Cultural bias and the evaluation of medical evidence: An update on the AAP
Since my article on the American Academy of Pediatrics’ recent change in policy regarding infant male circumcision was posted back in August of 2012, some interesting developments have come about. 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. In the second of these, 38 distinguished pediatricians, pediatric surgeons, urologists, medical ethicists, and heads of hospital boards and children’s health societies throughout Europe and Canada argued that there is: “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.”
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. To address this interesting allegation, I have updated my original blog post. Interested readers can click here to see my analysis.
Finally, please note that articles from the Journal of Medical Ethics special issue on circumcision are (at long last) beginning to appear online. The print issue will follow shortly. Also be sure to see this recent critique of the AAP in a thoughtful book by JME contributor and medical historian Dr. Robert Darby, entitled: “The Sorcerer’s Apprentice: Why Can’t the US Stop Circumcising Boys?”
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 substantially 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 metaphysics in the circumcision debate, and a note about respect. To appear in G. C. Denniston, F. M. Hodges, & M. F. Milos (Eds.), 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.
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My name is Brian Earp; I am a Research Associate 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.
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 say that the probabilistic health benefits conferred by the procedure just slightly outweigh the known risks and harms. Not enough to come right out and 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. But fear not: the AAP policy committee comes equipped with tap shoes tightly-laced, and its self-appointed members have shown themselves to be hoofers of the nimblest kind. Their position statement is full of equivocations, hedging, and uncertainty; and the longer report upon which it is based is replete with non-sequiturs, self-contradiction, and blatant cherry-picking of essential evidence.
VIDEO DEBATE LINKED TO BELOW – ARI KOHEN AND I DISCUSS THE ETHICS OF RELIGIOUSLY-MOTIVATED CIRCUMCISION
Ari Kohen doesn’t like my recent post about circumcision—the one in which I argue that it is unethical to remove healthy tissue from another person’s body without first getting his permission. I then go on to say that religious justifications cannot override this basic principle. Here’s that post again.
Ari is a professor of political theory and human rights at the University of Nebraska at Lincoln. In this blog post, he takes me to task for failing to take seriously the religious commitments of Jews in framing my arguments. And while he gets some things wrong about, for example, the relevance of “sexually-sensitive tissue” to my overall reasoning; and while he misses the point of my bringing up female genital cutting entirely (I’ve since edited my post to clear up any lingering ambiguity) – he is probably right that my approach to debating this issue is unlikely to win me any converts from within the ranks of the religious.
See updated material below – reply to a critic.
Of faith and circumcision: Can the religious beliefs of parents justify the nonconsensual cutting of their child’s genitals?
Circumcising minors on religious grounds amounts to grievous bodily harm according to a German court ruling issued on Tuesday. AFP News reports:
The regional court in Cologne, western Germany, ruled that the “fundamental right of the child to bodily integrity outweighed the fundamental rights of the parents. The religious freedom of the parents and their right to educate their child would not be unacceptably compromised, if they were obliged to wait until the child could himself decide to be circumcised.”
Some Jewish groups are up in arms. They insist that God has “non-negotiably” required that circumcision take place on precisely the eighth day after birth; hence waiting to perform the operation until the child could consent would amount to breaking this keystone covenant with their deity. Using the force of law to delay circumcision, then, is no different from banning it outright, since a delayed circumcision is religiously meaningless.
I don’t find this argument very compelling.
By Brian Earp
A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa may increase transmission of HIV
1. Experimental doubts
A handful of circumcision advocates have recently begun haranguing the global health community to adopt widespread foreskin-removal as a way to fight AIDS. Their recommendations follow the publication of three  randomized controlled clinical trials (RCCTs) conducted in Africa between 2005 and 2007.
These studies have generated a lot of media attention. In part this is because they claim to show that circumcision reduces HIV transmission by a whopping 60%, a figure that (interpreted out of context) is ripe for misunderstanding, as we’ll see. Nevertheless, as one editorial  concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”
Well, hold your horses. The “randomized controlled clinical trials” upon which these recommendations are based are not without their flaws. Their data have been harnessed to support public health recommendations on a massive scale whose implementation, it has been argued, may have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their exhaustive analysis of the RCCTs:
On the ethics of non-therapeutic circumcision of minors, with a pre-script on the law
By Brian D. Earp (Follow Brian on Twitter by clicking here.)
PRE-SCRIPT AS OF 25 SEPTEMBER 2012: The following blog post includes material from an informal article I wrote many years ago, in high school, for a college essay competition. I would like to think that my views have gained some nuance since that time, and indeed with increasing speed, as I have researched the topic in more detail over the past several months–specifically during the period of a little over a year since the blog post first appeared online. Since quite a few (truthfully: many thousands of) people have come across my writings in this area, and since I am now being asked to speak about circumcision ethics in more formal academic company, I feel it is necessary to bring up some of the ways in which my thinking has evolved over those many months.
The most significant evolution is away from my original emphasis on banning circumcision. I do maintain that it should be considered morally questionable to remove healthy tissue from another person’s genitals without asking that person’s permission; but I also recognize that bringing in the heavy hand of the law to stamp out morally questionable practices is not always the best idea. It is a long road indeed from getting one’s ethical principles in order, to determining which social and legal changes might most sensibly and effectively bring about the outcome one hopes for, with minimal collateral damage incurred along the way. Until enough hearts and minds are shifted on this issue, any strong-armed ban would be a mistake.
In the long term, however, I think the moral goal remains: that each male newborn should have the same legal protections enjoyed by his sisters, designed to preserve his sex organs in their healthy, natural form until such time as he is mentally competent to make a decision about altering them, surgically or otherwise.
The project for the meantime is to work on hearts and minds.
I am grateful to the many hundreds of individuals who have left thoughtful comments on my sequence of posts on the ethics of circumcision, and I look forward to developing my arguments in ever more sophisticated ways in the coming months and years as this important debate continues. I am especially grateful to those of my interlocutors who have disagreed with me on various points, but who have done so in a thoughtful and productive manner. May we all aim at mutual understanding, so that the best arguments may emerge from both sides, and so that the underlying points of genuine disagreement may be most clearly identified. — B.D.E.
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Routine neonatal circumcision in boys is unethical, unnecessary, and should be made illegal in the United States. Or so I argue in this post.
Yet lawmakers in California, it is now being reported, have introduced a bill with the opposite end in mind. They wish to ban legislation that could forbid circumcision-without-consent. Read that sentence again. What could be going on?