the person, or fear that you might sound stupid for not knowing more about the custom, or fear that the conversation might turn out to be awkward, or whatever the fear might be.
Respect, it seems to me, is very different from this. Respect has to do with taking certain positive things for granted. In my own experience, for example, I sometimes talk with my Jewish and Muslim friends about my views on the ethics of circumcision. Some of these friends are in agreement with me that ritual circumcision may be, at the very least, morally suspicious; but others hold a different view. Whatever their perspective, however, I respect these friends enough to know that they’ll listen to my arguments with an open mind, really consider what I’m saying, and engage in debate productively. And most of the time, to be sure, they respect me enough to know that I’ll extend them the same courtesy, which I will. Respect is not about avoidance, then, at least in my opinion. It is about the opposite of avoidance—it is about engagement, conversation, communication—so long as these are done in a fair-minded and well-intended way.
I also think that there is something potentially very condescending about the idea that someone’s feelings—religious or otherwise—might be so fragile and irrational that instead of just saying what you really believe, and having an honest conversation about it, you should tiptoe around, and blush, and make excuses, and pretend that you don’t mean what you mean or think what you think. That doesn’t seem like real respect either—and I think my religious friends would be quite rightly insulted if they thought that I was operating out of this kind of mindset when I talked with them about their beliefs and practices.
So, having said all that, in what follows, I am simply going to trust that I can engage directly with the ethical arguments for and against religiously-motivated circumcision, without having to hedge or qualify, or worry about whether I might offend someone for whom this practice is seen as being too sacred to talk about. People are free to disagree with me, of course, and I will be happy to take on board any constructive criticism they may have to offer. I am open to changing my views. But I do want to spend the rest of my time dealing directly with the arguments.
I will start with an argument against religiously-motivated circumcision, and then I will consider some common objections.
The premise of my argument is this. As a rule, it should be considered morally impermissible to sever healthy, functional tissue from another person’s body—perhaps especially if the tissue cannot “grow back,” and even moreso if it comes from the person’s genitals—without first asking for, and then actually receiving, that person’s informed permission.
Now, ordinarily, and with respect to almost every case we could imagine, this would count as a foundational ethical principle. It does presume that the individual is an appropriate unit for moral analysis; it does presume that individuals have certain rights, among which is the right to bodily integrity; and it does presume that the infringement of that right can only be permitted under conditions of informed consent (or in circumstances like a medical emergency).
Of course, someone could question or even deny any one of those presumptions, but then they would have to come up with a better way to ground their own moral theories that didn’t inadvertently create a justification for having parts of their body cut off without their permission. I’m not saying this is impossible, but it’s something to look out for. And actually, I think there is a competing meta-ethic hidden within religious defenses of circumcision—and it’s one that downplays the relevance of the individual, and specifically the individual as a child, to independent moral consideration—but I will come onto that point a little bit later on.
For now, let us assume that the ethical premise I’ve given is a reasonable one, and let’s take it for granted to see what follows. Well, since ritual circumcision involves the removal of healthy, functional, erogenous tissue from the genitals of a newborn or young child, and since babies and young children are incapable of giving meaningful consent to such a procedure, our principle is obviously violated, and therefore circumcision is unethical on this theory.
Now, this is not just abstract philosophy. As most of us know, a recent decision by a German court in Cologne—which said that ritual circumcision is a form of assault—relied on ethical reasoning very similar to what I have just laid out. And as we also know, this conclusion was not very readily accepted by a large number of religious leaders within Judaism and Islam, and even within some corners of Christianity. This last part should be a little surprising, of course, since the founder of Christianity—Paul (or Saul) of Tarsus—was explicitly and even energetically opposed to the practice of circumcision, as he made very clear in his letters to the earliest Christian churches. And, as Sami Aldeeb pointed out in his speech yesterday (see Aldeeb, 2012), this was the official church position for a pretty long time.
But, leaving that aside, what this reaction to the Cologne decision means is that we can look at some objections to the argument I have given that are not just hypothetical, but that have actually been given—and very recently—as serious attempts to defend ritual circumcision against the charge that it is an unethical practice. And I would like to consider a few of these objections one at a time.
The first objection is that religious circumcision is an ancient tradition, and one that is felt to be very important to the practice of Judaism or Islam. For example, Dieter Graumann, the president of the German Central Council of Jews, has said, “Circumcision of newborn boys is a fixed part of the Jewish religion and has been practiced … for centuries” (quoted in Hall, 2012). He then went on to criticize the Cologne ruling as being “outrageous” and “insensitive.” An Islamic representative, Ali Demir, made a similar point: “this is a … procedure,” he said, “with thousands of years of tradition behind it and [a] high symbolic value” (ibid.).
Now, as I was preparing this talk, I wondered about whether I should count these sorts of statements as being actual “objections” to the ethical case made by the German court. Seemingly, it should go without saying that something’s having been done for a long time does not in any way amount to an argument for its moral permissibility. The thing might actually be morally permissible, of course, but this just wouldn’t be the way to show it. The more I thought about it, however, the more I came to believe that I couldn’t just pass over the “ancient tradition” argument as a sort of a straw man. This is because this exact line of reasoning has been repeatedly cited in recent weeks, by a number of influential religious leaders, in a seemingly sincere attempt to shape public discussion on this topic. So I need to spend a little bit of time responding to this view, with what would otherwise be a statement of the obvious:
Many practices that are now regarded as being very clearly unethical had been going on for an extremely long time before anyone had the idea to question them. Examples include slavery, footbinding, the cutting of female genitals, and beating disobedient children with sticks. Usually these practices persisted without much alarm for one of two reasons. Either the moral standards that they would eventually be seen as violating had not yet had been developed, or those standards did exist for other cases but just weren’t commonly seen as applying to the practice itself until enough people sat down and made the connection. I think what’s happening right now with circumcision is not so much the first of these, but more the second. In other words, the relevant ethical principles—about bodily integrity, consent, protecting the vulnerable in society, and so on—have been available to us for quite some time now. It’s just that we’re so used to circumcision as a cultural habit, that many people fail to see how patently inconsistent this practice is with the rest of their own moral landscape.
