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. Both documents shine as likely examples of a “lowest common denominator” mélange birthed by a divided committee, some of whose members must be well aware that the United States is embarrassingly out of tune with world opinion on this issue.
By Brian Earp
A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa will increase transmission of HIV
Step 1. How not to design or conduct an experiment
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 supposedly show that circumcision reduces HIV transmission by a whopping 60%, a figure that wins the prize for “most misleading possible statistic” as we’ll see in a minute. Yet 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 (I use scare quotes deliberately) represent bad science at its most dangerous: we are talking about poorly conducted experiments with dubious results presented in an outrageously misleading fashion. These data are then harnessed to support public health recommendations on a massive scale whose implementation would almost certainly have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their exhaustive analysis of the RCCTs:
It was probably hard for the US National Science Advisory Board for Biosecurity (NSABB) to avoid getting plenty of coal in its Christmas stockings this year, sent from various parties who felt NSABB were either stifling academic freedom or not doing enough to protect humanity. So much for good intentions.
The background is the potentially risky experiments on demonstrating the pandemic potential of bird flu: NSABB urged that the resulting papers not include “the methodological and other details that could enable replication of the experiments by those who would seek to do harm”. But it can merely advice, and is fairly rarely called upon to review potentially risky papers. Do we need something with more teeth, or will free and open research protect us better?
By Charles Foster
I have just finished writing a book about dignity in bioethics. Much of it was a defence against the allegation that dignity is hopelessly amorphous; feel-good philosophical window-dressing; the name we give to whatever principle gives us the answer to a bioethical conundrum that we think is right.
This allegation usually comes from the thoroughgoing autonomists – people who think that autonomy is the only principle we need. There aren’t many of them in academic ethics, but there are lots of them in the ranks of the professional guideline drafters, (look, for instance, at the GMC’s guidelines on consenting patients) and so they have an unhealthy influence on the zeitgeist.
The allegation is ironic. The idea of autonomy is hardly less amorphous. To give it any sort of backbone you have to adopt an icy, unattractive, Millian, absolutist version of autonomy. I suspect that the widespread adoption of this account is a consequence not of a reasoned conviction that this version is correct, but of a need, rooted in cognitive dissonance, to maintain faith with the fundamentalist notions that there is a single principle in bioethics, and that that principle must keep us safe from the well-documented evils of paternalism. Autonomy-worship is primarily a reaction against paternalism. Reaction is not a good way to philosophise. Continue reading