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Science Requires Ethics

Intact America ran an open letter, as an advertisement, in yesterday's Washington Post urging the American Academy of Pediatrics not to recommend that American parents circumcise their infant sons as a strategy against HIV. [Full disclosure: I attended an event hosted by the organization and interact with some of its representatives because I support its cause.] It's a logical request, based on the necessary combination of science and ethics. A pro-circumcision advocate, Jake Waskett┬╣, has attempted a deconstruction of the letter, labeling it "propaganda". His support for that charge is preposterous, as any approach advocating the circumcision of healthy infant males must inevitably be, but his critique fails because he ignores the central issue involved. After a brief introduction, complete with an absurd assumption about Intact America's motives, Waskett quotes the opening paragraph:

American parents trust their pediatricians and rely on them for the best advice in caring for their children. As a matter of ethics, that advice cannot include neonatal male circumcision - a medically unnecessary, potentially risky surgery that no major medical authority in the world recommends.

I agree with this, although I'm not a fan of appeals to authority. As should be evident with the apparent intention of the CDC to recommend infant circumcision, it only takes one ill-conceived recommendation to distract from the core issue. Despite my misgivings, Intact America structures the argument correctly because it identifies that core: ethics demand not imposing medically unnecessary surgery on normal, healthy children, regardless of gender or potential benefits.

Waskett assesses this with an odd bit of snark about people inventing fire before issuing a parenthetical aside suggesting that the national medical bodies of African nations now implementing mass circumcision programs implies approval. Perhaps this is the case, which circles back to my reservation about an appeal to authority. But assuming it is not a point of fact. Still, if he's granted the point, what does this prove about Intact America's ethical argument? The risk of female-to-male HIV transmission through vaginal intercourse is a significant problem in Africa. In America HIV transmission risk through sex overwhelmingly involves male-to-male transmission, from which the (voluntary) circumcision of (adult) males has shown no statistically significant reduction. Even if this wasn't the case, the ethical issue of applying scientific research to healthy children through surgery centers on infant circumcision, not infant circumcision. That's the point Waskett ignores. His defense:

So what do we have left? A "potentially risky surgery". Well, yes, it is. There are risks, of course, albeit small. But these need to be weighed against the benefits: a reduction in the risk of certain conditions.

Finally, "medically unnecessary". Again, yes, it is. But that's not an argument against it: something can be beneficial, even advisable, without being necessary. Take vaccinations, for example: they're not strictly necessary, but they're certainly advisable.

Their claim that circumcision is unethical seems to be on shaky ground.

No, these risks need to be weighed against the need, or rather, the lack of need. The ethics of proxy consent require parents to choose a balance between the most effective and least invasive solution to remedy their child's malady. But there is no malady when the boy is healthy. Setting the ability to chase potential benefits as the ethical standard opens the range of allegedly valid parental interventions to include any number of surgeries we recognize as offensive. The science becomes ungrounded by any concern for the individual child as an individual.

Invoking the topic of vaccinations does not change this evaluation. There are similarities between circumcision and vaccination, based on potential benefits. However, the difference rests on how the problems the interventions are meant to prevent occur. For example, becoming infected with measles requires no effort other than participation in society, while acquiring HIV from an HIV+ female through vaginal intercourse requires a very specific action, an action not undertaken by infants. Comparing the two solutions as comparable for parental consent fails.

Add to this the fact that parents treat the same maladies circumcision is supposed to prevent with less invasive, non-surgical methods when they affect their daughters, and Waskett's argument misses the ethical case against infant circumcision because he's making the case for circumcision devoid of context and ethics. That's a case that works only if it's a voluntary decision by the adult male himself.

Next, Intact America requests that the AAP defend the ethics against infant circumcision rather than considering a revision in favor of the surgery since science necessarily involves ethics when applied to a person's body, particularly via proxy consent. Waskett calls this request "bizarre," despite having failed thus far to address the ethical argument made by Intact America.

Continuing:

[sic] still, more than one million American babies undergo the surgery every year driving one billion dollars in health-care spending.

And, no doubt, saving comparable figures in disease prevention.

Waskett's claim is based on speculation. Perhaps his analysis is correct, but he does not provide proof for his assumption here. We have statistics from other western nations demonstrating the incidence rates for the diseases to which he refers. Since we can analyze circumcision on these terms, "no doubt" is insufficient.

Regardless of the cost, the issue is still the ethics of circumcising healthy infant males. The individual matters, not America's males as a collective.

Continuing:

Most European nations, with circumcision rates near zero, have lower HIV/AIDS rates than the United States.

Are Intact America really so naive about epidemiology that they think that between-country comparisons constitute a decisive answer to such a question? Evidence-based medicine requires use of the best available evidence (usually randomised controlled trials), not the least (ecological analyses such as this are considered one of the weakest methodologies, and for good reason).

First, the "best available evidence" is that the infant male is healthy. No surgery is indicated or, therefore, justified. But that's nit-picking facts when it's as correct to stick with ethics.

Waskett seems to think that Intact America ignores the randomized controlled trials showing risk reduction in female-to-male HIV transmission from voluntary adult circumcision. The letter noted this fact in an earlier paragraph. Still, as I read the letter, Intact America is not making an argument about epidemiology. Rather, it is making an argument about populations and risk factors. The risk factors among America's population are similar to those of European nations, not African nations. Our risk is male-to-male transmission and shared needles during IV drug use. Circumcision protects against neither. Is that complete proof that infant circumcision in America, unlike the randomized trials involving adult volunteers in Africa, is irrelevant to the United States? No, and I don't think Intact America is suggesting otherwise. It is simply working from the central fact, which is that it is unethical to circumcise healthy infant males - who are not sexually active - to prevent a disease for which most of them will face minimal lifetime risk and for which less invasive, more effective prevention methods exist. Europe is an appropriate anecdotal case study that (infant) circumcision is not necessary to achieve the results health officials desire.