My colleague Anders Sandberg has given an argument for this view that I think is worth considering in a little bit of detail. He writes:
It is interesting to consider a fictional case: suppose I come up with a religion that claims [that] male nipples are bad, and should be removed in infancy in order to prevent various spiritual and medical maladies, as well as showing faith. I have no doubt that getting this new practice approved anywhere would be very hard, no matter how much I and my adherents argued that it was a vital part of our religion. No doubt arguments about unnecessary mutilation and infringement of children’s self determination would be made, and most would find them entirely unobjectionable. If my religion joined the chorus of religious critics to the German decision it is likely that the others would not appreciate our support: after all, they do not want approval for all religious surgery, just a particular one. And nobody likes to be supported by an embarrassing supporter.
But this seems to suggest that what is really is going on is [a] status quo bias and [something about] the social capital of religions. We are used to circumcision in Western culture, so it is largely accepted. It is very similar to how certain drugs are regarded as criminal and worth fighting, yet other drugs like alcohol are merely problems: policy is set, not based on actual harms, but … on a social acceptability scale and who has institutional power. This all makes perfect sense sociologically, but it is bad ethics. (Sandberg, 2012)
Now, I don’t think that Anders’ scenario is completely water-tight, and I don’t think that a theologically sophisticated religious person would find the “male nipples” example to be an appropriate or a complete analogy. But I do think that Anders is onto something when he suggests that if the “ancient tradition” objection does carry any weight in this conversation, it is for sociological reasons rather than ethical ones. In fact, I don’t see that this objection does any argumentative work for the defender of religious circumcision: It might work as a rhetorical strategy to affirm the social capital of his religion, but it isn’t an argument.
OK, I would like to move on to a second objection that I have heard a number of times in response to the Cologne decision, and one that is potentially a little harder to deal with. This objection is that circumcision is divinely mandated and hence obligatory for religious Jews and, according to some interpretations, maybe Muslims as well. In Judaism, as we all know, the mandate is even specific about the exact timing of the procedure: according to the book of Genesis, the baby’s foreskin must be removed on the eighth day after birth. And this timing is, according to a number of vocal religious commentators, quote, “non-negotiable.”
I want to start with this idea about non-negotiability. My first question is, according to whom? Certainly people like Dieter Graumann, the president of the German Central Council of Jews I mentioned before, has repeated this claim (see, e.g., Gedalyahu, 2012). And so have a number of influential, usually conservative or Orthodox Jews, some of whom have been saying some very authoritative-sounding things on behalf of, quote, “the Jewish people” (see, e.g., Harkov, 2012). But this seems to me to be somewhat disingenuous. As anyone who knows any actual Jewish people can attest, “the Jewish people” is not a collection of uncritical sheep who all think the same thing. “The Jewish people” do not uniformly adhere to the exact same theology. And, specifically, “the Jewish people” includes a large and growing number of individuals—including, in my view, individuals with exceptional moral insight—who simply do not believe that circumcision is a “non-negotiable” component of their religion (e.g., Goldman, 1998; Goodman, 1999; Glick, 2001; Milgrom, 2012; Pollack, 2013; Sadeh, 2013; Ben Yami, 2013; Ungar-Sargon, 2013; Steinfeld, 2013). I suppose someone could argue that certain conservative representatives within Judaism are theologically correct, and everyone else is deluded, but that would take a lot of time and energy and it would be an argument that would probably fail to convince anyone who didn’t already hold that view. Also, it would be much harder to express as a simple axiom, which is what the newspapers seem to appreciate. So instead we are confronted with a string of public declarations that make it sound like Judaism a monolith and that there are no meaningful debates to be had about the religious requirements implied by certain passages within the Torah.
Another point is this—and, again, I wish I were attacking a straw man here, but based on the mainstream, public debate I have seen going on in the last few weeks, I feel that some very basic points about the philosophy of religion need to be brought up as reminders. First, even though a person or a group of people may sincerely believe that a given practice is divinely mandated, it doesn’t necessarily follow that it is divinely mandated. Second, even if something really is divinely mandated, it doesn’t necessarily follow that it is non-negotiable. Third, even if something is felt to be non-negotiable, it doesn’t necessarily follow that it is morally permissible. And this brings us very quickly to the classic dilemma about what you’re supposed to do when God tells you to do something unethical.
We all know the puzzle about Abraham and Isaac: God tells Abraham that he must sacrifice his son. So what should Abraham do? There are a couple of well-known possibilities in logical space here. One option is that Abraham should assume that he’s misunderstood something. Since killing innocent children is unethical, and since God is a morally perfect being, God must not really have said that. Another option is that he starts to wonder if maybe he wasn’t really talking with God after all, but maybe it was Satan, or maybe just a voice in his own head. Or he can conclude that God is not as morally developed he used to think, or is even a source of evil. Whichever way he chooses to go, the correct answer from an ethical perspective is: No, I will not kill my son.
