Circumcision of Male Infants
Guidance for Doctors
There has been much debate on the ethics of circumcising baby boys, and
this guideline outlines the position of the BMA, with regard to circumcision
for medical purposes, and the issues doctors should take into account
when asked to perform circumcision for religious or cultural reasons.
The subject should not be confused with female "circumcision" which was
outlawed by the 1985 Prohibition of Female Circumcision Act. This issue
is addressed by a separate BMA Guidance.
Circumcision for medical purposes
These guidelines do not attempt to offer detailed guidance as to the
appropriateness of accepted therapeutic clinical procedures. Their aim
is to offer guidance on the ethical duty of doctors to treat patients
appropriately, and to keep themselves educated and aware of developments
in clinical practice.
This advice applies to all aspects of practice, including circumcision,
and can be outlined as follows:
- Where conditions can effectively be treated conservatively, it
is accepted good practice to do so. Even limited procedures should
only be carried out where there is good reason, and then only after
adequate conservative treatment. The BMA opposes unnecessarily invasive
procedures being used where alternative, less invasive techniques,
are equally efficient and available.
- Doctors have a duty to keep up to date with developments in medical
practice. Therefore, to circumcised for therapeutic reasons where
medical research has shown other techniques to be at least as effective
and less invasive would be unethical and inappropriate.
- Doctors must be allowed to make clinical judgements in individual
cases, based on the above, as to the treatment to be used. The BMA
would therefore have concerns at any prohibition of the use of techniques
which, in certain circumstances are considered by the profession at
large to be clinically appropriate.
It is rarely necessary to circumcise an infant for medical reasons. Doctors
must recognise that the appearance of the foreskin in infancy does not
act as a guide to whether it will became retractile in later life. Normal
anatomical and physiological characteristics of the infant foreskin can
be misinterpreted as being abnormal, and doctors should be familiar with
recognising this and reassure parents accordingly.
Circumcision for religious or cultural reasons
This guideline only addresses the position of doctors performing ritual
circumcisions, and not religious or cultural leaders.
Legality
Male circumcision is lawful under English common law. In the case
of R v Brown [1993] 2 All ER 75 HL, Lord Templeman talks about the circumstances
in which violence is not punishable under the criminal law.
"Even when violence is intentionally afflicted and results in serious
bodily harm the accused is entitled to be acquitted if the injury was
a foreseen incident of a lawful activity in which the person injured
was participating. Surgery involves intentional violence resulting in
serious bodily harm but surgery is a lawful activity. Other activities
carried on with consent by or on behalf of the injured person have been
accepted as lawful not withstandin that they involve actual bodily harm
or may cause serious bodily harm. Ritual circumcision, tattooing, ear-piercing
and violent sports including boxing are lawful activities."
Circumcision, in common with ear piercing and cosmetic surgery, has
never been the subject of a case in English law, but this assumption
of lawfulness has never been challenged.
[NOTE: This 1996 declaration that male circumcision
is lawful is now clouded by the passage of the Human Rights Act 1998.
See The
impact of the Human Rights Act 1998 on medical decision making
for more information.]
The duty to balance potential benefit and harm
With all procedures, professionals have an ethical obligation to weigh
the potential benefits and harms of the procedure and explain these
in an appropriate manner to the patient or person consenting on the
patient's behalf. Doctors unfamiliar with the practice and who receive
a request for circumcision may find it helpful to seek advice about
the physical risks of the procedure from doctors experienced in conducting
circumcisions. Paediatric surgeons and urologists are trained in circumcision.
The BMA does not have a policy on the ethics of male circumcision
for religious or cultural purposes but issues this guidance in response
to doctors for all relevant factors to be taken into account. The practice
of circumcision has previously been considered to be morally neutral,
that is, no harm was caused to the child and therefore with appropriate
consent from both parents or a person lawfully exercising parental responsibility,
it could be carried out. The neutrality of the procedure, however is
now being increasingly challenged although it is argued that it is in
the best interest of the child to be circumcised, to be accepted into
a religion or community. Arguably the procedure can confer social benefits
in some such circumstances.
Potential health benefits
However, the health, as opposed to the social, benefits of circumcision
are increasingly disputed. It is clear that there is no consensus amongst
the profession as to whether circumcision dose carry benefits to health
sufficiently large to justify the procedure. Arguments in favour of
circumcision cite reduced infection rates and hygiene. It is claimed
that it is protective against penile cancer, reducing the incidence
by a factor of 5000.[1] Arguments against circumcision usually stress
the damage caused to the penis from the operation, including scarring
and a lack of sensation. In addition, poorly performed circumcision
can give rise to infection and distress.