Continuing:

Furthermore, circumcision has significant risks, including infection, bleeding, impairment of sexual function, and even death. Earlier this year, an Atlanta family was awarded $2.3 million because a physician accidentally amputated much of their infant son's penis during a "routine" hospital circumcision. A Canadian baby bled to death in 2004, after being circumcised in a British Columbia hospital. In 2008, a baby from South Dakota bled to death, and his parents have filed suit against the hospital where he was circumcised, as well as the doctor who performed the surgery.

Yes, accidents happen, and of course they're tragic. But let's be sensible. If we're going to consider the risks associated with circumcision, we also have to consider the risks associated with non-circumcision. Babies die of urinary tract infections - and circumcision reduces the risk. Adults die of penile cancer (again, the risk is reduced) and of HIV (and again).

The complications of circumcision affect individuals. Those individual have rights. We recognize this for female minors, legislating against parental proxy consent for medically unnecessary genital surgery on daughters for any reason. The ethical argument against infant male circumcision involves the equal rights concept that the same protection should be applied to males. Waskett hasn't yet made a coherent case for denying these rights to male minors.

But on his demand that we include the "risks associated with non-circumcision," to an extent these must be lumped into the risks associated with living. That's sufficient since it's how we treat female minors, but it's worth noting that Waskett's argument is flawed because he ignores the context of those ailments, thereby avoiding the ethical issue of proxy consent. He ignores that alternate solutions exist for those risks associated with normal genitalia. Most infections are not life threatening and can be treated with interventions less severe than surgery. The other risks, such as HIV and penile cancer, involve causes (i.e. behavior) not directly related to the foreskin. This is the approach we take with female minors. It is the approach an ethical society would take with male minors.

┬╣ This is an assumption. I have interacted with Jake Waskett on previous occasions. The language, tone, and approach to the topic match what is found here. As added support, an excerpt in the entry quotes "...in favour of the surgery..." from the Intact America letter, which is a British spelling not found in the original letter. At least one other British spelling appears in the entry. Waskett is British. I leave open the possibility that I am mistaken and will correct if it becomes clear that I am.

Comments

You are correct. Jake is British. http://en.wikipedia.org/wiki/User:Jakew He also claims to be neutral about circumcision. Hah!

Jake is known as Jakew on Wikipedia where he has used his hyper-technical arguments to hijack and put a pro-circ slant on the Circumcision and Foreskin restoration articles. Using his hyper-technical editing, Jakew applies strict controls that are not found on hardly any other Wikipedia article. His editing really limits the usefulness of the Foreskin restoration article.

Jake also runs a library site with pro-circ articles at circs (dot)org (don't want to give him a free linkback!)

Along the lines of ignoring better treatment alternatives, he also ignores the HPV vaccine. And of course he tries to make an absurd comparision with vaccines.

It's also instructive to not how he describes the risks as minimal but does not apply that adjective to the purportked benefits which would be equally appropriate.

I agree with Restoring Tally. I have seem many writings of Waskett. He is pro-circumcision for all males.

Nicely written article.

Here's something you may want to write about.

Read this article "New York City Plans to Promote Circumcision to Reduce Spread of AIDS"
. See then how Dr. Frieden was promoting circumcision for gays immediately after the African studies came out even though these studies had nothing to do with gay sex.
He presumed circumcision would offer some protection for gays. Of course since then studies have shown circumcision slightly increase HIV infection in the gay populace.

In New your Dr.Frieden also worked with Dr. Blank who now is heading the AAP's Circumcision Task Force Policy soon to give their recommendations at the beginning of this year.

Researching these individuals I think you'll agree they are pro-circumcision.

Recently Dr.Frieden's CDC sponsored 2009 National HIV Prevention Conference in Atlanta, Georgia allowed this non scientific assault on intact males especially Blacks and Hispanics.
From David Wilton's CircumcisionAndHIV
"NHPC 2009: Report from a member of Intact America in attendance"

"At one of the last sessions, the speaker from "Operation Abraham," an Israel-based group that apparently hopes to be engaged to assist the U.S. in circumcising black and Hispanic males, put a photo of an intact male up on the screen. The figure of an elephant had been drawn around the penis so that the intact penis looked like an elephant's trunk. The words "Yes! A circumcision please!" had been added to the photo. I remonstrated loudly until this smear against intact males was taken down. I then promptly left the session. I am still awaiting a deserved, written, direct apology from Dr. Peter Kilmarx, Chief of the Epidemiology Branch of the Division of HIV/AIDS Prevention of the CDC, who was in attendance and from whom I demanded an apology."

As a courtesy, Tony, I thought I'd notify you that I've responded here.

Likewise I responded to YOU response there

Jake,

I'll have time to respond this weekend. There's a lot there, and I want to give it my full attention.

I have a crucial question that I hope Jake will condescend to answer HERE..

Can Jake offer a RATIONAL ETHICAL justification for non-therapeutic circumcision of infants.

By this, I mean, PROVEN benefits that outweigh the PROVEN harms and risks.

And by "proven", I mean proven by the requirements of SCIENCE.

It's poor logic to attack US/European "between-country" comparisons as not being "epidemiologically sound" and then immediately follow by comparing African data to that of the US. And this comparison is not "epidemiologically sound"? Talk about calling out apples and oranges by comparing apples and oranges...

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