Obviously a lot of people have looked at this case over the centuries, and I’m not the first one to give the analysis you just heard. As a number of commentators have noticed, there is a pretty big conflict in this story between the requirements of morality and the requirements of the divine mandate. Kierkegaard (1843) thought he could solve the puzzle by talking about the “teleological suspension of the ethical.” This is the idea that we should use our faith to rise above mere ethics and morality and enter into a higher, and more absolute relationship with the divine. Now I think that this is a very dangerous thing to propose. And I think it has real consequences, one of which is that the religiously-motivated suspension of morality has been a source of a lot of suffering, for a lot of people—including marginalized and vulnerable people—for a very long time.
But my sense, in fact, is that the large majority of contemporary religious believers don’t actually do this. What I mean is, when something is felt to be unethical, what they actually do is one of two things. Either they revise their understanding of what is divinely required in the first place; or else they engage in some very complicated psychological maneuvers—many of them unconscious—that lead them to conclude that the thing must not be unethical after all, even though it really looks like it is from every other perspective. So for circumcision, for example, they might downplay the harms, risks, and drawbacks of the procedure; or they might use euphemisms like “snip” or “flap of skin” when they talk about what it is that is being cut off; or they might emphasize the postulated health benefits (while ignoring disputes over their scientific credibility); or they might exaggerate the differences with female genital cutting, or exaggerate the similarities to vaccination, or whatever: a whole range of strategies that make it seem like circumcision isn’t so bad to begin with.
I have seen one major exception to this approach, however. And this comes from an interview conducted by the filmmaker Eliyahu Ungar-Sargon (see Ungar-Sargon, 2007). The clip starts with an Orthodox Rabbi named Hershy Worch talking about circumcision. He says:
It’s painful, it’s abusive. It’s traumatic, and if anybody who’s not in a covenant [with God] does it, I think they should be put in prison. I don’t think anybody has an excuse for mutilating a child. … Depriving them of [part of their] penis. We don’t have rights to other people’s bodies, and a baby needs to have its rights protected. I think anybody who circumcises a baby is an abuser, unless it’s absolutely medically advised. Otherwise – what for … ?
After a moment of what I interpreted as stunned silence, you can hear Eliyahu ask a pertinent question:
How does this covenant alleviate your ethical responsibility that you just so articulately posed? How is it that being in this covenant exempts you from that term … How can you not call yourself an abuser?
The Rabbi actually cuts him off and says:
I’m an abuser! I do abusive things because I am in covenant with God. And ultimately God owns my morals, he owns my body, he owns my past and future, and that’s the meaning of this covenant – that I agreed to ignore the pain and the rights and the trauma of my child to be in this covenant.
Now, I must tell you that—in an important sense—I have a lot of respect for this Rabbi. I think that his statements reach a level of honesty, and accuracy, and even Kierkegaardian philosophical consistency, that has otherwise been lacking from the public conversation on this issue. Here is someone who acknowledges, without hedging or qualification, that he is mutilating the penis of an infant. But he doesn’t take this knowledge as an excuse to go back to his scripture and re-interpret the original commandment, nor does he allow himself to believe that circumcision is a harmless little snip. He just doesn’t resolve the dissonance. Instead, he takes responsibility for his religious commitments, as well as for his behavior—and I think that in doing this, he gives us a rare and unmediated example of the power of religious belief to justify (what the Rabbi himself acknowledges is) the painful assault of a child.
So what should we do with this? I started with the idea that it should be considered morally impermissible to remove healthy, functional tissue from another person’s body without obtaining that person’s permission. And since circumcision violates that rule, I said it was unethical. Then I tried to show that the “ancient tradition” objection doesn’t get us off the hook, nor do the points about circumcision’s being divinely mandated or non-negotiable. So at this point, it seemed like we should be able to stick, at least provisionally, with the conclusion that circumcision is indeed a morally impermissible act.
But now we have something different. Now we have this idea to think about that maybe there’s something bigger than ethics – something like this direct relationship to the divine.
I said at the beginning that I thought there was a hidden meta-ethic behind religious defenses of circumcision, and I think that now we’re beginning to see what it might be. I think it’s this idea that an individual human being, such as a child, is not really the ultimate object of moral analysis. Instead there are other obligations, obligations that come from a community identity, from concern about historical continuity, or ritual continuity; obligations that come from a special covenant between a god and a group of people. And the effect of all this is that the individual child becomes a sort of non-entity. His body becomes not his body. His pain becomes an instrument in fulfilling a higher purpose.
And so, I think before we can get anywhere in this discussion, we are going to have to acknowledge that that is a very different meta-ethic. I think we have to acknowledge that certain religious commitments are based on a particular view of the universe, and that this view is in direct conflict with a “Western” moral focus on: individuals, on human rights adhering to those individuals as individuals, and on the notion that children and infants, above all, need special protection because they can’t defend those rights on their own.
I don’t have a good answer to this conflict. Obviously one can, in theory, adopt any meta-ethical view under the sun. One can adopt a view that says that parts of children’s bodies may be removed without their consent, if that is what a god requires; or one that says that animals should be set on fire and burnt at the altar (again, if that is what a god requires); or one that says that sparing the rod will spoil the child; or that our daughters should be stoned to death if they disobey, or whatever we want. All of these views are logically possible, and many of them are historically accurate. Many of them find direct textual support as well in the holy books of major religions.
But that isn’t how we tend to think about things in modern, Western societies; and it isn’t how we’ve set up our laws. We have a different sort of worldview that we use to make sense of concepts like individual rights, including the right to bodily integrity. So the idea I want to leave you with is this. If we think that there is any chance that we should give up these basic concepts—so that we can defer to a worldview that says that things like community identity are more important than individual identity (and the right to decide what happens to one’s own flesh)—then we’ll have to pay the price of that choice and face it honestly. And that means that the very same individuals who are asking for the religious freedom to perform circumcisions in a secular society, might have to be prepared to give up their own right to complain if someone wanted to cut off a part of their body, or interfere with their genitals without their consent. That is, as I say, a logically possible universe. But it isn’t one that I would want to live in, and I am not convinced that you can have it both ways.