It has also been argued that male circumcision may confer some health
benefits to female sexual partners. However, this view has been challenged,
together with the validity of the research on which it was based, and
there is no consensus on this issue at present.
Whatever the health implications of circumcision, the main impetus
for circumcising comes from culture and religion, not from medical or
scientific evidence.
Where such a lack of consensus exists, the position of doctors is
unclear. Individual doctors approached by patients requesting circumcision
for their son must counsel the parents about the implications of the
procedure, including the health risks involved. Any surgical procedure,
including one of a minor nature, carries with it risks and parents must
be made aware of these in order to give valid consent to the operation.
In addition, doctors usually consider appropriate anesthesia a requirement
and this also carries an element of risk.
Doctors must use their judgement as to whether or not to perform circumcisions.
In some circumstances, a doctor may think it better to do the circumcision,
or refer the child to a plastic surgeon, if he or she feels the child
is at risk of being circumcised in unhygienic or otherwise unsafe conditions.
Consent
The BMA strongly recommends that either the written consent of BOTH
parents, or of the person with parental responsibility be obtained for
circumcision. Parents must be aware of the nature and implications of
the procedure, and the risks involved.
Doctors should be aware of potential difficulties if both parents
do not follow the same cultural tradition. A case raised with the BMA
concerned a GP who circumcised, without any enquiry, a baby unknown
to him but whose parents were, in fact, unmarried and estranged. The
child's father had taken the baby without the mother's permission, fully
aware that the procedure would be completely contrary to her wishes
and that he had no legal right to consent. The mother made a formal
complaint about the doctor concerned.
[NOTE: The power of parents to consent to surgical
procedures may be exercised only in the best interest of the child.
See this letter
by Dr. Michael Wilks, Chair of the BMA committee on medical ethics for
more information.]
Expertise
The General Medical Council has no policy on the ethics of circumcision.
However, the Council would take action of a doctor were performing such
operations incompetently. One doctor, who carried out a number of circumcisions
that resulted in several boys being admitted to hospital in the period
from 1991 to 1993, was found guilty of serious professional misconduct.
Therefore doctors are advised not to undertake the procedure unless
confident of their expertise but may refer the family to another competent
practitioner.
Doctors commonly facing requests for circumcision will find it helpful
to establish whether there are colleagues in their area expert in this
field. Religious and cultural groups may have organisations, locally
or nationally, who give advice and can suggest practitioners who perform
circumcisions. For example, the Initiation Society, the professional
body for the organisation of (Jewish) Circumcision Pratitioners sets
professional standards and keeps a list of registered practitioners.
Other religious groups may have similar national or local registers.
Charging patients
Some doctors have been willing to provide circumcision routinely on
demand. While there is no duty upon doctors or hospitals to do so, some
will do this procedure without charge rather than risk the procedure
being carried out in unhygienic conditions.
Legal Issues
Circumcision, as any other surgical procedure, should never be carried
out by a doctor not trained in that particular operation. Normally,
that doctor would be a pediatric surgeon, a urologist, or other doctor
experienced in performing the operation.
Poorly performed circumcisions hold legal implications for the doctor
responsible. An action could be brought against a doctor responsible
on the child's behalf if the circumcision was carried out negligently.
Alternatively, the child could issue such proceedings in his own name
on reaching the age of 18 and the normal time limit for starting legal
proceedings would run from that birthday. However, because circumcision
is not an unlawful procedure, action could not be taken against a doctor
simply because a man was unhappy at having been circumcised at all.
A valid consent from a person authorised to give it on the patient's
behalf is sufficient in such cases.
Conscientious objection
Some doctors may wish to not perform circumcisions for reasons of
conscience. In such situations, both the BMA and GMC make clear that
doctors should not delay in explaining to the patient their own moral
position but not seek to impose their own moral viewpoint on patients
who do not share it. The provision of factual information is a different
matter and doctors can also explain the background to their conscientious
objection if the child's parents require them to do so.
In summary
- Circumcision is not unlawful, but care must be taken to obtain appropriate
consent from the parent(s) and inform them of the implications, as
with any surgical procedure.
- Circumcision for medical purposes should be carried out in accordance
with accepted good clinical practice.
- Doctors must consider the situation of each case with which they
are presented, and act according to their clinical judgement.
- It is recommended that written parental consent be obtained.