Adams, D. (1998). Is there an artificial god? Digital Biota 2. Lecture conducted from the University of Cambridge, Cambridge, UK. Available at: http://www.biota.org/people/douglasadams/.
Aldeeb, S. (2012). Islamic concept of law and its impact on physical integrity: comparative study with Judaism and Christianity. 12th Annual Symposium on the Law, Genital Autonomy, and Children’s Rights. Lecture conducted from Helsinki, Finland. Text available at: http://blog.sami-aldeeb.com/2012/10/01/conference-in-helsinki-30-september-2012-oral-version-on-circumcision/.
Ben-Yami, H. (2013). Circumcision: What should be done?. Journal of Medical Ethics, 39(7), 459-462.
Brassington, I. (2012, July 17). More on circumcision in Germany. Journal of Medical Ethics blog. Available at: http://blogs.bmj.com/medical-ethics/2012/07/17/more-on-circumcision-in-germany/.
Earp, B. D. (2011, August 26). On the ethics of non-therapeutic circumcision of minors, with a post script on the law. Practical Ethics (University of Oxford blog). Available at: http://blog.practicalethics.ox.ac.uk/2011/08/circumcision-is-immoral-should-be-banned/
Gedalyahu, T. (2012, July 3). Berlin hospital suspends circumcisions. Israel National News. Available at: http://www.israelnationalnews.com/News/News.aspx/157454#.UHxey46RMV0.
Glick, L. B. (2001). Jewish Circumcision. In Understanding Circumcision (pp. 19-54). Springer US.
Goldman, R. (1998). Questioning circumcision: A Jewish perspective. Boston: Vanguard publications.
Goodman, J. (1999). Jewish circumcision: an alternative perspective. BJU international, 83(S1), 22-27.
Hall, A. (2012, June 27). Religious groups outraged after German court rules circumcision amounts to ‘bodily harm.’ Daily Mail Online. Available at: http://www.dailymail.co.uk/news/article-2165431/Religious-groups-outraged-German-court-rules-circumcision-amounts-bodily-harm.html.
Harkov, L. (2012, August 22). German rabbi circumcision case sparks outrage. The Jerusalem Post. Available at: http://www.jpost.com/JewishWorld/JewishNews/Article.aspx?id=282134.
Kierkegaard, S. (1843/1946). Fear and trembling. In R. Bretall (Ed.) A Kierkegaard Anthology. New Jersey: Princeton University Press.
Milgrom, L. (2012). Can you give me my foreskin back? Open letter to Bent Lexner, Chief Rabbi of Denmark. Originally published as ‘Kan du give mig min forhud tilbage?’ in the Danish Daily Politiken. English translation available at: http://justasnip.wordpress.com/2013/01/19/can-you-give-me-back-my-foreskin-full-translation/.
O’Connor, D. (2012, September 14). A piece I really didn’t want to write on circumcision. BioethicsBulletin.org. Available at: http://bioethicsbulletin.org/archive/piece-i-didnt-want-to-write/.
Pollack, M. (2013). Circumcision: Gender and Power. In Genital Cutting: Protecting Children from Medical, Cultural, and Religious Infringements (pp. 297-305). Springer Netherlands.
Sadeh, E. (2013). Circumcision from the perspective of protecting children. Available at: http://www.savingsons.org/2013/06/circumcision-from-perspective-of.html.
Sandberg, A. (2012, June 28). “It is interesting to consider a fictional case …” [Web log comment]. Posted to: Earp, B.D. (2012, June 28). Of faith and circumcision: Can the religious beliefs of parents justify the non-consensual cutting of their child’s genitals? Practical Ethics (University of Oxford blog). Available at: http://blog.practicalethics.ox.ac.uk/2012/06/religion-is-no-excuse-for-mutilating-your-babys-penis/.
Steinfeld, R. (2013, Noveber 26). It cuts both ways: A Jew argues for child rights over religious circumcision. Haaretz. Available at: http://www.haaretz.com/jewish-world/the-jewish-thinker/.premium-1.560244.
Ungar-Sargon, E. (Producer and Director). (2007). Cut: Slicing through the myths of circumcision [Film]. Los Angeles: White Letter Production Studios.
Ungar-Sargon, E. (2013). On the impermissibility of infant male circumcision: a response to Mazor (2013). Journal of Medical Ethics, doi:10.1136/medethics-2013-101598.
 Just as with Mr. Meislahn, he did nevertheless go on to say more. See: http://blogs.bmj.com/medical-ethics/2012/07/17/more-on-circumcision-in-germany/.
 Some of these articles were published after the present lecture was delivered. They are cited here simply to give an indication of some of the most recent Jewish voices opposed to circumcision.
By Charles Foster
Fast food permanently reduces children’s IQ, a recent and unsurprising study reports.
What should be done? The answer is ethically and legally simple. Parents who feed their children junk food, knowing of the attendant risks, are child-abusers, and should be prosecuted. If you hit a child, bruising it, you are guilty of a criminal offence. A bruise on a child’s leg is of far less lasting significance than the brain damage produced by requiring a child to ingest toxic junk. A child injured by a negligent or malicious parent can also bring civil proceedings against the parent.
The findings of the recent study mirror those in other jurisdictions. And now that they have been widely disseminated it will be hard for parents to plead ignorance. Continue reading
Some days ago, two 13-year-old boys have been charged with first degree murder in Wisconsin (USA), as reported by the Daily News (New York). Allegedly, they went to one of the boy’s great-grandmother’s home, killed her using a hatchet and hammer, then stole her jewellery and her car – and went for a pizza afterwards.
After giving horrid details of the killing, the Daily News concludes its report with stating that the boys’ defence attorney tries to have the case moved to juvenile court. The reason why these 13-year-olds are not automatically charged as juveniles but stand trial in an adult court is that the USA allows prosecutors to try minors as adults when they commit certain violent felonies. In several states, children as young as 7 can be – and are – tried as adults for some years now. They can be convicted to adult sanctions, including long prison terms, mandatory sentences, and placement in adult prisons. (Since 2005, however, under 18-year-olds can’t be convicted to death sentence any more.)
UPDATED as of 27 May, 2013. See the bottom of the post.
The AAP report on circumcision: Bad science + bad ethics = bad medicine
For the first time in over a decade, the American Academy of Pediatrics (AAP) has revised its policy position on infant male circumcision. They now state that the probabilistic health benefits conferred by the procedure outweigh the known risks and harms. Not enough to positively recommend circumcision (as some media outlets are erroneously reporting), but just enough to suggest that whenever it is performed—for cultural or religious reasons, or sheer parental preference, as the case may be—it should be covered by government health insurance.
That turns out to be a very fine line to dance on. The AAP position statement is characterized by equivocations, hedging, and uncertainty; and the longer report upon which it is based includes a number of non-sequiturs, instances of self-contradiction, and cherry-picking of essential evidence (see analysis below).
The AAP appears to be out of tune with world opinion on this issue. On a global scale, medical authorities remain skeptical about whether circumcision of male minors confers any – let alone significant – net health benefits. Indeed, child health experts in Britain, Germany, Scandinavia, Australia, New Zealand, Canada, and elsewhere are predominately of the view that non-therapeutic circumcision (NTC) confers no meaningful health benefits on balance (considered against drawbacks, harms, and risks), and that it should be neither recommended to parents nor funded by health insurance systems.
Nota bene: these cosmopolitan physicians and the medical boards on which they sit have access to the very same data as the AAP. They just don’t draw the same conclusions.
In view of this empirical uncertainty on the medical question, it is problematic to assert, as the AAP does in its new report, that a person does not retain the right to decide whether he wishes to keep his own healthy foreskin–and thus preserve his genitals intact–and that the right belongs instead to his parents.
On the question of parental rights, a point of comparison is frequently raised, including the example of ear-piercing for little girls. Don’t parents have a right to do that? And how is circumcision any different?
There are two ways to respond to the ear-piercing example (and these responses may serve as templates for other comparable interventions). The first way is to suggest that perhaps ear-piercing, too, should not be permitted before the child herself can weigh in on whether or not she would like to have her own ears pierced. If she understands that it will be painful, that there are certain risks involved, and so on, and yet it’s still something she’d like to undertake, then so be it.
The second, stronger way, is to point out that the two practices—ear-piercing and infant male circumcision—are not remotely commensurate, neither in terms of the interventions themselves, nor their effects. Ear-piercing removes no tissue, does not threaten any bodily function, can be tolerated without anesthesia, and is reversible: the hole will close up over time if the child decides later on that she would like to have her earlobes hole-free.
By contrast, male circumcision removes up to half of the skin system of the penis, eliminates the motile and protective functions of the foreskin, cannot be tolerated without anesthesia, and is irreversible: anyone who resents having had his foreskin removed can never get it back.
Given, then, the substantial differences between ear-piercing and male circumcision—in terms of both the interventions themselves and their necessary (i.e., not just accidental or probabilistic) effects—that are directly relevant to the moral calculus involved in assessing their respective permissibility, much more work would be needed to establish that there is any kind of parity of reasoning between them.
Indeed, those who are skeptical about the ethical soundness of ablating the foreskin in infancy are not typically suggesting that any intervention that breaks the skin of any child at any age—regardless of the level of risk involved, and regardless of the diminishing effects on function, and regardless of the reversibility of the procedure, and regardless of the child’s having had an opportunity to give some input as to the desirability of the intervention—should be considered ethically dubious. Rather, it is precisely the level of harm involved, the degree of functional diminishment, the irreversibility, the impossibility of attaining any input from the person whose body (indeed whose penis) is to be permanently surgically altered, and so on, that mark out infant male circumcision as a specially problematic practice.
Parents can of course give proxy consent for needful therapeutic procedures aimed at treating a known pathology. That is, if the pathology presents a genuine threat to the child, and if the intervention cannot be delayed until the child understands what is at stake, and if there are not safer, more reliable, more effective alternative treatments. A healthy foreskin, however, is not a pathology. It needs no treatment at all. To remove it, therefore, on grounds of “proxy consent” is to misunderstand—quite egregiously—the ethical limits of parental authority.
A more reasonable conclusion than the AAP’s, then, is that the person whose penis it is should be allowed to consider, for himself, the available evidence (in all its chaotic murkiness) when he is mentally competent to do so—and make a personal decision about what is, after all, a functional bit of his own sexual anatomy and one enjoyed without issue by the vast majority of the world’s males.
Health benefits and medical ethics
According to the Seattle-based physicians group Doctors Opposing Circumcision, there is neither a medical nor an ethical case for removing healthy genital tissue from baby boys. They can’t consent to the procedure in the first place, and the bulk of the claimed—yet heavily disputed—health benefits don’t actually apply to them: babies are not sexually active, yet circumcision is supposed to protect chiefly against sexually-transmitted infections and related diseases. In any case, these are afflictions whose prevention is much more soundly assured by the use of a condom (and other safe sex practices) in adulthood than by genital surgery in infancy. With respect to the issue of urinary tract infections in early childhood, remember that these are rare for boys (about 1%), and can be easily treated with antibiotics if and when they do occur—no surgery required. A recent Cochrane Review—the highest standard of medical analysis—found no reliable evidence that circumcision does in fact protect against UTIs, and even studies that do find a link report that 111 circumcisions would have to be performed to prevent a single case of UTI.
So how did the AAP reach its much-hyped, yet ultimately fallacious, and as I will argue, ethically unjustified conclusion?
* * *
First, let us be clear about what their position is. “This is not really pro-circumcision,” explains one of the authors of the technical report behind the new analysis. You wouldn’t know that from reading the week’s headlines, which have taken the “health benefits” narrative and gone running impetuously on to town, but there it is from the horse’s mouth. Instead, the AAP believes that the purported benefits of circumcision are merely “sufficient” to “justify access to this procedure for families choosing it” and to “warrant third-party payment for circumcision of male newborns” if and when it does occur.
Here they depart from their 1999 statement in asserting that (1) the benefits of the surgery definitively outweigh the risks and costs and (2) that it is therefore justifiable to perform the operation without the informed consent of the patient. This does not follow. Just as with the parental “proxy” rule discussed above, in medical ethics, the risk/benefit rule was devised for therapeutic procedures aimed at treating an extant pathological condition, and for minor prophylactic interventions such as vaccination (interventions that, notably, most rational adults would choose for themselves, and that are rarely or never a source of later resentment). It has no relevance to nonessential amputative surgery, especially when it involves the removal of healthy, functional erogenous tissue from the genitals, and when (once again) safer, more effective substitute strategies exist for achieving the same ends.
One might be surprised to learn that the word “condom” does not appear even once in the 28 page AAP report.
In making their risk/benefit calculations, then, the AAP simply leaves out a critical bulk of factors relevant to the equation, including the existence of a range of proven healthcare strategies like condom-use or the administration of vaccines (including an effective HPV vaccine) and antibiotics. If they had taken the time to consider human rights and bodily integrity issues, the function of the foreskin, its value to the individual, and his possible wishes in later life, as well, their computations would arguably yield a different answer.
Some readers will be unaware that the AAP is not a dispassionate scientific research body, but rather a trade association for pediatricians. Those among its members and stakeholders who perform NTCs stand to profit from the procedure, to the collective annual tune of $1.25 billion according to one (albeit not impartial) estimate. Given the yawning potential for a financial conflict of interest, then, there needs to be a very strong, independent medical case for circumcision; and the AAP had better be able to show that it is both the safest and most cost effective means of promoting infant health. Both of these propositions fail, however, as I will continue to show in what follows.
* * *
The AAP has been tossing and turning on the question of circumcision since 1971, when it announced that “There are no valid medical indications for circumcision in the neonatal period.” Emphasis mine. From 1999 until August 27th of this year, the AAP had maintained that the “health benefits” of circumcision were perhaps neck-and-neck with the costs, at best, so that it could not recommend the procedure from a therapeutic perspective. This policy was in line with the still-current official position of every other major medical association in the world. Except, actually, those that now actively campaign against circumcision, such as the Royal Dutch Medical Association in Holland.
For the AAP to revise its stance, then, it stands to reason that something must have changed—either human biology has altered, or some new evidence must have cropped up—to justify tipping the cost-benefit scales away from their recently prior equilibrium. Indeed, the AAP circumcision task force makes much ado of a collection of studies conducted in Africa between 2005 and 2007 purporting to show a link between circumcision and a reduced risk of becoming infected with HIV.
According to the New York Times, these studies include 14 publications “that provide what the [AAP] characterizes as ‘fair’ evidence that circumcision in adulthood protects men from HIV transmission from a female partner.” Notice the phrase in adulthood. The AAP policy, by contrast, is concerned with circumcision in infancy, a procedure for which there is literally no evidence of a protective effect against HIV. Notice also “fair” rather than “good” evidence and that the findings apply exclusively to (heterosexual) (African) (adult) males. This is in contrast to females, for whom circumcision of the male partner is apparently a risk factor for becoming infected with HIV. The New York Times continues:
“Three of the studies were large randomized controlled trials of the kind considered the gold standard in medicine, but they were carried out in Africa, where H.I.V. — the virus the causes AIDS — is spread primarily among heterosexuals.”
There are a number of things to say about these “randomized controlled trials.” First, the trials appear to have been “controlled” in name only, as this exhaustive analysis demonstrates. Clinically relevant flaws included “problematic randomization and selection bias, inadequate blinding, lack of placebo-control … inadequate equipoise, experimenter bias, attrition … not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias … participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).” Hence, as I explained in this earlier post, the “Africa studies” may not have been a clear-cut example of “gold standard” medical research (but see the counterarguments cited in that commentary).
Critics have also pointed out that the “60%” figure that is typically offered as the relationship between circumcision and reduction of HIV infections is the output of a potentially misleading statistical sleight-of-hand: the absolute reduction between the circumcised and intact groups in these studies was just 1.3%. Whether such a reduction will have meaningful ramifications at the population level is the subject of ongoing dispute.
The next thing to highlight is the part of the quote that comes after the “but” – a very important “but” – namely that “[the trials] were carried out in Africa” where, as the article goes on to explain, HIV is mainly a heterosexual phenomenon. Outside of Africa, it is mainly not—it is largely transmitted among injecting drug users and gay men, at least in the United States—which means that even if we were to accept the data from the “randomized controlled” studies, we would have very little evidence that circumcision could be useful in the country that is actually the subject of the AAP’s analysis. The same holds for countries such as Australia, and New Zealand, and indeed most anywhere else in the developed world. The epidemiological and social environments are just flatly non-analogous — as this study shows.
Hence, as even the authors of the AAP report acknowledge, “the degree of benefit, or degree of impact [of circumcision], in a place like the U.S. will clearly be smaller than in a place like Africa.” Of course, we already knew that circumcision does not present a serious obstacle to heterosexual HIV-transmission in the U.S., since the U.S. has both the highest rates of infant circumcision and the highest rates of heterosexually transmitted HIV among industrialized nations. (Obviously there are innumerable confounding factors that can mediate the relationship between HIV rates and circumcision rates in different cultural contexts; the point here is that those factors play a bigger role than the percentage of excised foreskins in a country’s male population.)
But let’s put all that to the side. For even if it were true that circumcision offered a partially protective effect against heterosexually-transmitted, female-to-male HIV/AIDS (in epidemiological environments with very high base rates of such transmission) or other STIs such as HPV (for which, as I stated before, there is an effective vaccine), it would still not follow that the procedure could be ethically performed on infants, much less on infants in the developed world. Given that there is a cheaper, more effective, less invasive, less coercive alternative—namely condom-use and other safe sex strategies in adulthood—it is inconsistent with biomedical ethics to endorse the risky genital cutting of a young child toward the same ostensible end.
As pediatrician, statistician, and professor of clinical medicine Robert Van Howe showed in this recent cost-benefit analysis, infant circumcision is more costly and does more harm than leaving the baby alone, even based on models that start from very generous premises about the potential health benefits of foreskin-removal. If the AAP wants to justify “third party payments” it cannot plausibly claim them for a procure that is more perilous, more ethically problematic, less effective and less cost effective than available alternatives. The government dime is clearly better spent elsewhere.
So let’s review:
- The AAP used to say that circumcision could not be recommended on health grounds, which was, and as I have argued, remains, the only scientifically and ethically credible position for it to maintain.
- In 2012, the AAP revised its position (while stopping short of a recommendation) in light of “new evidence” suggesting that the health benefits could now be said to “outweigh” the harms and risks of the procedure.
- The “new evidence” consists almost entirely of data collected in Africa between 2005 and 2007 suggesting that circumcision in adulthood, in environments suffering from an epidemic of HIV/AIDS, may reduce the risk of contracting HIV through unprotected, female-to-male, heterosexual intercourse (although it may increase the risk of HIV transmission from males to females).
- These data, however, are of “fair” quality (according to the AAP), and show an absolute risk reduction for HIV of only 1.3% between the treatment and control groups. Yet even if these data were taken seriously on their own terms, they would only apply to adult heterosexual males in Africa – not to infants in the United States.
Indeed, the AAP report itself makes essentially this same last point: “… the task force recommends additional studies to better understand the impact of male circumcision on transmission of HIV and other STIs in the United States because key studies to date have been performed in African populations with HIV burdens that are epidemiologically different from HIV in the United States.” Emphasis mine.
Yes, and until those studies are run – and run properly, with consenting populations, under strict ethical controls – it would be prudent for the AAP to abstain from making unsubstantiated claims about the benefits of circumcising infants in the United States. Especially since, as they concede on page 772 of their report “the true incidence of complications after newborn circumcision is unknown.” It should go without saying that if one doesn’t know how often complications occur, then one is ill-equipped to assert that the benefits outweigh them. One wonders how they ran these calculations.
* * *
It took the AAP circumcision “task force” several years to choreograph its latest tap-dance routine. Why it has produced a document that is out of line with both world opinion and the most basic of bioethical principles is a fascinating—and troubling—question, but one which I cannot hope to answer in a single post. Whatever the reason, however, one can be sure that it has more to do with culture than with science. As medical historians and cultural analysts have meticulously documented, circumcision as a birth ritual remains deeply, and uniquely, embedded in American medical culture and in the naïve expectations of doctors and parents alike. This sets the U.S. apart from everywhere else in the developed world—certainly outside of religious communities for whom the ritual is still self-consciously sacramental, and by whom it is performed without needing the rationalization of “health benefits.” Like any ritual, American proponents of circumcision are loath to give it up, for dread of the unknown consequences.
* * *
UPDATE – as of 27 May, 2013
Since this post was first published in August of 2012, some interesting developments have come about. To begin with, two major critiques of the AAP documents were published in leading international journals, one in the Journal of Medical Ethics, and a second in the AAP’s very own Pediatrics. This second critique was penned by 38 distinguished pediatricians, pediatric surgeons, urologists, medical ethicists, and heads of hospital boards and children’s health societies throughout Europe and Canada. These authors stated unequivocally:
Only one of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.
So how did the eight members of the AAP special Task Force on circumcision reach a set of conclusions that are in direct contradiction to those reached by the majority of their peers in the developed world? As I speculated in my original post, and as the title of the critique I just quoted from makes clear, one plausible explanation is that there is: “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.” In other words, the AAP members come from an unusually pro-circumcision culture, such that their ability to evaluate the practice dispassionately may have been at least partially compromised.
Intriguingly, the AAP took the time to respond to this possibility in a formal reply, also published in Pediatrics earlier this year. Rather than thoughtfully addressing the specific charge of cultural bias, however, the AAP elected to boomerang the criticism, implying that their critics were themselves biased, only against circumcision. They write:
The central claim of these authors is that the conclusions of the task force report are culturally biased, leading the task force to a flawed understanding of what constitutes trustworthy evidence and to conclusions that are far from those reached by physicians in most other Western countries. The “obvious” cultural bias to which they refer apparently has its genesis in “the normality of non-therapeutic male circumcision in the US.” All of the commentary authors hail from Europe, where the vast majority of men are uncircumcised and the cultural norm clearly favors the uncircumcised penis. In contrast, approximately half of US males are circumcised, and half are not. Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision.
Let me take this one step at a time. First, the AAP states that “All of the commentary authors hail from Europe.” This is not true. Indeed, this factual error is emblematic of the committee’s lack of attention to detail as displayed in their earlier reports. Instead, the distinguished Canadian pediatrician Noni McDonald, the first woman to become a dean of medicine in Canada, was one of the authors of the commentary in question, and Canada is not in Europe. But perhaps the AAP was close enough. The other 37 authors do indeed hail from various European countries including several from England.
Notice, too, the AAP’s use of the term “uncircumcised penis” — as though it were a penis just waiting to be circumcised. They might also have called it an “intact”, “whole,” or “normal” penis, but their pro-surgery bias colors even their basic terminology. For a comparison, we would not ordinarily refer to a woman’s breasts as “un-mastectomized” in a report about breast cancer.
The AAP’s point about Europe, of course, is that it is a land “where the vast majority of men are uncircumcised and the cultural norm clearly favors the uncircumcised penis.” Perhaps the AAP would like us to believe, then, that it’s really just one regional cultural norm versus another. But in fact the vast majority of cultures worldwide happen to ‘favor’ the ‘uncircumcised’ penis (and indeed most living men possess one), as it is the default, healthy condition for male human beings as well as other animals. By contrast, non-therapeutic genital surgery performed on children is non-normative globally. In the case of female children, it is almost universally condemned.
(I am not arguing, of course, that mere global popularity is evidence in itself for the greater soundness of the dominant norm. There are a number of other reasons to favor the mis-identified “European” perspective, as I will explain in a moment.)
The AAP then states, “In contrast, approximately half of US males are circumcised, and half are not.” But note that this is a recent development. Rates in the US were as high as 80 percent in the late 1980s, and even higher in the 1960s when routine circumcision was at its peak. Note, too, that a recently-achieved 50% circumcision rate does not entail that the American norm regarding circumcision is only 50% favorable. Instead, attitudes toward circumcision in the US remain overwhelmingly positive, and uncircumcised men are frequently subjected to ridicule as well as to ignorant accusations of being “less clean.”
Furthermore, assuming pre-1980 dates-of-birth, and given the very high base rate of circumcision from that earlier period, it is more than likely that 100% of the male Task Force members are, themselves, circumcised. In addition, both the Chair of the committee, Dr. Susan Blank, and one of its members, Dr. Andrew Freedman, have a documented religio-cultural bias in favor of circumcision on top of any baseline “American” one: Dr. Freedman has admitted to ritually circumcising his own son on his parents’ kitchen table. Not only is this in violation of the AAP’s own code of bioethics prohibiting physicians from conducting surgery on family members (let alone in non-sterile environments), it also provides additional evidence of a pro-circumcision bias among the AAP Task Force members.
What does the AAP mean to demonstrate, then, with its reference to the 50% circumcision rate among American males post 1990? That they are “neutral” on the issue? Given that (evidently) not one of the American males actually sitting on the AAP circumcision committee has an intact penis, this citation is somewhat misleading. The strength of the “50/50″ defense is further diluted by the fact that fully 25% of the committee’s members, including its Chair, have reasons to support circumcision that are quite independent from any medical considerations. As Freedman stated in a recent interview, “I [circumcised my son] for religious, not medical reasons. I did it because I had 3,000 years of ancestors looking over my shoulder.”
This is not even to raise the specter of the committee’s bioethicist, Dr. Douglas Diekema. Diekema, too, gives a dangerously wide leeway for parental cultural motivations when it comes to healthcare decisions that may be harmful to children or that may violate children’s rights. Most notably, he has “testified on behalf of parents convicted of child neglect who failed, on religious grounds, to seek medical care for their seriously ill child.” He has also written in favor of certain forms of female circumcision, such as nicking girls’ clitorises with a razor if requested by their parents.
To imply, then, that the AAP committee was simply evaluating the evidence regarding circumcision from a “neutral” or “50/50″ position of normative equipoise is not only misleading, it is literally unbelievable.
But let us go along with the AAP and consider their argument a bit more. Let us even concede that the mainly European authors of the “Cultural Bias” commentary are, themselves, biased—only against circumcision rather than for it. Well … of course they are! Being biased against unnecessary surgeries performed on nonconsenting patients should be the default position of any healthcare professional worthy of the title. Such a position follows naturally from the principles of biomedical ethics that doctors become obliged to uphold upon receiving their medical degrees. The doctors’ country of origin should be of no consequence.
Let me summarize. By suggesting that a cultural norm favoring the non-therapeutic, non-consensual surgical modification of a child’s penis is somehow on par with, or just as reasonable as, a medical-ethical norm favoring the avoidance of such surgery unless it is absolutely required, the AAP committee simply reveals its cultural hand.
The “European” commentators, by contrast: “have ‘a clear bias against circumcision’ the same way they have a clear bias against parentally-elective infant toe amputation.” They should be biased against needless surgical risk, especially when the patient cannot consent. They don’t even need a special “Task Force on Leaving Boys’ Genitals Alone” to prove it.
I will close with an honest suggestion. Perhaps the next time the AAP convenes a committee to consider the prudence of cutting off people’s foreskins, they should think about appointing at least one member who actually has one.